Summary of How to Take a Patient History (full guide) | KharmaMedic

Main Ideas and Concepts

• Importance of Patient History

  Taking a patient history is a fundamental skill for doctors and forms the core of clinical practice.

• Context Awareness

  Understand the context of the patient interaction (e.g., emergency department vs. general practice). Adapt communication based on the patient's situation (e.g., newly admitted vs. long-term hospitalized).

• Building Rapport

  Establish a friendly and genuine connection with the patient to facilitate smoother communication.

• Structured Approach

  Follow a general structure for taking histories, which includes:

  • Presenting complaint
  • History of presenting complaint
  • Systems review
  • Past medical history
  • Drug history
  • Family history
  • Social history
• ICE Framework

  Use the ICE acronym (Ideas, Concerns, Expectations) to delve deeper into the patient's perspective and emotional state.

• WIPER Acronym

  Follow the WIPER protocol for patient safety and infection control:

  • Washing hands
  • Introducing yourself
  • Patient details verification
  • Exposing the patient if necessary
  • Repositioning the patient
• Open-Ended Questions

  Start with open-ended questions to allow patients to express themselves fully, then follow up with more specific inquiries.

• Acronyms for Specific Histories

  Utilize various acronyms for specific presentations:

  • SOCRATES for pain assessment
  • MOSC for gynecological history
  • GMC for obstetric history
  • BFGD for pediatric history
• Systems Review

  Conduct a quick systems review to ensure no significant details are missed, covering various body systems.

• Detailed Past Medical History

  Gather comprehensive information about the patient's past medical conditions, surgeries, and hospitalizations.

• Drug History

  Document all medications, including prescriptions and over-the-counter drugs, and check for allergies.

• Family and Social History

  Inquire about family health conditions and the patient's social circumstances, including lifestyle habits and support systems.

• Empathy and Sensitivity

  Approach sensitive topics, especially regarding family history and mood, with empathy and care.

• Final Tips

  If feeling stuck, ask the patient for their thoughts on possible causes or concerns, which may help clarify the situation.

Methodology (Detailed Bullet Points)

• Preparation
  • Understand the context of the patient’s visit.
  • Approach with kindness and a genuine demeanor.
• History Taking Structure
  • Start with the presenting complaint.
  • Explore the history of presenting complaint using open-ended questions.
  • Conduct a systems review with a few back-to-back questions.
  • Gather past medical history, drug history, family history, and social history.
• Utilize Acronyms
  • SOCRATES for pain.
  • MOSC for gynecological history.
  • GMC for obstetric history.
  • BFGD for pediatric history.
• Summarize and Clarify

  Summarize the information back to the patient to ensure understanding and completeness.

Speakers or Sources Featured

• Nasser (KharmaMedic) - Final year medical student at King's College London.

Notable Quotes

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Educational

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