Taking a patient clinical history



hello my name is Helen Ward and I'm a principal lecturer non-medical prescribing and advanced nurse practitioner at London South Bank University I'm going to talk to you today about introduction to history taking the aims of this session was to take a holistic patient-centered history we'd also like to identify framework to structure the history we want to be able to recognize the different situations that we might need to take a history from what does history taking enable you to do well it enables you to begin to formulate a diagnosis it helps to fill in the gaps and test any hypothesis that you might have it might well also establish the most important systems on which you need to focus your physical examination and most importantly it establishes a trust between you and your patient in order to take a comprehensive health history from your patient you need to have a structure to it need to be identify several different factors in order to enable you to get as much information from your patient as possible first of all you need to make sure that you've got your right patient you need to identify your patient secondly you need to identify the presenting complaint that your patient has come to see you for today it's quite useful at this point to be able to put into words or into the patient's words exactly why the patient has come to see you then you need to find out the history of the presenting complaint has this patient woken up with it with the symptoms this is the first thing this morning or has your patient had an ongoing situation related to those systems and has decided to come and see you today you also need to identify your patient's past medical history you want to find out whether the symptoms that the patient is presenting with are fitting in with the past paid medical history that the patient might have then you need to establish what your patient's current health history is like you might have got a patient that is normally fit and well that tells you that they feel very unwell because they've woken up with a fever or sore throat you might have got a patient that has a chronic conditions such as your PD coronary heart disease that manages their condition quite well and tells you that actually they're quite well for them today this all helps to put the symptoms that they're presenting with into perspective ask your patient have they got any allergies this could be any allergies to any drugs or medication that they might have taken previously or it could be an allergy to any food products that the patient may be sensitive to but it might well influence what you might be prescribing for them ultimately at the end of the consultation you need to know your patients drug history you need to take know whether your patients are taking any medications that they've bought over the counter or taking any homeopathic medicines or any pet medicines that have been prescribed to them by their doctor it's also important to establish your patients alcohol and smoking history alcohol can affect the liver if taken to excess over a number of years and so the history of alcohol intake needs to be considered similar with smoking many patients will tell you that they've given up smoking or they've cut down on their smoking just because they come to see a health professional ask your patients about their smoking history have they ever smoked and if they have ever smoked what types of cigarettes did they smoke or indeed with their smoking cigarettes or were they smoking recreational drugs ask your older patients whether they have been in an environment where smoking has been prevalent they may be passive smokers and that may have affected the present are presenting symptoms you need to ask your patients about their family history this is very important because you might want to put a link in between the family history and the symptoms of which they are presenting to you today you also need to ask your patients about their social history this can be very important we might need to find out in a woman about gynie history whether they've had any children what is their menstrual cycle like what was the first day of their last period you might want to find out about a patient's sexual history you might want to find out about your patients occupation or hobbies or job okay so let's move on then to taking the health history first of all once you make tea with your patients establish and establish relationship with your patients you need to ask your patients what is bothering you how can I help you today what brings you here today most of you will develop your own few words of making your patients feel at home when they come in and you need to take a history from them ask them what symptoms they are presenting you with what symptoms have they come to see you with today ask your patient what his or her problem might be what do they think the problem is ask them how or why it occurred and discuss with your patients the hoped or feared outcome of the consultation now let's think about using a consultation model to structure our history there are several different consultation models that you can use here at London South Bank University we favored the Calgary Cambridge model references to this can be found at the end of this session there are several different consultation models that you can use the cowboy' Cambridge one has six easy stages to use the first one is initiating the second session the second one is about gathering information the third one is providing a structure to your consultation the fourth one is building a relationship with your patient the fifth one is about explaining and planning and management of treatment or care with your patients and the sixth one is closing the session so let's start with initiating the session it's really important that you're able to greet and introduce yourself to your patients this is particularly important if you're developing a new role your patients need to understand what your new role is so they've got a good expectation of what to expect from the session it's very important at this stage to demonstrate an interest and concern for your patients you need to identify the reason for your patients attendance with you today your patients may have their own agenda you may need to screen your patients how many problems they got on their agenda you might need to establish which is the most important one and then ask them to come back and either see yourself or somebody else for another items on their gender then we need to gather as much information as possible from our patients to start with it's useful to be able to allow your patients to tell their own story in their own words patients don't always tell a story in their own words you might have to ask questions in order to facilitate this you may need to ask open questions or you may need to ask close questions you need to demonstrate to your patients that they are you're listening to them you might need to help your patients for the story to come out it's also quite important to be able to clarify what is being said with their patients your patients don't always tell the story in a chronological order it's up to you is the health profession to put that into a chronological order you need to understand the patient's perspective of the problem what are your patient's ideas or concerns about the presenting symptoms that they've got how is the problem that they're experiencing affecting them is it making them unable to go to work or carry out their activities of daily living what are the expectations of the consultation from your patients they expect you to make them better do they want you to refer them to somebody else what are their feelings or concern or or thoughts on the presenting problem they may have seen a television program or read an article in a magazine related the symptoms to themselves and now become very concerned about those symptoms observe your patients think about clues such as nonverbal communication how does your patient look what is their eye contact with you how are they dressed is it appropriate then we need to move on to providing a structure to the consultation here is quite useful to be able to summarize what your patient has said to you patients might have given you an awful lot of information in a very short space of time you might need a signpost where we are now where we are going to you might want to change the sequence or clarify the sequence with your patient just let me clarify with you is this the sequence in which these presenting symptoms have developed you may also need to try and keep the consultation on track your patients might be going off at a tangent you might need to tell them that you've only got a ten minutes within the consultation in which to provide the structure for the whole of the consultation with them and you might have to ask them to cut things short now we must build the relationship with our patients it's very important that we develop a rapport with our patients sometimes we might only have a 10 minutes in which to gather an awful lot of information from the patient we need to put it into some form of logical sequence and then we need to be able to develop a treatment and management plan for our patients it's important that we are empathetic towards the patients and provide support for our patients we must also be very sensitive in some cases because patients may be giving us very personal information it's important we involve our patients throughout the consultation we need to encourage the patients to share their thoughts with us we need to explain the process of the consultation as we go through it now we need to explain and plan the consultation here we need to provide correct amounts of information for our patients this is sometimes called chunking and checking here we can give small amounts of information and check that the patient understands what we are telling them we need to be able to assess the patient's starting point some patients may have a very good idea about their presenting symptoms and some patients may not we need to ask the patient's what other forms of information they might need we need to be able to explain at appropriate times with our patients and where possible avoid to give them any premature reassurance we need to make sure that the patient's aid and have accurate recall and understanding of the information that we are giving to them we might need to explore the information that they've given to us and put it into some form of logical order for them we might need to repeat or summarize areas of the consultation we may need to clarify terms with our patients you must try to avoid jargon wherever possible for some patients whose English is not the first language or who have learning difficulties we may need to use visual aids to convey information to the patients now we need to achieve a shared understanding and incorporate the patient's perspectives we may need to relate the explanations that we're giving to our patients to their illness framework we need to be able to invite the opportunity and encourage patients to contribute to the consultation and to ask questions we need to be able to able to establish our patient's own health beliefs there are reactions and their feelings towards the consultation or the information that we're going to give them now we need to plan a shared decision-making with our patients here the patient's need to be able to share their own thoughts we might need to give our patients suggestions rather than give them directions we want to involve our patients in the decision-making and to empower them to develop their own treatment and management plan here we might need to negotiate with the patient's we might need to offer them various choices and lastly we need to be able to check that our patients understand what we are selling them now we have to close the consultation here is quite useful to be able to summarize what you've said with your patients you may also need to enter a contract with your patients safety netting is very important your patients need to know when to come back or when to be referred to somebody else or when to go something like an accident and emergency department and finally we need to check with our patients they fully understand the consultation and the outcomes of the consultation we've talked about a lot of a lot of information we've been through a structured consultation so how much data do we really need if you don't know your patients you really do need to know and be able to establish a complete database with your patients some of you will be reviewing your patients or may know your patients or may have information on your patients already then you'll need an episodic or a problem centered history from your patients if you're reviewing your patients you may need to have a follow-up consultation with your patients and this will be building on information that you've already got with your patients or establishing any changes in your patients conditions with them some of you might be in a situation where you're in an emergency situation and in that situation you are not going to sit down and take up comprehensive health history from your patients you're going to establish the situation and Dan call for help as soon as possible sometimes once you've taken your history is quite useful to review some of the systems your gut feeling might say have I missed something out so you could use a sieve to help expand your differential diagnosis or you could ask about common symptoms from each system maybe do a top to toe approach if you like this ensures that no important symptoms are missed and it can allow you to move from a specific sorry from a general to a specific situation the detail that you ask your patients may will depend on their age or their health they status I believe that several special considerations that need to be taken into consideration when you are taking a history from a patient's things we've talked about today may relate easily related to an adult population you may need to adapt this if you're dealing with the pediatric population Elzy people may come with a carer or may have impaired hearing or visuals okay so you may need to adapt your consultation skills and relate them to your elderly patients and the adolescent population is also a special congroo to take into consideration I do hope this has helped you with providing a structure for your history and they'll be able to take this forward and practice with your patients in the future you

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