Professional Documents
Culture Documents
RS-History taking.
Haneen Salahat.
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Clinical Skills Record 1 RS History
Skills:-
What is sign posting?
It is telling the patient what youre going to do.
Eg: Now I would like to ask you some questions
concerning your past medical history.
Negotiation of Agenda:-
A Plan of action within a given time.
Eg:- deciding that a patient needs an X-ray therefore
booking them an X-ray appointment, or deciding that he
only needs rest so you tell them to have some rest and
drink orange juice and soup etc.. btqayyem el 7aleh.
Some patients will tell you I have work so I cant stay in
bed for 5 days, therefore you change the treatment to a
more suitable one.
Non-verbal and verbal cues
- Non-verbal cues:- eg
patient looks in pain with
hands on stomach
- Verbal:- Ahhhh my
stomach hurts.
Respect
Active Listening
Screening:- Make sure that
you didnt miss anything, so
check systematically
Summarizing:- *Dont forget
this in the OSCE, in order to
do this you have to keep up
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with the patient and not interrupt him, remember the key
words so that youll summarize his condition when hes
done.
Empathy:- Eg if patient tells you both parents died, My
deepest condolences..
Facilitation:- If the patient is thirsty you offer them a
drink, if the patient is limping you offer them a chair, etc..
Clarification ask a question so that you understand them
properly
Using simple language, no medical terms.
Logical order,
Patients perspective:- The patients view, which is
summarized with the word FIFE.
1- F - Feelings and concerns
2- I - Ideas:- Do you have an idea about the
symptoms you have or disease you have?,
some patients might think they have cancer for
example
3- F -Functionality, how does this affect your
daily life?
4- E - Expectations:- Dont ask, What do you
expect me to do for you? The patient will
think you dont know what youre doing, so
instead, ask, We know that you have and
that it affects your life in a certain way.. Do
you think that there is anything we can add to
your treatment that can benefit you more
from your perspective?
History:-
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1- Patients profile:-
Name, age, gender (if necessary eg. Transgender patients),
address, occupation..
2- Mode of transportation:- How did you come to the
hospital/clinic today? Ambulance, walking, by car..
3- Chief complaint :- What brings you here today? Shu el
moshkeleh elli jabatak hon el youm? What bothers you
the most?
4- SOCRATES :-
S -site Can you point with your finger at where the pain
is?
O -onset How did it start, was it sudden or gradual? Faj2a
wella shway shway?
C -Character Describe the pain, is it burning, stabbing,
etc..?
R -Radiation Does it move? *If the pain goes/shifts from A
to B or *stays at A and goes to B extension, or *Form 3:-
Referred pain. For example:- Patients with appendicitis,
when they lift their leg theyll be in pain.
Determine whether the pain is visceral pain or superficial. Eg
when a patient comes in complaining of stomach ache, your
mind immediately goes to visceral problems, eg constipation or
diarrhea or a bacteria, but then he goes on to specify that hes
in pain when he walks or climbs the stairs or when he laughs
then youll know that the cause of the ache is actually a
problem with the muscles.
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COPD patients:- their disease can manifest in two
presentations.
1- Patients with Emphysema can develop COPD.
In Emphysema there is destruction of the septa
between the alveoli forming bullae.
2- COPD
can also
be seen in
patients
with
chronic
bronchitis.
Pneumonia
- Is the inflammation of the lung.
- we expect to see:- fever, cough, sweating, dyspnea
difficulty breathing, hemoptysis coughing blood,
sputum, chest pain, nausea, vomiting, diarrhea,
fatigue.
Pulmonary Embolism:-
- Pulmonary embolism is the sudden blockage of a major
blood vessel (artery) in the lung, usually by a blood clot
- We expect to see:- chest pain, dyspnea, palpitations,
sweating, hemoptysis, fainting and anxiety, fainting.
o What is the difference between stress and anxiety?
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Stress is a very general term, it may be mechanical,
physical, psychological, Anxiety is more nervous, not
angry, but there are emotions, hes worried. If there is
continuous chronic stress, this turns to anxiety.
Pneumothorax:-
- The presence of air in the pleural cavity
- Low blood pressure, anxiety, dyspnea, palpitations,
chest pain, breathlessness.
Pulmonary edema:-
- Accumulation of fluids in the lung tissue
- Dyspnea, orthopnea When patient lays down, the fluid
covers a larger area so the patient will be very
uncomfortable and cant breathe than compared to
standing because while standing the fluid is present only
down.,
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-Paroxysmal Nocturnal Dyspnea:- Paroxysmal;- comes and
goes Nocturnal:- At night Dyspnea:- difficulty breathing.
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smokers, endotracheal tube, dyspnea due to tumor in
lung,
metastasis is when the tumor spreads from one site to
another, it might reach the lymph nodes, or the liver
resulting in jaundice the patient looks yellow because
the bile goes with the blood,
bone pain, headaches, numbness because the cancer
eats away at the nerves, seizures, muscle weakness,
dyspnea
*If a patient does not move his neck a lot, eg if he
works in marketing and stays in front of the monitor
all of the time, with time the there will be lack of
vascularity leading to tissue degeneration and
cartilages and this might affect a nerve, lets say in
on the left side and its muscles will undergo
hypotrophy so the muscles of his left arm will be
smaller than the muscles in the right arm.
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Dyspnea:- the difficulty in breathing is graded
from:- Grade 1 til 5 and 5b
Grade 1:- The lightest form of dyspnea and
grade 5b is the most severe
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