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Elicting the Patient's Story

Format of a Medical Interview and Oral Presentation
by

Lisa Weiss

on 21 October 2014

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Transcript of Elicting the Patient's Story

Eliciting the Patient's Story: Format of a Medical Interview and Oral Presentation
Basics
What have you learned so far?
The Medical Interview
The Pieces and Parts:
You give it a try
The Rest of the Information
Past Medical History
What's in it?
Why important?
Oral Presentation
Your way of telling the patient story
clear communication
Introductions
Establish Rapport
Comfort

Anything else??

Important Themes....
General to Specific
Open to Closed
Used the format as a guide but improvise when necessary
The order of the interview
Chief Complaint
History of Present Illness with summary
Past Medical History
Family Medical History
Psychosocial System Review with summary
Health Risk Factors
Review of Systems
and always remember to summarize!!!
Chief Complaint
Straight from the patient - the reason for coming.
History of Present Illness
Patient's description of her symptoms
Location
- Where does it hurt?
Character
- What does it feel like?
Severity
- Scale of 0-10 is usually used
Timing and Duration
- when does it occur? how often?
Precipitation and exacerbating factors
- what makes it worse? What makes it better?
Relieving Factors
- What have you done to make this better?
Associated Factors?
Patient's conception
- What do you think is going on? Have you had this before?
HPI Questions:
Now your turn....
in groups of 3 - 1 patient, 1 interviewer, 1 recorder
Family Medical History
System Review - what does this mean?
What type of diseases are important?
PMH: some tips
Adverse Drug Event vs. Allergic Reaction
what happened?
Medication Adherence
Over the Counter Meds and Herbals
Immunizations - find out which ones!
Some typical "trip-ups"
leading questions
moving to your "list" to fast
asking compound questions
accepting vague answers
How to get there....
Open ended transitions into these sections.
How has your health been in the past?
Tell me about your family's health
What do you do in your spare time?


Psychosocial System Review
The fun stuff....Where you really get to know your patient
Health Risk Factors
Follow the list - if they make sense
Watch NOT to judge...it can be hard not to

Review of Systems
Can seem exhaustive
Let the patient know what you are doing
A great way of figuring out a problem you can't solve or making sure you have ALL the information
Now your turn....
in groups of 3 - 1 patient, 1 interviewer, 1 recorder
Summarize info you obtained before moving on
Chief complaint
- in the patient's words
HPI
- include EVERYTHING that is relevant
PMH
- keep everything in it's category
FMH
- stay within the organ system
PSH
- tell the story in paragraph form
HRF
- state the positive
ROS
- state what you covered both positive and negative
Stick to the format - here is not the place to be creative
Before your seminar
Write out the case presentation
Practice your case presentation
you need to have eye contact.
Use the case presentation checklist
Now your turn....
in groups of 3 - all 3 write out your oral presentation. Practice it. 1 presenter, 2 listeners.
Contract with the Patient
What do you plan to do?
Are you using an electronic device or writing on paper?
How much time do you plan to spend?

The more you let the patient know the "plan" for the visit, the more comfortable the patient feels
remember to summarize for the patient!
http://www.ncbi.nlm.nih.gov/books/NBK349/

What is an example?
Starting the interview?
Thoughts?
OPEN ENDED QUESTIONS !!
MOST IMPORTANT:
Keep your question as open as possible for as long as possible...
Tell me more about that...
Open Ended Questions?
compound questions ?
interrupting?
leading questions?
Summaries - did they help?
You save time if you let the patient talk and you listen!
Transitions?
Full transcript