Topic > Analysis of the clinical methods used for medical history collection

Being a doctor means first of all knowing how to observe carefully and listen well. There must be an excellent interpersonal relationship between doctor and patient. So a doctor should be able to evaluate the signs, look for symptoms and arrive at a diagnosis quite methodically. This is where taking the story helps. It is the beginning of the management and healing of patients, free of any social, cultural or ethnic variation. It helps the doctor understand the patient's mood and analyze its signs. First, there should be a friendly greeting between both parties. The doctor should quickly evaluate some important things such as mannerism, hearing, walking, mood, speech, posture and any abnormalities evident in the patient during the first few minutes of the encounter. Then we can proceed with the story. Say no to plagiarism. Get a tailor-made essay on "Why Violent Video Games Shouldn't Be Banned"? Get an Original Essay Maintaining good eye contact is key. After explaining to the patient that we would fill an order by asking a few questions, we can hide the collection of general data that includes date of birth, age, employment history, social status, past medical history, family history, smoking habit and alcohol consumption. Monitoring the history over a period of time provides a descriptive picture of the patient's current status. This first part of the medical history is very important as it lays the foundation for an effective diagnosis. After the basic rituals, the patient should be encouraged to explain why he came for the consultation, at his own pace, without any interruption from us or any person accompanying him. Because even if interrupted a little, the patient will not be able to express his thoughts effectively and completely. Patients who present in a well-structured way are in the minority. So the doctor should stimulate the person by asking questions at the right time without offending him. Furthermore, the doctor should not miss important clinical clues that the patient may display during the conversation. And we should converse using terms that are easy for the patient to understand, rather than complex clinical terms. The doctor's open-ended questions make patients subconsciously approve of the doctor and want to talk enthusiastically about their problems, which can help us identify what is important to the patient. On the other hand, direct questions will block them, preventing them from adequately sharing their situation. This approach is “disease-centered”. The doctor should moderate his need to arrive at the diagnosis and the patient's experiences and feelings. The doctor should be able to relate the severity of the symptoms to the patient's personal life. What may seem critical in one person may not be a big deal in another. The degree of pain perceived by each individual is also different. Pain scale assessment is useful for managing the disease. The patient may be asked to rate the sensation of pain on a scale of 10 and rated accordingly. Most women rate labor pain as a 10. And although the patient may not be able to put things in order, the doctor should note down the details, even if suddenly, and deal with them later. Each doctor may have their own personalized scheme for taking medical history in different situations. However it follows a common pattern as follows:- Name, age, occupation, place of birth, any other form of identity, presenting problem, past medical history, specific past medical history, history of main presenting problem, family history, occupational history,smoking, alcohol, allergies, history of medications and treatments, and direct questions about exposed body systems. Diseases generally have multiple body systems malfunctioning. Therefore, a comprehensive assessment should address all body systems rather than just those systems that affect the patient's perception as a problem area. Various systems can be analyzed by asking questions related to the following aspects: Cardiorespiratory: chest pain, palpitation, ankle swelling, orthopnea, nocturnal dyspnea, shortness of breath, etc. GIT: abdominal pain, dysphagia, weight loss or gain, nausea, jaundice, bowel pattern, rectal bleeding etc. Genitourinary: hematuria, nocturia, dysuria etc. Locomotor: joint pain, mobility changes etc. Neurological: seizures, fainting, vision, hearing, wasting, spasms, headaches etc. Analyzing the patient's words in the depths of the mind without throwing them back to his face is elementary in taking the anamnesis. Some areas need careful clarification. Pain is one of these areas. It usually confuses doctors. Therefore it is possible to investigate the location, the radiation, the character, the severity, the time course, the factors that aggravate the pain, the factors that alleviate it and the associated symptoms to precisely identify the problem related to the disorder. Asking patients directly what medications they have taken is not as effective. Instead, encouraging them to realize and remember everything they have taken by constantly and carefully asking about certain medications that may have interfered is helpful in noting drug history. Likewise, taking family history can also be challenging. It may be helpful to find out about any illnesses that run in their family, their family tree, and whether other family members have had the same problem before. The person's occupation also influences the current condition, especially in non-organic problems induced by exposure to various environmental elements. Alcohol poses serious health risks. So it is best to have a measure of the reported amount of alcohol consumed in units of alcohol per week. The CAGE assessment is a smart approach to recording the details of a patient's drinking habits. C - cut; A - Angry; G - Guilty; E - Open your eyes. It is also important to take past medical history into consideration without giving in completely to what the patient expresses, so that any misinterpretation of the patient's past medical disorder or a misdiagnosis by a previous doctor does not influence our diagnosis current. Each patient is unique; the same goes for the experience of taking medical histories from different patients, even if in most cases we follow a common routine. Talkative, angry, or knowledgeable patients or people accompanying a patient can pose a challenge to the doctor. Talkative patients talk too much providing much less important details and need to be managed with a well-balanced mix of direct and indirect questions. In angry patients, anger may be part of the symptomatology or be due to circumstances or expressed in response to diagnosis or treatment. If this attitude is as harmful as breaking contact between the two parties, then it is better to suggest that the patient change doctors. Today doctors should provide as many details as possible about the patient's condition so as to wisely choose the best treatment option and take care of themselves after treatment. But doctors should also be able to handle well-informed patients who are stubborn about certain perceptions and facts they hold. Your doctor should also be able to assess whether that is important.