History taking and the interview
How to interview and what goes in each part of the clinical history.
17 pages
Topic
- Analysing a symptom: onset, site, character, radiation and moreEvery symptom is described with the same attributes so another clinician understands exactly…
- Clinical simulation and the OSCE: practising the examinationPractising history taking and examination on actors, manikins and models before real patients…
- From findings to diagnosis: problem list, differential and SOAP noteClinical reasoning puts together what the patient tells and what is found to reach the most…
- Health-related quality of life: what it measures and how it is usedHow illness and treatment change the way a person feels and lives, measured with the patient's…
- Interviewing in special situations: interpreters and breaking bad newsSpeaking through an interpreter or breaking bad news takes preparation, plain language and…
- Nursing assessment: head-to-toe and focused assessmentNursing assessment is the first stage of the nursing process: gathering data about the patient…
- The periodic health examination: what to check and screen at each ageThe check-up of a person without symptoms: what is asked, measured and screened at each stage of…
History
- Background history by system: what to ask organ by organThe past illnesses, exposures and family history that matter most when the problem is in the…
- Chief complaint and history of present illnessThe chief complaint is the reason for the visit in the patient's words; the present illness is…
- Comprehensive geriatric assessment: function, cognition, fallsIn an older person diseases are not enough: what they can do alone, memory, mood, nutrition and…
- Gynecologic and obstetric historyThe gynaecologic and obstetric history covers a woman's menstrual history, pregnancies…
- Medicines, allergies and habits: tobacco, alcohol and other substancesKnowing a patient's medicines, allergies and use of tobacco, alcohol or other substances…
- Past medical, surgical, family and social historyThe past history gathers the patient's illnesses, operations and habits and the family's…
- Pediatric history: perinatal, growth, development and vaccinesA child's history adds questions about pregnancy, birth, feeding, growth, development and…
- Review of systemsThe review of systems is a quick head-to-toe check for symptoms the patient did not mention
- The clinical history: its parts and their orderThe clinical history is the ordered record of what the patient tells, what the examiner finds…
- The medical interview: rapport, open questions and listeningThe interview is the conversation in which the clinician gets to know the patient and the…
A to Z
Educational content on the clinical exam; it is learned and practised under supervision. It does not replace assessment by a health professional and is not for self-diagnosis.
Representative model, for educational purposes only.