Patient-centered Medical History Taking

Trevino A. Pakasi Dept of Community Medicine Faculty of Medicine Universitas Indonesia

Objectives
At the end of the session, students will be able: To take medical history based on the patients needs To take medical history according to the standard procedure To withdraw hypothesis or synthesize individual health problems based on the medical history taking

Outline of the course

Introduction lecture Practicing

What youve learned?

Empathy Humaniora Communication skill Interpersonal relation skill

Exploring both the disease and illness experience

Physical, History, lab

Understanding the whole person

Finding common ground

Context

Patient presents cues

Disease Illness
Ideas, expectations, feelings, effect on function Disease

Problems Goals Roles

Mutual decision

Illness

Person

Enhancing the patient-doctor relationship

Incorporating prevention and health promotion

Being realistic

The patient-centered clinical method. Sumber : Stewart et. Al.(1995)

Medical History
Purpose of history taking: Understanding of the complain Understanding the patients feeling Understanding the symptoms or illness when exists Hypothesis of problems and possible cause

General Procedure
Verification of the patients identity Reason for visiting the physician Chief complain of illness when occured Other related symptoms if any History of the current problems Pass medical problems related with the current problems Other medical history that might be important Family medical history Specific questions

Verification of identity
Full name Age or date of birth Address Background of the patients: formal education, working, insurance coverage

Remember to start the conversation by interpersonal touch!

Reason of visiting
Usually patients visit regarding his/her concern of any existing health problems / presence of illness Patients goal to be healthy Patients goal to reduce risk

Formulation of medical history

Identity Chief complain / reason to visit Other related symptoms History of the current problems Pass medical problems Medical history in the family

Specific question
For example in pediatrics patient: history of birth, lactation, immunization, growth and development For example in obstetrics patient: menarche, monthly cycle For example in eldery: daily activity at home For example in psychiatrics: pre morbid condition, personality

Specific question in family medicine service

Related with the family: Family tree Family cycle Functioning in the family Culture and habbits in the family Housing and environment

Formulation of holistic diagnosis

Aspect 1: patients concerned, knowledge, perceiveness, worries Aspect 2: clinical / medical problems POMR Aspect 3: internal factors Aspect 4: external factors Aspect 5: disability score