CSU - history taking

i almost forgot to record the procedure for history taking.

3 feb 2010

with Dr.Sow (who is in charge of CSU history taking curriculum decisions)

she mentioned merging the behavioral study CSU station with the actual long history taking Stations in the future.

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long history taking.

there are 9 components in long history taking.

Personal Detail,

Presenting Complaint,

History of Presenting Complaint,

Systemic Review,

Past Medical History

(Drug History)

Family History

Social History

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Personal Detail has several components.

Name

Age

Sex

Address

Race

Religion

Occupation

Marital Status

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Presenting Complaint should be "in patient's own words".

e.g. chest hurts and feels tired

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history of presenting complaint has several components.

Site

Onset

Character

Radiation

Associated symptoms

Time (when it started, how long it lasts)

Exeberating factor and relieving factor

Severity

Perhaps it would be nice to add this too;

How it may affect his life, what concerns he has for the symptoms

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Systemic Review - the reason for systemic review questioning is to

1) make sure s/he does not have other illness

2) narrow down diagnosis.

go from a general review

-weight change

-apatite change

-"Are you stressed?"

to...

head

eye

nose

ear

lungs

CVS

Bowel

Urinary

Limbs

Muscular

etc etc

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