Taking the Clinical History

Taking the Clinical History

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In an era of ever-increasing dependence upon technology, physicians are losing the basic skills of patient examination and taking the medical history. This book describes the scenario in which the physician sits down with a patient to elicit a medical history. For example, how to greet a patient, how to discover the patient's chief concern, how to elicit symptoms, how to manage feelings as the patient and physician interact, and how to choose topics to explore, and use the appropriate word selection, phrasing, and tone of voice. A good history leads to trust and rapport, and also to the determination of the best management of the patient's condition. Dr. William DeMeyer, a well-known physician and author of the major text on the neurologic exam, describes how to take a medical history, and also explains the reasons why it is done in a particular way. The author reviews the actual questions that a health provider should ask and the responses to a patient's answers. More importantly, the author describes how to listen to the patient's real needs as a person, rather than just a repository of symptoms.show more

Product details

  • Paperback | 368 pages
  • 137.16 x 208.28 x 22.86mm | 385.55g
  • Oxford University Press Inc
  • New York, United States
  • English
  • 0195373774
  • 9780195373776
  • 1,171,651

Table of contents

CONTENTS ; 1. OUTLINE OF THE CLINICAL HISTORY ; Definition and Scope of the Clinical History ; Detailed Outline of the Clinical History ; 2. BASIC DEFINITIONS: DISEASE, SYMPTOMS, SIGNS, SYNDROMES, AND DIAGNOSIS ; I. What is Disease? ; II. Manifestation of Disease by Symptoms and Signs ; III. Diagnosis and Differential Diagnosis of Disease ; IV. Summary ; 3. THE IMPORTANCE OF THE CLINICAL HISTORY ; I. Why the Clinical History is the Most Important Event in the Practice of Medicine ; II. The Clinical History as a Mutual Process of Knowing between the Physician and the Patient ; III. The History is the Only Way to Diagnose the Many Diseases that Produce Only Symptoms but no Signs ; IV. How the History Focuses the Physical Examination ; V. Why No Physical or Laboratory Finding Has Meaning Until Integrated with the Patient's Full Clinical History ; VI. How the History Provides the Basis for Public Health Policy ; VII. Summary ; 4. HOW THE PHYSICIAN'S ETHICS AND GOALS DETERMINE THE CONTENT AND TECHNIQUES OF THE CLINICAL HISTORY ; I. The Ethical and Operational Components of the Medical Model for the Patient-Physician Relationship ; II. Origin of the Ethical Code for the Practice of Medicine ; III. How Each Ethic of the Medical Model Shapes the History ; IV. Replacing Social Responses with Professional Responses ; V. The Atcual Operational Steps of the Medical Model for the Practice of Medicine ; VII. Beyond the Consulting Room ; VIII. Summary ; 5. PRIVACY: THE SETTING AND THE APPAREL FOR AN OPTIMUM CLINICAL HISTORY ; I. Privacy and the Private Interview ; II. The Room Design for the Medical Interview ; III. Personal Attributes of the Physician ; IV. Use of the Telephone and Telemedicine ; V. Summary ; 6. THE PATIENT'S CHIEF CONCERN AND PRESENT ILLNESS ; I. The Initial Contact and the Face Sheet ; II. Format for the Clinical History ; III. Technique for Meeting the Patient ; IV. THe Patient's Chief or Presenting Concern ; V. Listening: The Essential Technique of the Clinical History ; VI. Technique for Eliciting the PResenting Concern and Current Illness ; VII. Historical Analysis of Recurrent Attacks that are Similar ; VIII. Current Medications and Management ; IX. Closing the Present Illness History in Preparation for the Past Clinical History ; X. Summary ; 7. THE PAST CLINICAL HISTORY AND THE REVIEW OF SYSTEMS ; I. Eliciting the Past Clinical History ; II. The Review of Systems (ROS) ; III. Visualize the Head and the Nervous System ; IV. Next Visualize the Motor (Muscular) System ; V. Next Visualize the Skeletal System ; VI. Next Visualize the Bone Marrow ; VII. Next Visualize the Chest and Its Contents and Start with the Respiratory System ; VIII. Next Visualize the Cardiovascular System ; IX. Next Visualize the Gastrointestinal System ; X. Next Visualize the Renal System ; XI. Next Visualize the Reproductive System ; XII. Next Visualize the Endocrine System ; XIII. Next Visualize the Immune and Lymphatic System ; XIV. Finally Visualize the Skin ; XV. Environmental/Toxic Exposure History ; XVI. Supplementing the Standard History and Review of Systems with Inventories, Rating Scales, and Structured Interviews ; XVII. Efficiency in the Review of Systems: The Long and Short of It ; XVIII. Summary ; 8. THE FAMILY HISTORY ; I. Transition to the Family History ; II. Diagramming the Pedigree ; III. Special Problems in the Family History of Pediatric Patients ; IV. Summary ; 9. THE PSYCHOSOCIAL HISTORY AND MENTAL STATUS HISTORY ; I Introduction to the Mental Status Examination ; II. Quick (but effective) Overall Screening of the Patient for Mental Illness ; III. Detailed Inquiries into the Patient's Mental Status ; IV. The Sensorium or Sensorium Commune: Common Sense and Its Testing ; V. An Ethics, Values, and Spiritual History ; VI. Special Features of the History in Suspected Dementia ; VII. A Historical Tutorial with Rufus of Epheseus ; VIII. Summary ; 10. THE PREGNANCY AND DEVELOPMENTAL HISTORY (FOR PEDIATRIC PATIENTS) ; I. Introduction to the Developmental History ; II. Reproductive History ; III. Labor and Delivery History ; IV. Neonatal History ; V. Classification of Infant Behaviors for Judging the Neurodevelopmental History and the Neurodevelopmental Examination ; VI. Attending to the Mother's COncerns about her Infant's Development ; VII. The Developmental History for Infants from Birth to Two Years of Age ; VIII. The Developmental History for Children More than Two Years of Age ; IX. Discussing Developmental Retardation with Parents ; X. Summary ; 11. THE PREVENTIVE HISTORY AND WELLNESS ; I. Importance of the Preventive History ; II. Preventive History and Preventive Programs for Infants and Children ; III. Preventive History and Preventive Programs for Teens and Adults ; IV. Preventive History and Preventive Programs for Adults ; V. The Positive Promotion of Wellness ; VI. Summary ; 12. SUCCEEDING WITH THE DIFFICULT HISTORY ; I. The Good and the Poor Historian ; II. Causes for Difficult Histories and their Differential Diagnosis ; III. Keeping the Difficult Patient on Track During the History ; . IV. Emotional Interactions Between Patient and Physician that Results in a Diffcult History ; . V. When It's a Question of Honesty or Accuracy of the History ; . VI. When It's a Question of Irreconcilable Differences Between the Patient and the Physician ; VII. Summary ; 13. ENDING THE CLINICAL HISTORY, RECORDING IT, AND INTEGRATING IT WITH THE PHYSICAL EXAMINATION ; I. Three Questions to Close the History, Prior to the Physical Examination ; II. Acquiring Additional History ; III. Recording the Physical History ; IV. Integrating the History and Physical Examination to Complete the Initial Medical Record ; V. Integrating the History and Physical Examination, Illustrated by Analyzing the Commonest Sympton of All: Headaches ; VI. Summary ; 14. THE HISTORY, APPROPRIATE MANAGEMENT, INFORMED CONSENT, AND PATIENT AUTONOMY ; I. How the Same Techniques for the Clinical History Evaluate Patient Autonomy and Informed Consent ; II. Interrelations of Appropriate Management, Informed Consent, and Patient Autonomy ; III. Extending the History when the Patient Declines Appropriate Management ; IV. How Promotion of Elective Cosmetic Surgery of Normal Tissues Biases the History ; V. The Clinical History, Physician-Assisted Suicide, and Euthanasia ; VI. The Clinical History, the Living Will, and Planning for Terminal Care ; VII. An Example of How a Knowing Medical History Guided the Care of a Terminally Ill Patient ; VIII. Best Examples of the Medical Model ; IX. Summary ; X. Epilogue: A Personal View ; 15. THE CLINICAL HISTORY OF THE MEDICAL MODEL COMPARED TO ALTERNATIVE MODELS ; I. THe Science-based Clinical History ; II. Definition of Alternative Medicine ; III. Accomplishments of Physicians who Adhere to the Medical Model ; IV. Epilogue ; 16. FOSTERING EMPATHY AND COMPASSION ; I. Discovering the Patient's Personhood ; II. Experiences in Compassion ; III. Suggestions for Additional Sessions ; IV. Feeling an Affinity for the Past of our Profession ; V. Selected References for Comparisonshow more