THE MEDICAL INTERVIEW

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THE MEDICAL INTERVIEW
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CHARACTERISTICS OF THE MEDICAL INTERVIEW

• Open-ended questioning
• Silence
• Facilitation
• Confrontation

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COMPONENTS OF THE MEDICAL INTERVIEW

• Introduction
• Reason for Visit/Admission
• Chief Complaint
• History of the Present Illness

• Past Medical History
• Psychosocial History
• Family history
• Review of systems

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COMPONENTS OF THE MEDICAL INTERVIEW

• Introduction
• Name
• Age
• Sex
• Demographics

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COMPONENTS OF THE MEDICAL INTERVIEW

• Reason for Visit/Admission
• Referral
• Procedure
• Diagnosis and treatment

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COMPONENTS OF THE MEDICAL INTERVIEW

• Chief Complaint
• Patients own words
• Duration

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COMPONENTS OF THE MEDICAL INTERVIEW

• History of the Present Illness
• Location
• Quality
• Severity
• Context (setting)
• Alleviating factors

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COMPONENTS OF THE MEDICAL INTERVIEW

• History of the Present Illness
• Aggravating factors
• Associated manifestations
• Impact on quality of life
• Current therapy
• Alternative therapy/practitioners

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COMPONENTS OF THE MEDICAL INTERVIEW

• Past Medical History
• Overall health
• Allergies/Drug sensitivities
• Medications
• Surgery

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COMPONENTS OF THE MEDICAL INTERVIEW

• Past Medical History
• Trauma
• Transfusions
• Adult illnesses
• Childhood illnesses

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COMPONENTS OF THE MEDICAL INTERVIEW

• Past Medical History (contd)
• Pregnancies
• Occupational exposure
• Routine healthcare
• Immunizations
• Last physical / dental / eye examination

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COMPONENTS OF THE MEDICAL INTERVIEW

• Past Medical History (contd)
• Routine healthcare (contd)
• Cholesterol
• Pap smear, breast self-exam and practitioner
  exam, mammography

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COMPONENTS OF THE MEDICAL INTERVIEW

• Past Medical History (contd)
• Routine healthcare (contd)
• Test for occult blood in stool
• Alternative therapies/practitioners
• Exercise
• Safety/accident prevention

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COMPONENTS OF THE MEDICAL INTERVIEW

• Psychosocial History
• Patient profile
• Lifestyle risk factors
• Stress and support
• Spiritual history
• Sexual history

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COMPONENTS OF THE MEDICAL INTERVIEW

• Family History
• Immediate family members
• Inherited medical conditions
• Family diseases (DM, CAD, HBP, etc.)

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COMPONENTS OF THE MEDICAL INTERVIEW

• Review of Systems
• General (weight, fever, fatigue)
• Skin
• HEENT
• Neck

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COMPONENTS OF THE MEDICAL INTERVIEW

• Review of Systems
• Pulmonary
• Breast
• Cardiovascular
• Gastrointestinal

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COMPONENTS OF THE MEDICAL INTERVIEW

• Review of Systems
• Urinary
• Male Genital / Gynecological
• Musculoskeletal
• Peripheral vascular

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COMPONENTS OF THE MEDICAL INTERVIEW

• Review of Systems
• Endocrinological
• Hematological
• Neurological
• Psychiatric

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CHARACTERISTICS OF THE MEDICAL INTERVIEW

• Introduction 1 min
• Patient demographics 5
• Chief Complaint/Present Illness 15
• Past history 5
• Psychosocial/Family History 6
• Review of systems 5

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COMPONENTS OF THE MEDICAL RECORD

• Introduction
• Reason for Visit/Admission
• Chief Complaint
• History of the Present Illness

• Past Medical History
• Psychosocial History
• Family history
• Review of systems

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COMPONENTS OF A PATIENT PROGRESS NOTE

• Subjective
• Objective
• Assessment
• Plan

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