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Section II Inquisition Dr. Zhuoren Lu First Hospital Xian Jiaotong University
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The completeness and accuracy of the information collected by inquisition will contribute to the proper diagnosis, management and treatment of the patient ’ s problem. Two major components of medical interviews: content technique
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Content of the interview introduction chief complaint history of the present illness past medical history review of systems personal history family history closure
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Technique: interview skills Organization Timeline Transitional Statements Pacing of interview Questioning Skill-Type of Question Questioning Skill-Duplication Questioning Skill-Summarizing Questioning Skills-Lack of Medical Terms Questioning Skill-Documentation Rapport-Facilitative Behavior
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Appearance and Courtesy Rapport-Facilitative Behavior Rapport-Positive Verbal Reinforcement Patient ’ s Perspective Impact on Patient and Family and Self Image Support system Patient ’ s Expectation Patient ’ s Understanding Admitting Lack of Experience Rapport-Encouragement of Question Closure of the interview
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Five basic elements: AEIOU Audition: to listen to your patient cordially and carefully. Evaluation: to judge the relevance of data you obtained and importance to the patient ’ s problem. Inquiry: to obtain complete information, and clarify and document this information. Observation: to watch the patient ’ s expression, Understanding: to understand the patient ’ s major concern, elicit the patient ’ s perspective on his illness and explore the patient ’ s expectation regarding diagnosis and treatment.
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Outline of Case Record 1. Biographical data 2. Chief complaint: 3. History of present illness 4. Past history 5. Review of system 6. Personal history 7. Marital history
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8. Menstrual history 9. Childbearing (reproductive) history 10. Family history 11. Physical examination 12. Laboratory tests and instrumental examination 13. Summary 14. Primary diagnosis
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