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Section II Inquisition Dr. Zhuoren Lu First Hospital Xian Jiaotong University.

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Presentation on theme: "Section II Inquisition Dr. Zhuoren Lu First Hospital Xian Jiaotong University."— Presentation transcript:

1 Section II Inquisition Dr. Zhuoren Lu First Hospital Xian Jiaotong University

2  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

3 Content of the interview  introduction  chief complaint  history of the present illness  past medical history  review of systems  personal history  family history  closure

4 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

5  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

6 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.

7 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

8 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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