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Dr Raj
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History Physical Examination Reports of Investigations and Lab data Differential Diagnosis Diagnostic plan Therapeutic plan
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Source of History: Patient Demographics: Name Age or DOB Gender Religion/race/sect Occupation address
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Patients problems in his own words for which he is seeking treatment.
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Story or narrative of patients problems in chronological order. Each symptom should be in separate paragraph with description of the symptom. What immediate measures were taken to relieve the symptoms
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Pain as example: Site Onset Character Radiation Associated factors Timing Exacerbating and Relieving factors Severity
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Childhood Illness Adult Illness Medical Surgical Obstetric /Gynecological Immunizations
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Illness and cause of death in blood relatives Pedigree chart Important in genetically transmitted diseases like cancer or enzyme disorders as well as lifestyle diseases
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Lifestyle Habits and addictions Education and job satisfaction Family life and Sexual life Diet and exercise Financial situations Social and religious well being
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Short questions where the patient can answer in “Yes” or “ No” Set of questions focusing each systems
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Vitals and general survey Focused examination
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Upper Limb Lower Limb
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Its is skilled process of getting relevant information from the patient which can help in the rendering service to the patient.
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Active listening Empathic response Guided questioning Non verbal communication
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Validation Reassurance Partnering Summarization
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Transitions Empowering patient
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Preparation. Greeting patient and establishing rapport. Establishing Agenda Inviting Patient story and exploring patient perspective (FIFE)
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Identifying and responding to the patients Emotional cues Expanding and clarifying the patient’s story Generating and Testing Diagnostic Hypotheses.
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Sharing treatment plan. Closing the interview Taking time for self reflection
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Demonstrating cultural humility. Cultural competence? A set of attitude, skills, behaviors, and policies that enable organizations and staff to work effectively in cross-cultural situations.
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Self-Awareness Respectful communication Collaborative partnerships
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Challenging patients The silent patient. The Confusing patient. The patient with altered capacity. The Talkative Patient. The Crying patient
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The angry and disriptive patient. The patient with a language barrier.(INTERPRET) The patient with low literacy. The patient with hearing loss. The seductive patient
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Thank you
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