RAD1125 - History Taking - Chapter 12

Chief complaint

primary medical problem as defined by the patient; important because it focuses the clinical history toward the single most important issue

chronology

time element of the history, usually including the onset, duration, frequency, and course of the symptoms

clinical history

information available regarding a patients condition; traditionally comprises data on localization, quality, quantity, chronology, setting, aggravating, or alleviating factors, and associated manifestations.

leading questions

undesirable method of questioning; provides information that may direct answers towards a suggested symptom or complaint

localization

determination of a precise area, usually through gentle palpation or careful wording of questions

objective

perceptible to the external senses

quality

description of the character of the symptoms — ex: the color, quantity and consistency of blood or other body substances; size or number of lumps or lesions; frequency of urination or coughing; or character of pain

subjective

pertaining to or perceived only by the affected individual; not perceptible to the senses

carl rogers qualities

respect

genuineness

empathy

what questioning techniques are used to get the history of a patient?

open-ended questions

facilitation (nod, say yes, go on)

silence

probing questions

repetition

summarization

what type of questions do you want to avoid asking?

leading questions

sacred seven

localization

chronology

quality

severity

onset

aggravating or alleviating factors

associated manifestations