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
Patients problems in his own words for
which he is seeking treatment.
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
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Adult Illness
Medical
Surgical
Obstetric /Gynecological
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Immunizations
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Illness and cause of death in blood relatives
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Pedigree chart
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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
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Focused examination
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Upper Limb
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Lower Limb
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
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Empathic response
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Guided questioning
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Non verbal communication
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Validation
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Reassurance
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Partnering
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Summarization
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Transitions
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Empowering patient
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Preparation.
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Greeting patient and establishing rapport.
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Establishing Agenda
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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.
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Closing the interview
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Taking time for self reflection
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Demonstrating cultural humility.
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Cultural competence?
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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
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Respectful communication
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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