History-Taking, Assessment, Diagnosis, and Formulation

2019 ◽  
pp. 127-150
Author(s):  
James H. Lake
Keyword(s):  
History Taking

Computer based simulated patient for teaching history-taking

1973 ◽  
Vol 37 (8) ◽  
pp. 27-31
Author(s):  
HA Brody ◽  
LF Lucaccini ◽  
M Kamp ◽  
R Rozen
Keyword(s):  
Simulated Patient ◽  
History Taking ◽  
Teaching History ◽  
Computer Based

Observer Variation in Clinical Diagnosis - A Computer-Aided Assessment of its Magnitude and Importance in 552 Patients with Abdominal Pain

1973 ◽  
Vol 12 (02) ◽  
pp. 108-113 ◽  
Author(s):  
P. W. Gill ◽  
D. J. Leaper ◽  
P. J. Guillou ◽  
J. R. Staniland ◽  
J. C. Horhocks ◽  
...  
Keyword(s):  
Abdominal Pain ◽  
Clinical Diagnosis ◽  
Error Rate ◽  
Diagnostic System ◽  
Diagnostic Error ◽  
Observer Variation ◽  
History Taking ◽  
Computer Aided ◽  
Computer Based ◽  
Initial Survey

This report describes an evaluation of »observer variation« in history taking and examination of patients with abdominal pain. After an initial survey in which the degree of observer variation amongst the present authors fully confirmed previous rather gloomy forecasts, a system of »agreed definitions« was produced, and further studies showed a rapid and considerable fall in the degree of observer variation between the data recorded by the same authors. Finally, experience with a computer-based diagnostic system using the same system of agreed definitions showed the maximum diagnostic error rate due to faulty acquisition of data to be low (4.7°/o in a series of 552 cases). It is suggested as a result of these studies that — at least in respect of abdominal pain — errors in data acquisition by the clinician need not be the prime cause of faulty diagnoses.

Computerization of the Patient History -Patient Answers Compared with Medical Records

1986 ◽  
Vol 25 (04) ◽  
pp. 222-228 ◽  
Author(s):  
M. J. Quaak ◽  
R. F. Westerman ◽  
J. A. Schouten ◽  
A. Hasman ◽  
J. H. Bemmel
Keyword(s):  
Internal Medicine ◽  
Medical Records ◽  
Patient Record ◽  
Frequency Of Occurrence ◽  
History Taking ◽  
Patient History ◽  
Patient Complaints ◽  
Computerized Patient Record ◽  
Extensive Information ◽  
Experienced Physician

SummaryComputerized medical history taking, in which patients answer questions by using a terminal, is compared with the written medical record for a group of 99 patients in internal medicine. Patient complaints were analysed with respect to their frequency of occurrence for all important tracts, such as the respiratory, the gastro-intestinal and the uro-genital tracts. About 36% of over 3,200 patient answers were identical in the patient record and the written record, but a considerable percentage of complaints (56%), that were present in the patient record, were missing in the written record; the reverse was true for 4.5%. A computerized patient record appears to contain more extensive information about patient complaints, still to be interpreted by the experienced physician.

Sexual History Taking Curriculum: Lecture and Standardized Patient Cases

MedEdPORTAL ◽  
2014 ◽  
Vol 10 (1) ◽  
Author(s):  
Rita Lee ◽  
Danielle Loeb ◽  
Austin Butterfield
Keyword(s):  
Sexual History ◽  
Standardized Patient ◽  
History Taking ◽  
Sexual History Taking

Oxford Cases in Medicine and Surgery

2015 ◽  
Author(s):  
Hugo Farne ◽  
Edward Norris-Cervetto ◽  
James Warbrick-Smith
Keyword(s):  
Chest Pain ◽  
Case History ◽  
Clinical Medicine ◽  
Real Life ◽  
General Medicine ◽  
Diagnostic Approach ◽  
History Taking ◽  
Presenting Symptoms ◽  
Essential Resource ◽  
Physiological Systems

Oxford Cases in Medicine and Surgery, second edition, teaches students a logical step-by-step diagnostic approach to common patient presentations. This approach mirrors that used by successful clinicians on the wards, challenging students with questions at each stage of a case (history-taking, examination, investigation, management). In tackling these questions, students understand how to critically analyse information and learn to integrate their existing knowledge to a real-life scenario from start to finish. Each chapter focuses on a common presenting symptom (e.g. chest pain). By starting with a symptom, mirroring real life settings, students learn to draw on their knowledge of different physiological systems - for example, cardiology, respiratory, gastroenterology - at the same time. All the major presenting symptoms in general medicine and surgery are covered, together with a broad range of pathologies. This book is an essential resource for all medicine students, and provides a modern, well-rounded introduction to life on the wards. Ideal for those starting out in clinical medicine and an ideal refresher for those revising for OSCEs and finals.

scholarly journals Acute pancreatitis in a patient with COVID-19

2021 ◽  
Vol 14 (2) ◽  
pp. e239656
Author(s):  
Rawan A Rahman AlHarmi ◽  
Tahera Fateel ◽  
Jalila Sayed Adnan ◽  
Kamel AlAwadhi
Keyword(s):  
Acute Pancreatitis ◽  
Pulmonary Disease ◽  
Invasive Procedure ◽  
Pancreatic Injury ◽  
History Taking ◽  
Complicated Course ◽  
Operating Surgeon

COVID-19 mainly causes pulmonary disease. Involvement of gastrointestinal and hepatobiliary systems, among other systems, has been reported. We report a case of acute pancreatitis in a patient with resolving COVID-19 pneumonia. History taking and investigations excluded other causes of pancreatitis. This case demonstrates the possibility of pancreatic injury in patients with COVID-19, in line with previously reported similar cases. We believe that it is imperative to screen patients presenting with acute pancreatitis for SARS-CoV-2. It is also important to take into consideration that patients with a complicated course who require an invasive procedure such as drainage might pose a risk of transmission to the operating surgeon or interventionist.

Changes in alcohol history taking by psychiatric junior doctors: an audit

1995 ◽  
Vol 12 (1) ◽  
pp. 37-39 ◽  
Author(s):  
Simon J Taylor
Keyword(s):  
Illicit Drug ◽  
Statistical Significance ◽  
Inpatient Admission ◽  
Junior Doctors ◽  
History Taking ◽  
Drug Usage ◽  
Acute Psychiatric Wards ◽  
First Time

AbstractObjective: In recent years a number of articles have highlighted deficiencies in drinking histories taken by junior doctors. This study examines whether standards have improved as a result. It also examines for the first time: 1. the quality of drinking histories taken from patients following parasuicide; and 2. the quality of illicit drug usage histories.Method: An audit of case notes was undertaken of 114 patients admitted to a district hospital's acute psychiatric wards or assessed following overdose. Two periods were considered; one preceding many of the articles, and the second four years later.Results: There was an overall improvement from 58% of histories in 1988 having no mention of alcohol usage to 25% in 1992. (X2MH=10.57, p<0.01). There was, however, insufficient improvement of quantitative histories to reach statistical significance. Histories taken as part of an overdose assessment were not significantly different from those taken for inpatient admission. In 1992, 27% of patients had any illicit drug usage history recorded which represented a statistically significant improvement (X2MH=5.91, p<0.02) compared with four years earlier.Conclusions: Although improvements have been noted, alcohol and drug histories remain inadequate.

The 6C model for accurately capturing the patient’s medical history

Diagnosis ◽  
2021 ◽  
Vol 0 (0) ◽  
Author(s):  
Taro Shimizu
Keyword(s):  
Artificial Intelligence ◽  
Differential Diagnosis ◽  
Patient Safety ◽  
Information Processing ◽  
Safety Concern ◽  
Data Gathering ◽  
Diagnostic Errors ◽  
Accurate Diagnosis ◽  
History Taking ◽  
Novel Approach

Abstract Diagnostic errors are an internationally recognized patient safety concern, and leading causes are faulty data gathering and faulty information processing. Obtaining a full and accurate history from the patient is the foundation for timely and accurate diagnosis. A key concept underlying ideal history acquisition is “history clarification,” meaning that the history is clarified to be depicted as clearly as a video, with the chronology being accurately reproduced. A novel approach is presented to improve history-taking, involving six dimensions: Courtesy, Control, Compassion, Curiosity, Clear mind, and Concentration, the ‘6 C’s’. We report a case that illustrates how the 6C approach can improve diagnosis, especially in relation to artificial intelligence tools that assist with differential diagnosis.

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