1 MEDICAL HISTORY

2 p MEDICAL HISTORY FORM

3 MEDICAL HISTORY ID & DEMOGRAPHICS: name, age, height, weight.CHIEF COMPLAINT: major health problem & time course. E.g.. Chest pain for 3 hours. HISTORY OF PRESENT ILLNESS: details about the complaint. PAST MEDICAL HISTORY

4 REVIEW OF SYSTEMS: systematic questioning about different organs.FAMILY HISTORY MEDICATION/DRUG HISTORY SOCIAL HISTORY

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6 Personal History: Nurse: What’s your name? Mr. Kim: James KimNurse: Where do you live? (What’s your address?) Mr. Kim: My address is Sam rak dong, Kim Cheon City, Kyoung Buk. The postal code is 740. Nurse: What’s your phone number? Mr. Kim: Nurse: Are you living alone? Mr. Kim: No, I’m with a family. Nurse: What’s your occupation? Mr. Kim: I’m a student.

7 Chief Complaint: What seems to be the problem? Chest pain for 2 hours.What’s troubling you? Abdominal pain for 1 day. What are you suffering from? Back pain for 1 week. What brings you here today? Difficulty of urination for 2 days.

8 Symptoms: I have chest pains. severe back pain. toothache. (나는 치통)headache. (나는 머리가 아프다) stomachache. runny nose. sore throat. sprained my ankle.

9 History of Present Illness:Analyzing Symptom: Site (location) Radiation (the spread; propagation) Onset : start/beginning (is it gradual or sudden?) Character (quality) Severity (intensity) Timing/Duration (when/how long?) Precipitating or Triggering factors (set off, initiate) Aggravating factors (what makes it worst?) Relieving factors (what makes it better or disappear?) Associated symptoms (other symptoms) Previous Occurrence

10 What’s the matter? Where’s the pain? 고통은 어디 있습니까? Can you describe the pain? How long have you had the pain? Is the pain constant or does it come at intervals? Does your chest hurts?

11 MEDICAL HISTORY ID & DEMOGRAPHICS: name, age, height, weight.CHIEF COMPLAINT: major health problem & time course. E.g.. Chest pain for 3 hours. HISTORY OF PRESENT ILLNESS: details about the complaint. PAST MEDICAL HISTORY

12 REVIEW OF SYSTEMS: systematic questioning about different organs.FAMILY HISTORY MEDICATION/DRUG HISTORY SOCIAL HISTORY

13 Dialogue 1: Clinical HistoryMs Lee: How old is Min Soo? Mother: He’s five years old. Ms Lee: What’s his problem? Mother: Well, when he came home from nursery school yesterday, I noticed he had a rash on his face. He had a little cold last week. Ms Lee: Does he have a fever? Mother: It was 39 degrees this morning. Ms Lee: Have you noticed any other changes?

14 Mother: Well, spaghetti is his favorite food, and I fixed it for dinner last night but he just didn’t feel like eating it. Ms Lee: Has he had any other illnesses? Mother: Just three months ago he had the mumps. Ms Lee: Has he been in the hospital before? Mother: No, never.

15 Dialogue 2: Nurse Choi: What brings you to the hospital?Mr. Ko: I’ve had trouble breathing. Nurse Choi: How long have you had this problem? Mr. Ko: About two weeks. It seems to be getting worse. Nurse Choi: Have you taken any medicine? Mr. Ko: Well, sometimes I’ve had to take antihistamines but it didn’t help. Nurse Choi: What did you do then? Mr. Ko: I just waited to see if it would go away.

16 Nurse Choi: Are you having any difficulty sleeping?Mr. Ko: Yes, I have to sleep with my head on two pillows. Nurse Choi: How’s your appetite? Mr. Ko: Not very good. I don’t feel like eating. Nurse Choi: Are you having regular, normal bowel movements? Mr. Ko: Yes. No problem there.

17 Dialogue: Symptoms Ms. Kim: Hi Lee. How are you today?Ms. Lee: I’m not feeling so well. Ms. Kim: Oh, I’m sorry to hear that. What seems to be the trouble with you? Ms. Lee: I’ve got a sore throat and I think I’m running a fever. Ms. Kim: That sounds like the flu. You’d better go see the doctor.

18 Dialogue: Check-up Doctor: What’s your problem?Patient: I’ve got a bad fever. I’ve been feeling very hot and uncomfortable for the last few days. Doctor: Oh I see. And have you got a temperature? Patient: Yes, it was over 37 last night. Doctor: I’d better check it. Now it might be something you’ve eaten. Have you been eating any spicy foods?

19 Patient: No, not that I remember.Doctor: Well, I think you’re probably getting the flu. Patient: I think so. Doctor: Yes, I’ll give you something for the fever. Take three of these tablets three times a day after eating.

20 Referring A Patient: Referral: a recommendation to consult the (professional) person or group to whom one has been referred; Ex. “The insurance company says that you need a written referral from your physician before seeing a specialist." Referral Letter

21 Samples of Referral Forms:

22 QUIZ

23 Match each question with the appropriate response.A. I’m Sora Yun. My resident number is B. Yes, I am allergic to pollen. C. No, I don’t smoke. D. You should contact my father. E. Yes, I am taking flu medicine. F. I was born on September 30, 1990. G. I’ve been having some terrible pain in my stomach. 1. Are you taking any medication? 2. What brings you here today, Ms. Yun? 3. Are you allergic to any medication, plants, animals, or pollen? 4. May I have your name and resident number, please? 5. What’s your date of birth? 6. Whom should we contact in case of emergency? 7. Are you a smoker?

24 Match: Analyzing of SymptomSite/Radiation Onset Character/Intensity Timing/duration Precipitating factor Aggravating factor Relieving factor Associated symptoms Previous occurrence When did you begin to notice them? Where is the pain? In what part of your head? Do they come at any special time of the day? How long do they last? Does it help to take aspirin or to lie down? Have you ever had this kind of headache before?

25 Listening: Fill in the blanks:Hello I’m Dr. Hunter. I’d like to listen to your ________. Please pull up your shirt. Take a deep ________. Hold it. Breathe out. In. Out. In. Out. I am feeling short of breath. Then please open your mouth and say, “ahhh..” Your ______ is a bit ________. I think you have a flu. It has been going around lately. Right. I’ll write you a __________. Take two tablets twice a day. Yes, Doctor. Can I go back to work tomorrow? You’d better stay in bed for the next few days.

26 Getting a Diagnosis True or False:1. The doctor would like to listen to the patient’s heart. 2. The patient has dyspnea. 3. The doctor examined the patient and the diagnosis is flu. 4. The doctor gave a prescription and instructed the patient to take two capsules twice a day. 5. The doctor said that the patient can go back to work tomorrow.

27 Thank You..