7lab 2 FCM I

FCM-I Lab2
History taking:
Chief complaint , History of present illness, Past
medical history, and Family history
Chief complaint attributes
1. Onset: When did it start?
2. Location: Where is it?
3. Radiation: Is it localized or radiating? Where?
4. Quality: Type of pain. What is it like?
5. Quantity: How bad is it on a scale of 1 to 10?
6. Setting [Duration / Frequency /Timing]: Include How long? How often?
Constant or intermittent?
7. Aggravating Factors: Does anything make it worse?
8. Relieving Factors: Does anything make it better?
9. Treatments tried: What? Did it work?
10. Effect on function/ life: How is the pain affecting your quality of life and
work?
11. Associated Symptoms if any: Have you noticed anything else that
accompanies it?
Lab Exercise - 1
 Smaller groups of 2
 Randomly pick your case: You are the PATIENT…
 Give first page to your partner, who is playing a doctor

 Page 2 is a checklist for you while role playing as a
patient
Page 1: Opening scenario for doctor
 John Tyler, a 29- year-old male comes to clinic

complaining of ‘headache’
 Doctor’s Tasks:
1. Introduction
▪ Greet, Self intro, Shake hand, Patient’s name, Eye contact
2. Obtain chief complaints with all attributes
▪ Ask specific and clear questions for all attributes
3. After seeing the patient, complete a brief write-up including
patient’s identifying data and chief complaint with attributes
4. Be prepared to present your case in class
Page 2: Checklist for patient
 John Tyler, a 29- year-old male comes to clinic complaining of

‘headache’
Checklist:
1. Introduces self by name and role

2. Shakes patient’s hand
3. Determines how to address patient and uses the name correctly
4. Makes eye contact with patient
5. Clean white coat with clearly displayed name badge, and Looks
smart
Page 2: Checklist for patient (contd.)
CHIEF COMPLAINT: Headache
1. Onset- About three month ago
2. Location – It is here (patient points to the left side of the Patients!
head)
3. Radiation – No - Let your doctor ask
4. Quality – Throbbing specific and clear
5. Quantity/ Severity –It is 7 out of 10 questions
6. Setting (Duration / Frequency / Timing) – The pain is not
constant, it comes and goes. Initially it was once a week & - Do not respond to
4/10, gradually getting worse and now 2-3 times everyday & vague/ open-ended
7/10. The headache may come any time, last for about 1 to 2 questions
hours, I am having one right now. - Rather you may ask
7. Aggravating factors – Stress, Long distance travel ‘What does that mean,
8. Relieving factors – Rest, Tylenol pills doctor?’
9. Treatments tried – Tylenol pills occasionally; very little
help.
10. Effect on function (life) – I am a train driver. When I have
pain, I can’t concentrate on my work.
11. Associated symptoms - None
Sample write-up by Doctor
 29 yo M, train driver visits with c/o headache for 3

months. The pain is located on the left side of head
with no radiation. It is intermittent and throbbing in
nature. Initially the headache started with frequency
of once a week which was 4/10 in severity. However, it
has progressively worsen to 7/10. Now these headaches
occur 2–3 times a day, last for 1–2 hours. Headaches
are exacerbated by stress, and long duration travel
and are partly relieved by rest, and Tylenol pills.
Patient is unable to concentrate on his work during
these headaches.
 Brief/ present your write-up within group
 Feedback from patient and discuss
 Switch roles
 Repeat
Lab Exercise - 2
 Make new groups
 Chief complaint of pain + associated symptom like…

 Headache with dizziness
 Chest pain with palpitations
 Abdominal pain with diarrhea
 Joint pain with fatigue
 Also Past medical history, and Family history
 Brief write-up and be prepared to present your case in

class
Associated symptoms:
Patient is complaining of chest pain and associated cough.

Cough attributes:
1. Onset: When?
2. Location: Not relevant
3. Radiation: Not relevant
4. Quality: Type/ color of cough? What is it like? Any blood?
5. Quantity: Amount of cough?
6. Setting [Duration / Frequency /Timing]: Include How long? How often?
Constant or intermittent?
7. Aggravating Factors: Does anything make it worse?
8. Relieving Factors: Does anything make it better?
9. Treatments tried: What? Did it work?
10. Effect on function/ life: How is this cough affecting your of life and work?
11. Associated Symptoms if any: -
Past Medical History (PMH)
 Childhood illnesses:
 measles, rubella, mumps etc.
 Adult Illnesses in four areas:
 Medical: such as DM, HTN, Asthma; Hospitalizations, At-risk sexual
practices
 Surgical: dates, indications, and types of operations
 Obstetric/gynecologic: GPA status, menstrual, LMP, contraception
 Psychiatric:
 Immunizations:
 DPT, MMR, influenza, hepatitis B etc.
 Screening tests:
 tuberculin tests, Pap smears, mammograms, stools for occult
blood, and cholesterol tests etc.
11
Family History (FH)
 Disorders that a patient's direct blood relatives have

suffered from
 Grandparents, Parents, Siblings, Children, Grandchildren
 Important for diseases with proven genetic influences

like..
 Hypertension, Diabetes, Hyperlipidemia, Coronary artery
diseases
 Sickle cell anemia, Thalassemia
 Cancers of Breast, Ovary, Prostate, Lung etc
 Thyroid dysfunctions
 etc…
12
Thank you
13

7lab 2 FCM I

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FCM-I Lab2

 Randomly pick your case: You are the PATIENT…

 Give first page to your partner, who is playing a doctor

 John Tyler, a 29- year-old male comes to clinic

 John Tyler, a 29- year-old male comes to clinic complaining of

1. Introduces self by name and role

 29 yo M, train driver visits with c/o headache for 3

 Feedback from patient and discuss

 Chief complaint of pain + associated symptom like…

 Brief write-up and be prepared to present your case in

Patient is complaining of chest pain and associated cough.

 Disorders that a patient's direct blood relatives have

 Important for diseases with proven genetic influences

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