UNIVERSIDAD NACIONAL DE CHIMBORAZO

FACULTY OF HEALTH SCIENCES
SCHOOL OF MEDICINE

ENGLISH APPLIED TO CASE ANALYSIS

PROFESSOR
Dr. Lucila Jazmín de la Calle Andrade

AUTHORS:

González Gissela

Medina Kerly

Tingo Fátima

Rosero Tatiana

Valdiviezo Lizeth

COURSE AND PARALLEL: 10th Semester “B”

SUBMISSION DATE: March 25th, 2025

DIAGNOSTIC EVALUATION

PATIENT HISTORY TAKING: MEDICAL INTERVIEW

1. Key Components of an Effective Medical Interview

A medical interview consists of three main phases: introduction, information gathering, and closure. Key skills include active listening, empathy, and open-ended questioning to encourage patient responses. Establishing rapport involves maintaining eye contact, using a calm tone, and demonstrating cultural sensitivity. Ensuring accurate data collection requires clarifying patient responses, summarizing key points, and using structured questioning techniques to cover history of present illness, past medical history, family history, and social history. (Kurtz et al., 2017)

2. Strategies for Encouraging Openness in Reluctant Patients

To foster openness, clinicians should establish trust by reassuring confidentiality and showing nonjudgmental acceptance. Using motivational interviewing techniques, such as reflective listening and affirmations, encourages patients to share concerns. Open-ended questions like, "Can you tell me more about what worries you?", along with normalizing statements, help reduce fear or embarrassment. If reluctance persists, exploring alternative communication methods, like written responses or family involvement, may be helpful. (Miller & Rollnick, 2013)

PHYSICAL EXAMINATION

3. Significance and Techniques of Auscultation

Auscultation is essential for detecting cardiac and pulmonary abnormalities. For the heart, use the diaphragm to listen for high-pitched sounds (S1, S2, murmurs) and the bell for low-pitched sounds (S3, S4, bruits) at the aortic, pulmonic, tricuspid, and mitral areas. For lungs, assess breath sounds (vesicular, bronchial, adventitious) in at least six anterior and eight posterior sites. Key findings include wheezing (asthma), crackles (pneumonia), and absent sounds (pneumothorax). (Bickley, 2020)

4. Importance of Skin Inspection and Key Findings

Skin inspection can reveal systemic diseases, infections, and malignancies. Signs to assess include color changes (pallor, cyanosis, jaundice), lesions (ABCDE criteria for melanoma), texture (dryness, thinning), and vascular abnormalities (petechiae, purpura). Findings can guide diagnoses, such as petechiae in thrombocytopenia, hyperpigmentation in Addison’s disease, or jaundice in liver dysfunction. Skin assessment is also crucial for detecting pressure ulcers, infections, and dermatological conditions. (Fitzpatrick et al., 2019)

References

Bickley, L. S. (2020). Bates' Guide to Physical Examination and History Taking. Wolters Kluwer.

Fitzpatrick, T. B., et al. (2019). Fitzpatrick's Dermatology in General Medicine. McGraw-Hill.

Kurtz, S. M., et al. (2017). Skills for Communicating with Patients. CRC Press.

Miller, W. R., & Rollnick, S. (2013). Motivational Interviewing: Helping People Change. Guilford Press.