Clinical Skills! Flashcards
General Systematic Enquiry questions?
(9 questions)
FF-W-T-SS-P-NN
“I am just going to go through some general symptoms, and if could you possibly tell me if you are experiencing them or not”
1 - Fatigue/malaise (Tired)
“Have you been feeling more tired than usual?”
2 - Fever/rigors
“Have you had any fevers? Any shivering?”
3 - Weight/appetite
“Have you noticed any changes in your weight? What about your appetite?
4 - Skin: rashes/bruising/bleeding
“Have you noticed any skin changes, such as rashes, bruising or bleeding?”
5 - Sleep disturbance
“Have you been able to get a restful sleep at night?”
6 - Thirst
“Have you been more thirsty than usual?”
7 - Pruritus
“Have you been more itchy than usual?”
8 - Night sweats
“Have you experienced any night sweats?”
9 - Neck swelling/lumps
“Have you noticed any swellings or lumps around your neck?”
Resp Systematic Enquiry questions?
12 questions
1 - Cough
2 - Sputum (alt. plegm)
“are you coughing anything up? such as sputum or blood?”
3 - Haemoptysis
(see above)
4 - Dyspnoea
“any SOB?”
5 - Wheeze
6 - Chest pain (pleuritic)
Symptoms of Sinusitis: 7 - Blocked nose 8 - Nasal discharge "runny nose?" 9 - Facial pain 10 - Reduced smell
11 - Earache
12 - Sore throat
CVS Systematic Enquiry questions?
6 questions
1 - Chest pain
Dyspnoea: 1 - on exercise? 2 - at rest? 3 - orthopnoea? "while lying down?" 4 - paroxysmal nocturnal "at night?"
3 - Palpitations
“have you been noticing your heartbeats a lot more?”
4 - Ankle oedema
“any ankle swelling?”
5 - Varicose veins
(if asked): “any enlarged leg veins?”
6 - Claudication
“any pain in legs, thighs or buttocks on walking?”
GI Systematic Enquiry questions?
19 questions
1 - Appetite/weight loss or change
2 - Mouth/teeth/tongue
“noticed any differences in your mouth, teeth or tongue?”
3 - Dysphagia
“had any difficulties swallowing?”
4 - Dyspepsia/heartburn
“had any heartburn or indigestion (pain in upper tummy after eating?)”
5 - Nausea/vomiting
6 - Haematemesis
“vomiting blood?”
7 - Jaundice
“have you been noticing any yellowing of the eyes or skin?”
8 - Abdominal pain
“any tummy pain? What about/does it come on when eating a fatty meal?”
9 - Abdominal distension (+ bloating)
Bowel habit: (7)
10 - Change - “are u passing stools more or less frequently than usual?”
11 - Constipation
12 - Diarrhoea
13 - Blood
14 - Mucus
15 - Colour of stools: Pale? Black? (melaena)
16 - Faecal incontinence - “are u having any difficulties in getting to the toilet on time?”
Perianal symptoms:
17 - Haemorrhoids
18 - Pain - “any pain down below? what about any itching?”
19 - Itching
Urinary Systematic Enquiry questions?
1 - Frequency
2 - Dysuria
3 - Nocturia
4 - Polyuria
5 - Oliguria
6 - Haematuria
7 - Retention - acute or chronic?
“are you able to completely empty your bladder when urinating?”
8 - Incontinence
“do you struggle in making it to the toilet on time?”
9 - urge? - “do you have any warning before needing to urinate?”
10 - stress - “do you suddenly urinate upon coughing, sneezing, or doing physical activity?”
Prostatic symptoms (Males):
11 - hesitation - “any difficulty in initiating the stream?”
12 - poor stream - “any difficulties in maintaining a stream?”
13 - dribbling - “any dribbling at the end of a urinary stream?”
14 - incomplete emptying of the bladder - “do you feel the need to pass more urine shortly after completing a urinary stream?”
Other: 15 - Abdominal pain 16 - Weight loss 17 - Nausea or vomiting 18 - Sexually active? 19 - Erectile Dysfunction?
Nervous System Systematic Enquiry questions?
Speech disturbance
- Dysarthria
1 - “are you experiencing or has anyone commented on any slurring of your speech?”
- Dysphagia - receptive and expressive
2 - “are you having difficulty understanding speech? what about initiating speech?”
3 - Headache
- SOCRATES
- ?affects activities of daily living
4-6 - Fits/faints/loss of consciousness
- What do they mean by the word “fit”?
- What happened before, during and after the loss of consciousness?
- > before: ?feeling unwell, ?any symptoms that they were going to have a loss of consciousness
- > during: ?abnormal movements, ?incontinence, ?tongue biting
- > after: ?recovered quite quickly, ?sleepy, ?confused, ?injured themselves from falling on the ground
7 - Dizziness, vertigo
- clarify “vertigo” = feel like the whole room is spinning, enough to affect their balance
- any sweats, palpitations, nausea, or vomiting associated with it?
8 - Balance
- clarify “loss of balance”
- ?some of the time or all of the time
- ?walking aids to help w balance issues
9 - Vision – acuity, diplopia
- “do you have clear vision?”
- “are you experiencing any double vision?”
10 - Hearing
- “do u have any hearing issues at all?”
11 - Weakness
- when did it start?
- how long did it occur for?
- when did it stop?
12-14 - Numbness/tingling/paraesthesia (pins + needles)
- when did it start?
- how long did it occur for?
- when did it stop?
Which additional questions would you ask in ICE for GI Urinary incontinence?
- Stopped going out?
- Only going to places where they know there is a toilet?
- Avoiding public transport?
What would you ask if a neuro pt. described that they were having “fits”, “faints” or “loss of consciousness”?
- What do they mean by the word “fit”?
- What happened before, during and after the loss of consciousness?
- > before: ?feeling unwell, ?any symptoms that they were going to have a loss of consciousness
- > during: ?abnormal movements, ?incontinence, ?tongue biting
- > after: ?recovered quite quickly, ?sleepy, ?confused, ?injured themselves from falling on the ground
What questions would you ask about “bowel habit” from a GI pt?
(7 questions)
- Change
“are u passing stools more or less frequently than usual?” - Constipation
- Diarrhoea
- Blood
- Mucus
- Colour of stools: Pale? Black? (melaena)
- Faecal incontinence - “are u having any difficulties in getting to the toilet on time?”
What is the appropriate introduction for a consultation?
- Identifying yourself and the pt clearly:
- > “Good morning/afternoon, my name is Hira Ahmad and I am a 2nd year medical student, can I just confirm your name and date of birth please?”
- > “And how would you like me to address you today?”
- > “Can I just confirm that on your wrist band? Perfect, thank you”
- Explain the reason for the consultation and gain consent to proceed:
- > “Today I would like to take a history from you which would involve me asking you some questions about what has brought you in to the GP surgery/A+E/hospital, would that be okay?”
- > “Do you have any questions for me before I begin?”
What would you ask in HPC?
- “So can you tell me about what has brought you in to the GP surgery/A+E/hospital today?”
- “Anything else?”
- “And how long has this been going on for?”
Details of all current symptoms:
- This may include: SOCRATES(F)
Site, Onset, Character, Radiation, Associated Symptoms, Timing, Exacerbating/relieving factors, Severity, Functional consequences
- Ask relevant systematic enquiry: “I am now just going to ask you a couple of questions about other related symptoms that you may be experiencing, would that be okay?”*
- Summarise everything the pt. has said back to them: ask them if u have missed anything!*
- Ask general systemic enquiry: “I am now just going to ask you some more questions about some more general symptoms that you may be experiencing, would that be okay?*
- Ask pt. perspective (ICE): “What are you worried that this could be?;” “Are you worried about the symptoms that you are experiencing, “What is worrying you?;” What did you expect when you came to the GP surgery/A+E/hospital today?”
What would you ask for SOCRATES(F)?
- Site:
- > “where is the pain?” or
- > “where is the pain most felt?”
- Onset:
- > “When did it start?,”
- > “did it occur suddenly or gradually?,”
- > “is it progressively getting any better or worse with time?”
- Character:
- > “what is the pain like?”
- > “(if asked for an example): stabbing? aching?”
- Radiation:
- > “does the pain radiate anywhere?”
- Associated symptoms?
- Timing
- > “does the pain occur only at certain times of the day/month/year?”
- > “how many times does it occur in a typical day/month/year?”
- > “does the pain follow any particular trend in terms of timing?”
- Exacerbating/Relieving factors:
- > “does anything make the pain better/make it worse?”
- Severity:
- > “can you rate the pain on a scale of 1-10, with 1 being not painful at all and 10 being the worst pain you have ever experienced”
- Functional consequences:
- > “is this pain stopping you from doing anything you would normally do?”
How do you ask about patient’s perspective?
When would you ask this?
- (ICE!)
- > Ideas: “What do you think that this could be?”
- > Concerns: “Are you worried about that/the symptoms that you are experiencing?”
- > Expectations: “What did you expect when you came to the GP surgery/A+E/hospital today?”
- Ask after Systematic enquiry (after HPC + relevant systematic enquiry)
What would you ask for PMH?
- Notable illnesses:
“Have you had any notable illnesses in the past?” - Previous surgeries:
“Have you had any previous surgeries?” - (if this is the case): “were there any problems or adverse events during the procedure?”
- GP-managed condition: “Do you currently have any long-term health conditions that is being managed at the GPs?”
- JAMTHREADS:
“I am just going to ask you a couple of screening questions regarding any conditions that you have or may have had in the past, they just require a yes or no answer, would that be okay?”
“Have you had any Jaundice? Anaemia? MI (heart attack)? TB? do you have Hypertension? Rheumatoid Arthritis? Epilepsy? Asthma or COPD? Diabetes? have you had a Stroke in the past?”
What would you ask in DH/Allergy History?
-> “Are you on any medication atm?”
Drugs:
- Name? Dose? Frequency? Route? Indication concordance?:
-> “What is the name of the drug you are taking atm?”
-> “What is the dosage?”
-> “How often is it to be taken?”
-> “What is the formulation of the medication? ie. tablet, liquid, patch?”
-> “Are you taking it as prescribed?”
-> “Are you experiencing, or have experienced, any adverse effects to the meds?”
- OTC? Herbal remedies? Vitamins/Mineral tablets? Recreational drugs?
-> “Do you currently have any allergies to anything?”
Allergies:
-> “Are you allergic to anything?”
-> “What about any meds, ie. penicillin?”
-> “What about to any food? latex?”
What would you ask for FH?
- “How would you describe the health of your parents?” “What about your siblings?”
- > (if died): “I am sorry to hear that - is it possible to find out what they died of? What age were they?”
- > “How is the health of your children?”
- “Are there any conditions that run in your family?”
- > (if so): “Are there any other family members are affected by this that you know of?”
What would you ask for SH?
10-11 points
“I am just going to ask you some questions about your social circumstances and general health + wellbeing, is that alright? It may sound a bit like a list, so just bear with me!”
- Household members:
“Who do you live with at home?” - Work circumstances:
“Do you work at all?” “What do you work as/used to work as?” - Driving status:
“Do you drive at all?” - Physical activity:
“Are you physically active?” “How often are you active each week?” - Diet:
“How would you describe your typical diet?” - Smoking:
“Do you smoke at all or have you ever smoked?” (if so): “how long did you smoke for?” “how many cigarettes were you averaging a day?” - Alcohol:
“Do you drink alcohol at all?” (if so): “How much would you typically drink in a week?” - Recreational drugs (If not asked yet):
“Do you take any recreational drugs?” - Hobbies:
“Do you have any hobbies?” - Pets:
“Do you have any pets?” - Overseas Travel:
“Have you been abroad recently?”
Explanation and planning:
1 - What kind of information do we explain to the pt?
2 - What problems can arise at the explanation stage?
3 - How do you gauge the correct amount of info to give each pt?
4 - What are the objectives when closing a consultation?
1 - Bad news, test results, what a test or procedure involves, medications or other therapies, what to expect from them
2 - Not providing the correct amount + type of info
- Not presenting info in a way that aids recall + understanding
- Not incorporating the pt’s perspective
- Importance of basing the explanation on what the pt. has told you and their current understanding -> pts. often want more rather than less info
3 - Chunking + checking -> assess the pt’s starting point -> take pt’s history before starting the explanation
- Ask the pt. what other info would be helpful
- Give explanations at appropriate times with appropriate language
- Use of pauses/silence, signposting, memory aids (ie. leaflets)
4 - Confirming the plan of care and clarifying the next steps for pt. and doc
- Establishing contingency plans or safety netting
“If your experiencing worsening symptoms such as … then you should make another appointment to come and see us”
- Maximising concordance or shared decision making by offering choices, if/as appropriate -> this is to build the doc-pt. relationship for the future
What should you specifically ask about in a Diabetic history?
- So essentially, the pt. has come in with something else, but the pt. has an established diagnosis of diabetes and you are going to ask additional questions in the history regarding their diabetes diagnosis*
- Presenting complaint
- HPC:
-> diagnosis of diabetes
“So can you tell me if you are currently experiencing any symptoms related to your diagnosis of diabetes that you know of?”
-> ask about change in symptoms before and after the diagnosis of diabetes: thirst, polyuria/nocturia, changes in weight, lethargy, blurred vision, paraesthesia/numbness or pain in the extremities
“So I am just going to ask you a few questions about some symptoms you may have been experiencing related to your diagnosis of diabetes, if you could just tell me if you are experiencing these, and if you have or have not experienced these before your diabetes diagnosis”
“So have u been experiencing increased thirst? And what about before your diabetes diagnosis?”… - Patient’s perspective:
- > impact of diabetes on their life?
- > any concerns they may have?
- “Do you feel that your diabetes is affecting your day-day life? In which areas?”
- “Are you worried about anything regarding your diagnosis of diabetes?”
- PMH:
- > IHD?
- > Foot ulceration?
- > Diabetic eye disease?
- Medication History + Allergies (for T1DM):
- > type(s) of insulin taken, regimen and how they manage this (by counting carbs and monitoring their blood glucose)
- > also ask about rotation of injection sites
- > remember to discuss if they are taking their insulin/meds as prescribed, or if they are having any difficulties in doing so!!
- FH:
- > DM?
- > Autoimmune disease?
- > IHD?
- SH:
- > Smoking
- > Driving (DVLA)
- > Physical Activity
- > Diet history
- Full Systematic Enquiry:
- > General
- > Resp
- > GI
- > Neuro
What should you ask in an Endocrine history?
- PC: and duration and reason for attendance today
- HPC: gather info as usual
- > General Systematic Enquiry: fatigue, change in energy levels, sweating, weight change, changes in appetite, thirst, itchy skin, rashes, bruising or neck lumps, ask about any hair loss or increased hair growth
- > CVD: Tachycardia, Palpitations, Chest pain,
- > GI: change in bowel habit (ie. diarrhoea or constipation), changes in weight + appetite
- > Genitourinary: polyuria, nocturia
- > Sweating, Hair distribution
- > Skin changes
- > Changes in Skin colour ie. pigmentation
- > Nervous: headaches, dizziness, visual loss, confusion and blackouts
- PMH: prev. hx of any neck surgery for thyroid swelling?
- DH + Allergies : HRT? thyroid drugs? diabetic drugs, insulin? prostate drugs? chemo and RT? steroids?
- FH: autoimmune disease? thyroid disease? DM?
- SH: smoking, diet + lack of physical activity
