Ebook - history and examination Flashcards
what are the three basic parts to a history?
the biomedical data, the patient’s perspective and the context
what are the first and second steps in the history and how would you achieve this?
the presenting complaint and the history of the presenting complaint. To achieve this build rapport, be prepared, identify the patients problem and ideas, listen without interrupting, confirm problems and check for further problems, explore each fully, clarify, summarise, screen and move on.
what does the systematic enquiry checklist comprise?
check that there are no other symptoms relating to the presenting complaint. Also checking to see if there are no other problems impacting on the patients life
what are the core symptoms for CVD?
Chest pain Shortness of breath at rest or exertion Lie flat, pillow use - (orthopnoea) Breathless at night (may be PND; ask for a clear description of this) Palpitations Ankle swelling (peripheral oedema) Cold/blue hands, feet Pain in calves on walking (Claudication)
what are the core symptoms for respiratory?
Cough (time period crucial) Sputum, colour, volume Any blood in sputum? (haemoptysis) Shortness of breath Wheeze Fever, night sweats Recent CXR Breast: lumps, bleeding, discharge
what are the core symptoms for GIT?
Bloating, distension Indigestion , heartburn Problems swallowing (dysphagia) Pain on swallowing (odynophagia) Change in weight Bowel habits; change?, colour, consistency Faecal incontinence
what are the core symptoms for genitourinary?
Incontinence Frequency & Volume of urination Pain on passing urine (dysuria) Night time urination (nocturia) Colour of urine Blood in urine (haematuria) Hesitancy, dribbling Genitourinary pain Genital rashes, lumps Menstrual cycle
what are the core symptoms for neurological?
Headaches Vision, hearing + aids for this Speech difficulties (dysphasia, dysarthria) Dizziness, vertigo Faints, fits, blackouts Weakness Numbness Coordination problems Walking, unsteadiness, falls Sleep disturbances Tremors Concentration Memory
what are the core symptoms for musculoskeletal?
Joints; pain, stiffness, swollen Variation in joint pain during day Fingers painful/blue in cold Dry mouth, red eyes Fever, skin rashes, ulcers Nodules or lumps Back or neck pain
what are the core symptoms for mental health?
Any recent change in mood (Any thoughts of self harm) Any problems with memory or concentration? Hallucinations or delusions Intellectual change
what are the core symptoms for endocrine?
Prefer hot or cold rooms/weather Sweating Fatigue Hand trembling Neck swelling Change in weight Thirst Change in urine volume/frequency
what are the core symptoms for vascular?
Pain at rest or walking (calves – claudication) Skin changes or ulceration Cold hands and or feet Reduced exercise tolerance Loss of/reduced sensation Swollen ankles
what would you ask for PMHx?
Have you ever been in hospital?
Have you ever seen a hospital specialist?
Is there anything you see your GP regularly for?
Have you ever had an operation?
what would you ask for drug Hx?
Are you prescribed any medication?
If yes – Do you always manage to take it?
Do you have a problems taking any of your medication?
Do you use a compliance aid?
Does anyone help you take your medications?
Dispensing – Monthly/weekly/daily
Do purchase any medicines from the pharmacy?
Have you purchased any medicines over the internet?
Allergy status
Drugs – prescribed, over the counter
Other allergens
What is the reaction – anaphylaxis vs intolerance (a detailed description of this is essential as it may affect decisions to treat with certain medications e.g. Penicillin)
What would you ask for Social Hx?
Smoking (pack year history)
Alcohol (units per week)
Recreational drugs (legal/illegal)
Occupation, hobbies and pets
Overseas travel
Housing
Functional status & driving
Social, private or family carers (if yes: who, how often and what they do)
Dependents
