General History Taking Flashcards
What does MJTHREADS Ca stand for?
Myocardiac infarction Jaundice Tuberculosis Hypertension Rheumatic fever Epilepsy Asthma Diabetes Stroke Cancer (and treatment if so)
How should you structure the Hx?
Intro PC HPC PMHx DHx A FHx SHx SR Summary
What should you cover in PC? Ask the questions
What it is
ICE
What should you cover in HPC? Ask the questions
SOCRATES
What should you cover in PMHx? Ask the questions
MJTHREADSCa
Have you had any chest or heart problems?
Any liver problems? Have you or the people around you noticed a yellow tinge to your skin/eyes?
Have you contracted TB before?
Have you ever had problems with BP?
Have you had a throat infection recently? Have you had any problems with your joints?
Do you have epilepsy?
Asthma?
Diabetes?
Stroke?
Cancer?
Clarify this PMHx: COPD
Ask about when the patient was diagnosed, their current and previous treatments, whether they have ever required non invasive ventilation (“a tight-fitting face mask”), whether they have been to intensive care
Clarify this PMHx: MI
Ask about angina, previous heart attacks, any previous angiograms (“a wire put into your heart from your leg or from your arm”), previous stenting
Clarify this PMHx: diabetes
Duration of diagnosis, current management including insulin and usual control of diabetes i.e. well- or poorly-controlled
What should you cover in DHx? Ask the questions
Prescribed meds
IV drugs (current or previous)
Recreational drugs
OTC medications
When asking about medications what should you ask?
Dose, frequency, route and compliance (i.e whether they regularly take these medication).
If they take medication weekly ask what day of the week they take it.
If they take a medication with a variable dosing (e.g. Warfarin) ask what their current dosing regimen is
What should you cover in A? Ask the questions
Does the patient have any allergies?
If allergic to medications, clarify the type of medication and the exact reaction to that medication.
Specifically ask about whether there’s been a history of anaphylaxis e.g. “throat swelling, trouble breathing or puffy face”
What should you cover in FHx? Ask the questions (2)
Ask the patient about any family diseases relevant to the presenting complaints (e.g. if the patient has presented with chest pain, ask about family history of heart attacks).
Enquire about the patient’s parents and sibling and, if they were deceased below 65, the cause of death
If relevant and a pattern has emerged from previous history sketch a short family tree
What should you cover in FHx? Ask the questions (6 topics)
Alcohol intake Tobacco use Employment Home situation - house or bungalow? Any carers? Daily activities? Mobility and aids? Social/family support? Do they think they're managing? Travel history Further SHx
In further SHx if it’s a respiratory presenting complaint what else should you ask about? (6)
Ask about pets, dust exposure, asbestos, exposure to the farms, exposure to birds or if there are any hobbies
In further SHx if it’s a infectious/disease related presenting complaint what else should you ask about? (6)
Ask for a full travel history including all occasions exposure to water, exposure to foreign food, tuberculosis risk factors, HIV risk factors, recent immunisations
