Health Assessment Flashcards
What are the 10 steps in the sequence of history taking
- The present complaint
- Past Medical History
- Mental Health
- Medication History
- Family History
- Social History
- Occupational History
- Systematic enquiry
- Further information from a third party
- Summary
Five stages to summarise history taking
- Explanation and Planning
- Aiding accurate recall and understanding
- Achieving a shared understanding
- Planning through shared decision making
- Closing the consultation
Should you first focus on a patients symptoms or diagnosis
symptoms
Questions about onset
Was it sudden or has it gradually occurred?
Questions about duration
How long does it last
Questions about site and radiation
Where does it occur? Does it occur anywhere else?
Questions about aggravating and relieving features
Does anything make it better or worse?
Questions about associated symptoms
When this happens does anything happen with it, such as nausea, vomiting or headaches?
Questions about fluctuating
Are the symptoms always the same?
Questions about frequency
Have you had it before
What four things are important to capture when taking a patients past medical history
Diagnosis, Dates, Sequence, Management
Aspects of general health
Well being, energy, appetite, sleep, weight change, mood/anxiety/stress
Aspects of cardiovascular system
Chest Pain, Breathlessness, Palpitations, Ankle Swelling, Pain in lower leg when walking
Aspects of CNS
Headaches, dizziness, vertigo, sensations, fits/faints, weakness, twitches, tinnitus, visual disturbance, memory or concentration changes
Aspects of Endocrine system
Excessive thirst, tiredness, heat intolerance, hair distribution, change in appearance of eyes
Aspects of gastrointestinal system
dental/ gum problems, tongue, difficulty in swallowing, painful swallowing, nausea, vomiting, heartburn, colic, abdominal pain, change in bowel habits, colour of stool
Aspects of Genitourinary system
Pain in urinating, blood in urine, risk assessment for sexually transmitting infections
Aspect of men only
Hesitancy passing urine, frequency of micturition, poor urine flow, incontinence, urethral discharge, erectile dysfunction, change in libido
Aspects of musculoskeletal system
Joint pain, Joint Stiffness, Mobility, Gait, Falls, Time of day pain
Aspects of respiratory system
Shortness of Breath, Cough, Wheezing, Sputum, Blood In Sputum, pain when breathing
Aspects for women only
Onset of menstruation, last menstrual period, timing and regularity of periods, length of periods, type of flow, vaginal discharge, incontinence, pain during sexual intercourse
What should you ask about after medical history
If they have any allergies
What is the cage system
Have you ever felt the need to Cut down?
Have people Annoyed you by criticising your drinking?
Have you ever felt Guilty about your drinking?
Have you ever had a drink to steady your nerves in the morning (Eye opener)?
