Health Assessment

Question 1

What are the 10 steps in the sequence of history taking

Answer 1

1. The present complaint
2. Past Medical History
3. Mental Health
4. Medication History
5. Family History
6. Social History
7. Occupational History
8. Systematic enquiry
9. Further information from a third party
10. Summary

Question 2

Five stages to summarise history taking

Answer 2

1. Explanation and Planning
2. Aiding accurate recall and understanding
3. Achieving a shared understanding
4. Planning through shared decision making
5. Closing the consultation

Question 3

Should you first focus on a patients symptoms or diagnosis

Answer 3

symptoms

Question 4

Questions about onset

Answer 4

Was it sudden or has it gradually occurred?

Question 5

Questions about duration

Answer 5

How long does it last

Question 6

Questions about site and radiation

Answer 6

Where does it occur? Does it occur anywhere else?

Question 7

Questions about aggravating and relieving features

Answer 7

Does anything make it better or worse?

Question 8

Questions about associated symptoms

Answer 8

When this happens does anything happen with it, such as nausea, vomiting or headaches?

Question 9

Questions about fluctuating

Answer 9

Are the symptoms always the same?

Question 10

Questions about frequency

Answer 10

Have you had it before

Question 11

What four things are important to capture when taking a patients past medical history

Answer 11

Diagnosis, Dates, Sequence, Management

Question 12

Aspects of general health

Answer 12

Well being, energy, appetite, sleep, weight change, mood/anxiety/stress

Question 13

Aspects of cardiovascular system

Answer 13

Chest Pain, Breathlessness, Palpitations, Ankle Swelling, Pain in lower leg when walking

Question 14

Aspects of CNS

Answer 14

Headaches, dizziness, vertigo, sensations, fits/faints, weakness, twitches, tinnitus, visual disturbance, memory or concentration changes

Question 15

Aspects of Endocrine system

Answer 15

Excessive thirst, tiredness, heat intolerance, hair distribution, change in appearance of eyes

Question 16

Aspects of gastrointestinal system

Answer 16

dental/ gum problems, tongue, difficulty in swallowing, painful swallowing, nausea, vomiting, heartburn, colic, abdominal pain, change in bowel habits, colour of stool

Question 17

Aspects of Genitourinary system

Answer 17

Pain in urinating, blood in urine, risk assessment for sexually transmitting infections

Question 18

Aspect of men only

Answer 18

Hesitancy passing urine, frequency of micturition, poor urine flow, incontinence, urethral discharge, erectile dysfunction, change in libido

Question 19

Aspects of musculoskeletal system

Answer 19

Joint pain, Joint Stiffness, Mobility, Gait, Falls, Time of day pain

Question 20

Aspects of respiratory system

Answer 20

Shortness of Breath, Cough, Wheezing, Sputum, Blood In Sputum, pain when breathing

Question 21

Aspects for women only

Answer 21

Onset of menstruation, last menstrual period, timing and regularity of periods, length of periods, type of flow, vaginal discharge, incontinence, pain during sexual intercourse

Question 22

What should you ask about after medical history

Answer 22

If they have any allergies

Question 23

What is the cage system

Answer 23

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)?