Histories Flashcards
Headache Hx
HPC (2) Systems review (6) Constitutional symptoms (4)
PMHx, DHx, FHx, SHx
HPC:
- SOCRATES
- Excessive stress
- Previous episodes
- Worse on coughing/lying down
Summarise
Systems review:
- FFF
- Visual disturbance or pain on eye movement
- LOC
- Weakness or numbness
- Balance problems
- Neck stiffness or rashes
- Red eye (glaucoma)
Constitutional symptoms:
- Fever
- WL
- Night sweats
- Fatigue
Weakness Hx
HPC (6) Systems review (6) Constitutional symptoms (4)
PMHx, DHx, FHx, SHx
HPC:
- Distribution
- Duration and onset
- Sudden or gradual
- Constant or intermittent
- Pain
- Relieving/exacerbating factors
Previous episodes
Summarise
Systems review:
- FFF
- Visual disturbance or pain on eye movement
- LOC
- Weakness or numbness
- Balance problems
- Neck stiffness or rashes
Constitutional symptoms:
- Fever
- WL
- Night sweats
- Fatigue
Seizure HPC (4) Summarise Systems review Constitutional symptoms (4)
PMHx, DHx, FHx, SHx
HPC:
- Witnessed or unwitnessed
- Before (aura/chest pain/palpitations), during (jerking, tongue biting, incontinence), after (drowsy, how long it took to return to normal)
- LOC and duration of LOC
- Injury during collapse
Systems review:
- Visual disturbance or pain on eye movement
- LOC
- Weakness or numbness
- Balance problems
- Neck stiffness or rashes
Constitutional symptoms:
- Fever
- WL
- Night sweats
- Fatigue
Abdo Hx
PC
Dysphagia (9)
CoBH (6)
Abdo pain (1)
Important Qs (10)
Constitutional symptoms
PMHx, DHx, FHx, SHx
Dysphagia
- Progressive or sudden
- Liquids/solids
- Getting stuck or difficulty initiating swallow
- Odynophagia
- Regurgitation/vomiting/halitosis
- WL
- Current nutrition intake
- Hoarseness
- History of reflux
CoBH
- Diarrhoea/constipation = frequency
- Consistency and colour
- Blood (fresh or mixed in)
- Melaena
- What’s normal for them
- If constipation, passing wind?
Abd. pain
SOCRATES
- N+V (blood?)
- Dysphagia
- Reflux (worse when lying down)
- Pain on eating
- Jaundice
- Dark urine or pale stools
- CoBH (what is normal for them, consistency, colour, mucous and blood)
- Pain on defecation (relieved by defecation?)
- Incomplete emptying
- Incontinence
Fever, WL, night sweats and fatigue
Chest pain
HPC
Associated symptoms (7)
B-symptoms (3)
Cardiac RFs (4)
VTE RFs
PMHx, DHx, FHx, SHx
HPC: SOCRATES
Any previous episodes?
Associated symptoms:
- Palpitations
- Cough, SOB, wheeze
- Tenderness
- Anxiety and stress
B-symptoms: Fever, WL, night sweats
RFs:
- DM
- HTN
- High cholesterol
- FHx of cardiac problems
VTE:
- Recent travel
- Calf pain or swelling
- Clotting disorders
- (COCP)
Palpitations
HPC (4)
Associated symptoms (5)
Cardiac RFs (4)
VTE RFs
HPC: Onset Triggers (alcohol, caffeine, stress) Duration Termination (self or anything that can be done)
Any previous episodes
Associated symptoms:
- Cardio: chest pain
- Resp: cough, SOB, wheeze
- Anxiety: tingling around mouth or limbs, stress, nausea
- Endocrine: WL, CoBH, agitation, headaches and sweating
RFs:
- DM
- HTN
- High cholesterol
- FHx of cardiac problems
VTE:
- Recent travel
- Calf pain or swelling
- Clotting disorders
- (COCP)
SOB
HPC (7)
Resp RFs (3) Cardiac RFs (4) Systems review (3)
HPC: ONERESP Onset Nature Exacerbating factors Relieving factors Exercise tolerance Sleep (PND) Pillows (orthopnoea)
Resp RFs:
- Resp: asbestos exposure, pets at home, foreign travel
- VTE: calf pain or swelling, previous clots in leg, (COCP)
- Lung cancer: WL, fever, night sweats, hoarseness or back pain
Cardiac RFs:
- DM
- HTN
- High cholesterol
- FHx of cardiac problems
Systems review:
- Resp: cough, wheeze, sputum
- Cardio: chest pain, palpitations
- Anxiety: tingling around mouth or limbs, stress, nausea
Gynae Hx
Gynae systems review:
- Pain
- PV bleeding
- Post-coital bleeding/pain
- Pruritus/itching
MOSC:
Menstrual Hx:
- LMP
- Duration of menses
- Frequency of cycle
- HMB (flooding and clots)
- Severe pain
Obstetric Hx:
- Any children at home (if Y - problems and mode of delivery)
- Any previous pregnancy
- Any terminations or miscarriages
Sexual Hx:
- Currently sexually active
- Last time sexually active
- Any previous STI
Contraception + cervical smear :
- What is being used
- What has been tried
- Any plans to conceive in the near future
- Up to date with smear
Obs
RFs:
1st trimester = bleeding, N+V, pain
2nd trimester = headache/vision/fatigue (PET)
3rd trimester = bleeding, pain
Current pregnancy:
- Conception by intercourse or IVF
- Gestation (via LMP)
- Any problems thus far? Do you feel like you are well supported?
- Booking visit
- Attending scans and screening? (chromosome screen at 10 weeks and anomaly scan at 20 weeks)
- Any other children or previous pregnancies
- Foetal movements (if >18 weeks)
Previous pregnancy:
- Complications during pregnancy?
- Preterm?
- Mode of delivery?
- Complications during brith?
- Birth weight of baby
- NICU
PMHx:
- Rhesus status
- Long term condition control pre pregnancy
- Smear history
Alcohol Motivational Interviewing
ASMA
action, social effect, motivation, action
About current habit:
- What? (amount and type of alcohol drank)
- When? (morning/evening)
- Where? (home/pub and alone?)
- Why? (enjoyment?)
Social effect:
- Effect on self (injuries + medical problems)
- Effect on family/friends
- Effect on finances
- Effect on work
- Police related trouble
- Driving
Motivation:
- Have they ever thought about stopping?
- Why they have decided to stop? What changed?
- What are the next steps?
- What do they envisage for the future
Action:
- How do they think the best way to cut down will be?
- After permission, give a few options which may help (community alcohol team, support group, Vit B1 supplements, detox programs)
Falls Hx (3) What extra questions do you need to ask? (5) SHx
Examination (4)
Investigations (4)
Management (3)
Falls Hx:
Standard before, during, after.
How long were you on the floor and how you were found/brought into hospital.
Head trauma.
- Chest pain/palpitations/SOB
- Dizziness, vertigo or balance problems
- Changes to vision or hearing
- Joint pain or stiffness
- Any previous falls (Y - no. of falls in last 12 months)
SHx: CFS score (dressing = 6, shopping = 5)
Examination:
The main systems to think about with a fall are the heart, balance organs - brain, eyes and ears - and musculoskeletal so I would like to examine all of these.
I would also like to perform and AMTS.
Investigations:
To try and find out why you are falling there are a few basic investigations we can try to help find the cause:
1. ECG
2. Bloods (FBC, glucose, U+E and CK)
3. Lying and standing BP
4. Imaging if suspicious of fracture or head injury
Management:
Because falls are multifactorial there are many changes we can implement to help reduce your risk of future falls and this requires input from many teams.
1. Optimise physical symptoms through lifestyle changes or medications.
2. Improve strength with physiotherapy
3. Make modifications to your home such as extra railings or a pendant alarm
Dementia
Examination (1)
Investigations (2)
Management (6)
Safety net (2)
Dementia:
From what you’ve told me this does sound like it could be dementia. However there are some other physical causes that can reflect these symptoms which we need to exclude first before diagnosing dementia.
Examination:
1. MMSE - this involves a series of tasks which test memory and cognition
Investigations:
- Blood tests (Ca2+, Mg2+, TFTs, B12 and folate)
- Brain scan
Management:
If all our investigations come back normal then we can begin to consider a dementia diagnosis. Unfortunately there is no cure for dementia but there are things we can do to make the condition more manageable for you and your family.
Conservative:
- Involvement of carer for social and personal needs
- Care co-ordinator
- Family support groups
- PT/OT
- The DVLA will have to be informed who will advise you further about driving.
Medical:
- Anti-cholinesterase
Safety net:
- Dementia is a gradual process. If there is a sudden worsening of symptoms then it may indicate undetected infection - please see me if this happens.
- If you have any further questions, require clarification or need more support then we can have another discussion
Stroke Hx:
RFs (4)
Examination (2)
Investigations (1)
Management (5)
Stroke:
NB: make sure to establish timeframes to consider thrombolysis
RFs: AF DM High BP High cholesterol
I am worried that this is a stroke so we should act quickly to confirm whether or not this is the case. There are other causes of these symptoms but we need to rule out a stroke first.
Examination:
- I will need to do an A-E assessment to check that you are stable and there is no risk of deterioration.
- Then I will need to perform a full neurological and cardiovascular examination to get a better picture of what is going on.
Investigations:
We need to do a CT scan of your head - this will confirm whether or not you have stroke but also whether it is due to a clot or a bleed. This will guide our management.
Management:
You will need to be admitted.
1. If it is due to a clot then we will start you on 300mg of aspirin to be taken for 2 weeks. The you will be switched to a different anti platelet to be taken indefinitely.
2. Consider whether or not in the thrombolysis window.
3. Then we need to find out why you have had a stroke. This will involve further investigations such as:
- An ECG
- USS of you carotid arteries
- Cerebral angiogram
4. Then long term management will require an MDT input with OT/PT, stroke doctors, SALT and your GP.
5. We may also look to identify if there are any lifestyle changes that can be implemented to prevent this from happening again.
