History Flashcards
General History sturcture
PC HPC ------- PMH DH FH SH
ICE
SOCRATES
Site Onset Character Radiation Associated symptoms Timing Exacerbating factors Severity
PMH
What to ask
What to check for
Significant illness
Operations
Mental health
Check for: MI, diabetes, HTN, Asthma, COPD, Stroke/TIA
DH
What to check for
Prescription
OTC
Illicit
Compliance / control
Allergies (explain reaction
What to check for in FH
HTN/MI etc
Cancer
Atopy: eczema, asthma
Autoimmune(T1DM, Coeliac, Vitiligo)
Social history
WTAJTPDS
Who lives with them Type of accommodation ADLS (cook clean, shop) Job (current/past) Recent travel Pets Drink smoke drugs
CV review
Chest pain, SOB (exertion, lying down, night time, rest) Palpitations, ankle swelling, claudication
Resp review
Cough, sputum, SOB, wheeze, fever, night sweats
GI review
Change in weight / appetite / bowel habit, swallow difficulty, reflux, pain, blood / slime in bowel, incontinence
Neuro review
Headache, change in hearing / vision / speech, faints / blackouts, fits, weakness, numbness, sleep disturbances, tremor, memory loss
GU review
Incontinence, Frequency/urgency/hesitancy, nocturne, dribbling, colour change, blood, rashes, lumps, sexually active (preg?)
Skin review
itch rashes bruise swelling pigment
MSK review
Joint pain / stiff / swelling, back/neck pain, sore eyes, skin rashes
Haem review
Bruising, Bleeding, Lumps in groin / axilla, PE/DVT
Endocrine review
Heat / cold intolerance, Neck swelling, fatigue, weight change, polydipsia/polyuria
