history Flashcards
What are the different parts in history taking?
PC HPC PMH D and A FH SH Systemic enquiry Summary - see if the patient agrees - is there anything more you'd like me to know about at the end. ICE
What s in PC
Cause for presentation/most important symptoms
Duration of symptoms
Whats in History of presenting complaint
Details of all current symptoms Site Onset Characteristics Radiation Associated Symptoms Timing (Duration, Course, Pattern) Exacerbating/Relieving factors Severity Functional Consequences
Whats in PMH / Surgical history?
Notable illnesses/surgery/GP managed long term condition
Notable adverse events / problems during management of illness
Whats in Drugs and Allergies?
Drugs - name, dose, frequency, route of administration
Include prescriptions, over the counter and complementary / alternative medicines, and recreational drugs
Allergies:
Allergens - medicines and otherwise
Effect
Other sensitivities/ significant adverse or sensitivities to medicines
Whats in Family history?
First degree relatives:
- age and current health/cause of death/ age of death
- Details of notable illness
Ask about extended family if history is strong
Whats in Social History?
Smoking - Duration and amount Alcohol - amount and type Substance abuse if not covered in Drugs history Excercise - time spent exercising every week Social circumstances Household members if relevant Work circumstance Hobbies Pets Overseas travels
Whats in a General Systemic enquiry?
Fatigue / malaise Fever / rigors Weight / appetite Skin : Rashes/bruising/ bleeding Sleep disturbances Thirst Pruritus Night sweats Neck swelling/lumps
Whats in a Resp systemic enquiry?
Cough Sputum Haemoptysis Dyspnoea Wheeze Chest pain Symptoms of sinusitis: - Blocked nose - Nasal discharge - Facial pain - Reduced smell Earache Sore throat
Whats in a CVS systemic enquiry?
Chest pain Dyspnoea - at rest / on ex/ orthopnoea / proxysmal nocturnal Palpitations Ankle Oedema Varicose veins Claudication
Whats in a GI/ alimentary systemic enquiry?
Appetite/ weight loss or change Mouth / teeth / tongue Dysphagia Dyspepsia/heart burn Nausea / vommiting haematemesis Jaundice Abdominal pain Abdominal distension (+bloating) Bowel habbit: Change/ constipation/ Diarrhoea / blood / mucus/melena /feacal incompitence Perineal symptoms haemorrhoids eg pain / itching
Whats in a repro systemic enquiry?
Frequency/ dysuria/ nocturia/ polyuria/ oliguria
Haematuria
Incontinence / urgency
Males:
Prostatic symptoms - dificulty / stream / dribbling
Erectile dysfunction
sexually active?
Females:
Last menstraul period Gestation/ EDD if pregnant post menopausal bleeding if menopausal Cycle - regularity, duration and degree of bleeding) Intermenstraul or post coital bleeding Intermenstrual or postcoital bleeding Contraception / HRT / sexually active Date of last cervical smear Obstetric history parity / gravidity Vaginal discharge
Whats in a Nervous system systemic enquiry?
Speech disturbances Cognitive impairment (Use MSQ) Headache Fits/faints/ loss of consciousness Dizzines or vertigo Balance Vision - acuity, diplopia Hearing Weakness Numbness/tingling/ paraesthesia
Whats in a MSK systemic enquiry?
Do your have any pain or stiffness in your muscles back or joints?
Can your dress yourself completely without difficulty?
Can you go up and down the stairs without any difficulty?
Is there any history of trauma?
Whats in a psychiatric systemic enquiry?
Mood - depression, euthymic, elated
Anxiety/ panic symptoms?
Memory problems/ confusion
Abnormal thought content - odd ideas, paranoi, obsessions
hypochondrial concerns
Perceptual abnormalities / hallucinations
Risk to self or others
Insight into illness - the need for medication treaatment or to be in hospitaL
