History Taking Flashcards
1
Q
What are the parts of SOCRATES
A
- Site
- Onset
- Character
- Radiation
- Associated symptoms
- Timing – duration, course, pattern
- Exacerbating/relieving factors
- Severity
- Functional consequences
2
Q
What should be asked about PMH?
A
- JAMTHREADS
- Visit health care professional regularly for anything
- Chronic conditions
- Past surgery’s
- Adverse effects with management of conditions or surgery – anaesthesia
3
Q
What should be asked about drug and allergies?
A
- For each drug – name, dose, frequency, route of administration, indication
- Ask about prescription medicine (ask oral contraceptive pill), over the counter, complementary/alternative medicines, recreational drugs
- Allergies and effect
- Other sensitivities
4
Q
What should be asked about FH?
A
- Ask if aware of any conditions running in family
- Ask about parents – age/death and what died of, health
- Ask about brothers and sisters – health
- Ask about children – health
5
Q
What should be asked about social history?
A
- Occupation
- Hobbies
- Exercise
- Diet
- Smoking – duration and amount
- Drinking – amount and type
- Substance abuse
- Household members
- Social circumstances
- Pets
- Overseas travel
6
Q
General
A
- Fatigue/malaise
- Fever/rigors
- Weight/appetite
- Thirst
- Neck swelling/lumps
- Sleep disturbance
- Night sweats
- Pruritis (itchiness)
- Skin – rashes, bruising, bleeding
7
Q
Resp
A
- Cough
- Sputum – colour
- Haemoptysis (cough up blood)
- Chest pain (pleuritic – stabbing pain)
- Dyspnoea (shortness of breath)
- Wheeze
- Sinusitis – block nose, nasal discharge, reduced smell, facial pain
- Earache
- Sore throat
8
Q
CVS
A
- Chest pain
- Dyspnoea – at rest/on exercise/orthopnoea (lying down)/paroxysmal nocturnal (sudden attack at night)
- Palpitations
- Ankle oedema
- Varicose veins
- Claudication
9
Q
Alimentary
A
- Appetite/weight loss or change
- Mouth/teeth/tongue
- Dysphagia (problems swallowing)
- Dyspepsia (heartburn)
- Nausea/vomiting
- Haematemesis
- Jaundice
- Abdominal pain
- Abdominal distension
- Fat intolerance
- Bowel habit
- Change/constipation/diarrhoea/blood/mucus/melaena/foecal incontinence
- Perianal symptoms
- Haemorrhoids, pain, itching
10
Q
Neuro
A
- Vision
- Acuity, diplopia
- Speech disturbance
- Balance
- Dizziness/vertigo
- Hearing
- Cognitive impairment (use mental state assessment)
- Headache
- Fits/faints/loss of consciousness
- Weakness
- Numbness/tingling/paraesthesia
11
Q
Genito-urinary
A
- All
- Frequency/dysuria/nocturia/polyuria/oliguria
- Haematuria
- Incontinence/urgency
- Males
- Prostatic symptoms – difficulty/stream/dribbling
- Erectile dysfunction
- Sexually active
- Females
- Last menstrual cycle
- Postmenopausal bleeding if menopausal
- Cycle (regularity, duration and degree of bleeding)
- Intermenstrual or postcoital bleeding
- Gestation/expected date if pregnancy
- Obstetic history parity/gravidity
- Sexually active
- Contraception/hormonal replacement therapy
- Vaginal discharge
- Date of last cervical smear
12
Q
MSK
A
- Do you have any pain or stiffness in your muscles, joints or back
- Can you dress yourself completely without any difficulty
- Can you go up and down stairs without any difficulty
- Is there a history of trauma and what was the mechanism of injury
13
Q
Information giving
A
- Take history
- Explain
- What does patient think cause is, what do I think cause is
- Further investigations to help formulate diagnosis
- Treatment – symptomatic, curative or support like counselling or time of work
- Negotiate
- Incorporate patients perspective
- Summarise patients perspective
- Understand there concerns and expectations
- Plan
- Suggest plan
- Ask patient how they feel about that and negotiate as above, summarise there points, ICE
14
Q
SBARR
A
- Situation
- Who – introduce yourself, clarify name and grade of person speaking to and provide basic details of patient
- Where – provide patients location
- When – provide timing of current problem
- What and why – clear what aspects of management need advice on, explain current working diagnosisis
- Background
- Admission reason
- Date of admission
- Current diagnosis
- Past medical and surgical history
- Medications and allergies
- Investigation results
- Current management and patients response
- Assessment
- Vital signs – BP, pulse, RR, oxygen saturation and temperature
- Examination findings, ABCDE approach for acutely unwell patient
- Overall clinical impression
- Recommendation
- Suspected diagnosis, what I think needs to happen and in what time frame I expect those things to happen
- Response and review
- Check that I have understood current situation and ask any questions
- Clarify expectations of response
- Document the discussion in patients notes
- Thank person
15
Q
What do you ask for menstal status questionaire (MSQ)?
A
Mental Status Questionnaire, score less than 7 indicates cognitive impairment, max score 10:
- Town
- Address
- Year
- Month
- Date
- Age
- Month born in
- Year born in
- Name of prime minister
- Previous prime minister
