History taking Flashcards
How should you start a history?
Wash your hands and don PPE if appropriate.
Introduce yourself to the patient including your name and role.
Name and date of birth.
Explain that you’d like to take a history from the patient.
Response
Can you tell me how you have been feeling?
What should be asked in a urinary history?
Frequency (UTIs)
Output
Urgency (detrusor instability)
Night time (bph)
Dysuria: typically associated with urinary tract infection
Blood: associated with UTIs, trauma (e.g. catheter insertion) and renal tract cancers (e.g. bladder cancer, renal cancer).
Itching or vomiting
Rigors or fevers
Dribbling
How else can you take a urinary history?
Frequency Urgency Nocturia Blood (y) Dysuria (a) (y) Appearance Not able to go Dribbling (n) Itching (g) (h) terminal dribbling
OR
Frequency, urgency, nocturia, blood, appearance, dribbling, itchy, smells, sex
What can you use for red flags?
Blood Unitentional weight loss Fever F(vomiting) Sweats Secretions
What technique can you use to take a history?
What? When? Where? Why? How? History?
What is required for a rheumatological history?
Pain Rashes, skin lesions and nail changes Immune Stiffness Malignancy Swelling and sweats
What questions should you ask for a fall?
Before: What were you doing Where did it happen When Any flashing lights Any change in temperature Any numbness
During
Did you lose consciousness
Did you wet yourself
Did you hurt yourself
After Did you have any weakness Strange movements Any pain Bleeding
Have you fallen before
What questions should you ask for a fall?
Before: What were you doing Where did it happen When Any flashing lights Any change in temperature Any numbness
During
Did you lose consciousness
Did you wet yourself
Did you hurt yourself
After Did you have any weakness Strange movements Any pain Bleeding
Have you fallen before
What should be asked in a sexual history?
Blood? Ulcers? Dysuria? Discharge? Itchy/ itching? Exacerbated? by Sex?
BUDDIES
What is a key aspect of the stroke history?
Event - what happened Precipitating factors - diabetes, AF Onset Severity Time Engagement and activities Driving, dominance
What questions should be asked in a respiratory history?
MR CHEST
Muscle wasting
Rash
(Swelling calf)
Cough Heamoptysis Exertion Sputum Temperature
What associated symptoms should you check for in chest pain?
PC BOTSSS
Palpitations Cough Breathless Orthopnea + Temperature Sweating Sickness Sputum
Causes of a funny turn?
The potential diagnoses vary widely, and include neurological, cardiovascular, metabolic, vestibular, and psychological conditions.
Systemic problems with cancers?
Back pain Blood Night sweats Weight loss Fevers
What should you always ask about for PMH? (madidas)
MI Anaemia Diabetes Ischaemic heart disease Dyslipidemia Asthma Surgeries
