History taking Flashcards
1
Q
History taking in an older person
A
• Current reason for admission
• History of presenting complaint
o S
o O
o C
o R
o A
o T
o E
o S
• Systemic enquiry
o Falls history
o Assessment of cognition – collateral history to ascertain if any change
o Continence assessment – bowels and bladder history
• Past medical history and disease severity
• Current medication list and compliance
• Drug allergies
• Social and functional history
o Their home (home/Residential home/ Nursing home/Sheltered accommodation)
o Support? POC?
o Mobilisation?
o Any adaptations?
o Alcohol/smoking
o Diet
• Wishes and advance decisions regarding care if appropriate – some people may not want investigations etc. or have advance directives or do not resuscitate orders.
2
Q
what to remember when taking an Older Person history
A
- falls history
- assessment of cognition
- continence assessment
- support at home e.g. POC
- any new changes in. medication (think polypharmacy)
- advance directive e.g. RESPECT form
3
Q
HPC in resp
A
-
Dyspnoea – MRC score, Exercise Tolerance, triggers, relieving factors, diurnal variation, orthopnoea, PND
- how many pillows?
- do you wake up in the night gasping for air?
- Chest Pain – site, severity, radiation, triggers, relieving factors, associated symptoms
- Wheeze – triggers, relieving factors, diurnal variation, associated cough
- Cough – dry or productive, triggers, relieving factors, diurnal variation, association with eating or dyspepsia, positional, nasal secretions, associated fever
- Sputum – how much over 24 hours, colour, consistency
- Haemoptysis – quantity and frequency, fever / night sweats, appetite, weight loss
4
Q
PMH resp
A
- All relevant
- Asthma (previous hospitalisation / ITU)
- COPD
- DVT / PE
- Nasal Polyps
- Previous lung infections, including TB
- Childhood lung infections
- Surgery
- Cardiovascular illness
- Cancer
5
Q
family history resp
A
- Respiratory Disease
- Cardiac disease
- Cancer
- Thrombophilia (if DVT / PE)
- Cystic Fibrosis (if young and chest infections)
6
Q
social history resp
A
- Smoking – current (pack years), ex (pack years, when stopped), never or passive; also vaping
- Occupational History – specifically asbestos
- Pets – specifically cats, birds (budgies, parrots, pigeons) – also friends / neighbours
- Recent Foreign Travel
- Immobility – flights / long car or bus journeys Activities of daily living – self care, cooking, cleaning, shopping, type of accommodation, helpers / carers
- Alcohol
- Performance Status (Cancer)
7
Q
respiratory examination
A
General Inspection
- Take a step back and survey from end of bed
- Any obvious discomfort / pain
- Breathlessness
- Colour / cyanosis
- Purse lip breathing
- Accessory muscles
- Audible noises e.g. stridor / audible wheeze
- Respiratory rate
- Tremor – side effects
- Bedside clues e.g. oxygen, nebs, inhalers, sputum pot, chest drain
Hands
- Clubbing (can also check toes)
- Peripheral cyanosis (can also check toes)
- Nicotine / tar staining
- CO2 retention flap
Face
- Eyes for Horner’s syndrome
- Mouth – central cyanosis
- Swelling - SVCO
Neck
- Trachea
- JVP
- Lymph Nodes
Chest Inspection
- Shape
- Scars
- Drains
- Abdo / back inspection
Chest expansion and percussion
Chest Auscultation
- Normal (vesicular)
- Absent
- Pneumothorax
- Pleural effsion
- Crackles – if heard ask patient to cough then listen again
- Fine crackle
- ILD (Velcro in PF), CHF
- Coarse crackles
- Wheeze
- asthma
- Fine crackle
- Stridor
- Upper resp obstruction
- Bronchial Breathing - pneumonia
Vocal Resonance (99- with hands or auscultating)
- Normal
- Reduced – COPD, asthma air or fluid in pleural space or decrease in lung density
- Increased – pneumonia ()solfi transmits more sound than liquid or air)
Complete your examination
- Look at legs
- State that you would like to see Observation chart
- PEFR if appropriate
- Cover patient / help them get dressed
- Thank the patient
Presenting findings
- Good eye contact
- Positive findings from history and examination
- Consider differential diagnoses and investigations to help distinguish these
- Remember basic relevant basic science, e.g. pathophysiology, microbiology, pharmacology, etc.
- Guide the patient through each step and be conscious of their comfort
8
Q
presenting complaints in cardio
A
- Chest pain
- Cardiac
- Angina
- Unstable angina
- MI
- Aortic dissection
- Pericarditis
- Non-cardiac
- MSK
- PE
- Pneumonia
- GORD
- Gall stoes
- Cardiac
- Syncope
- Palpitation
- Shortness of breath
- Limb pain and swelling
9
Q
HPC chest pain
A
- Use Socrates
- Site
- Onset
- Character
- Radiation
- Associated symptoms
- Time course
- Exacerbating and relieving
- Severity
- Cardiac or non cardiac
- Cardiac
- Diffuse
- Crushing
- Radiates to neck and arm
- Associated with feeling unwell
- Worse on activity
- Non-cardiac
- Focal
- Sharp
- Precipitated with breathing
- Improves on rest
- Cardiac
10
Q
HPC syncope
A
-
Before
- Any trigger?
- Prodrome?
- Faint
- Dizzy
- Sick
- Ringing in ears
- Visual disturbances
- Palpitations
- Did the patient change colour?
-
During
- How long unconscious
- Convulsions?
- Character?
- Any tongue biting
- Any incontinence
-
After
- How long was the recovery
- Was it witnessed
11
Q
HPC palpitation
A
-
Onset
- When?
- Sudden?
- What were you doing
- Precipitating and relieving factors
- Rate and rhythm
- How dast did they feel?
- Does it feel regular or irregular?
- Do you feel like you are missing a heartbeat
- Could you tap out the pattern of the palpitations
- Duration and frequency of palpitations
- Adverse clinical features associated with palpitations
- Syncope
- Pre-syncope
- Chest pain
- SoB
- Sweating
- Extreme fatigue
- Associated symptoms
- Chest pain
- Low mood
- Tremor
- Sweating
- Heat intolerance
- Weight loss
- Productive cough
- Fatigue
- Vomiting and diarrhoea
12
Q
HPC SoB
A
- Onset and duration
- Acute, chronic, constant, intermittent
- Exacerbating factors
- Allerviating factors
- Rest
- Inhalers
- GTN
- Timing
- Associated symptoms
- Wheeze or stridor
- Cough: productive or dry? Colour?
- Chest pain: pleuiritic or cardiac sounding
- Palpitations
- Ankle swelling
- PND
- Orthopnoea
- Exercise tolerance- quantify how far the patient can walk before stopping due to SoB
13
Q
HPC limb pain and swelling
A
-
Onset and duration
- Pain constant or intermittent
-
SOCRATES
- Cramping
- Numbness
- Pain
- Tingling
- weakness
-
Exacerbating factors
- Walking
-
Relieved by
- Rest
-
Any swelling?
- Are you taking any water tablets
- Do they go down when you lie flat?
-
Breathing
- How many pillows do you sleep with?
- Do you wake up during the night gasping for air?
14
Q
Quick Systems Review (if time in exams)
A
- Weight loss, night sweats, loss of appetite
- Any fainting, changes in eyesights, headaches
- Bowels ok? Appetite / weight loss
- Any problems with your water works?
- Joint pains? Rashes?
- Neuro / Cardio
15
Q
PMH cardio
A
- All relevant
- Cardiac
- Heart failure
- MI
- Diabetes
- High cholesterol
- Stroke
16
Q
FH cardio
A
- Respiratory Disease
- Cardiac disease
- Cancer
- Thrombophilia (if DVT / PE)
- Cystic Fibrosis (if young and chest infections)
17
Q
SH cardio
A
- General social context
- Type of accom
- Who they live with
- Any carer input
- Carry out tasks independently
- Smoking – current (pack years), ex (pack years, when stopped), never or passive; also vaping
- Recreation drug use
- Diet
- driving
- Occupational History – specifically asbestos
- Pets – specifically cats, birds (budgies, parrots, pigeons) – also friends / neighbours
- Recent Foreign Travel
- Immobility – flights / long car or bus journeys Activities of daily living – self care, cooking, cleaning, shopping, type of accommodation, helpers / carers
- Alcohol
- Performance Status (Cancer)
18
Q
endocrine history
A
Hormones produce widespread effects in the body, and states of hormonal deficiency or excess typically present with symptoms that are generalized, diffuse and nonspecific. Symptoms of tiredness, weakness or lack of energy or drive and changes in appetite or thirst are common presentations. Other typical ‘hormonal’ symptoms include changes in body size and shape, problems with libido and potency, periods or sexual development, and changes in the skin (dry, greasy, acne, bruising, thinning or thickening) and hair (loss or excess). The differential diagnosis is often wide but endocrine disorders should be always considered when assessing a patient with any of these common complaints.
The past, family and social history is essential for making the diagnosis, planning appropriate management and inter- preting results of borderline hormonal blood tests.
- The past history should include previous surgery or radiation involving endocrine glands, menstrual history, pregnancy and growth and development in childhood.
- A full drug history will exclude common iatrogenic endocrine problems
- A family history of autoimmune disease, endocrine disease including tumours, diabetes and cardiovascular disease is frequently relevant, and knowledge of family members’ height, weight, body habitus, hair growth and age of sexual development may aid interpretation of the patient’s own symptoms.
19
Q
rheumatology HPC think about
A
pain
stiffness
swelling and deformity
fatigue
weakness
20
Q
rheumatology pain
A
- Most common presenting complaint
-
Site
- Originators for pain: synovium, joint capsule, subchondral bone and peri-articular muscle
-
Onset
- Was onset acute e.g. gout, PMR or insidious e.g. RA and SLE
- Nocturnal pain? E.g. inflammatory or destructive process
-
Character
- What type of pain is it?
- Neuralgic pain- burning pins and needles
-
Radiation
- Does the pain radiate?
- Could this be referred pain e.g. aaa causing back pain, diaphragmatic pain referred to the shoulder, intervertebral disc prolapse causing radiculopathy
- Associated symptoms
- Timing
-
Exacerbating/relieving factors
- Pain aggravated by rest (inflammatory arthritis) or activity (OA)
- Better with NSAIDs or steroids (inflammatory)
- Is pain worse on particular movement e.g. indicated peri-articular pathology (e.g. resisted wrist extension in tennis elbow)
-
Severity
- How bad is it?
- Is this truly articular pain or is it peri-articular (tenosynovitis seen in RA, achilles tendinitis and lateral epicondylitis seen in PsA)
- Pain due to tenosynovitis or tendinitis is usually triggered only by certain movements
- Lateral epicondylitis (tennis elbow) will be felt on the outside of the elbow joint. Worse on resisted elbow extension.
- Achilles tendinitis felt just above the heel and is worse on active plantar flexion
- De querbains tenosynovitis is felt in the snuffbox area of the wrist and is worse when pinching or using thumb to operate a smart phone
- Could this be muscular pai- fibromyalgia and inflammatory muscle disease
-
Pattern of joint/muscle involvement
- Is it proximal (PMR)
- Is it distal (OA, gout, PsA)
- Small joint only? Early stages of RA
- Large joints only? OA
- Large and small joints? Later stages of RA
- How many joints?
- 1 joint= monoarticular
- 2-4 joints= oligoarticular or pauciarticular
- >4 joints= polyarticular
- Symmetrical (RA) or asymmetrical (PsA and gout)
- Is the spine involved (not usually in RA, may be in PsA and is the main feature of AS
21
Q
joint distribution in various rheumatic diseases
A
22
Q
rheumatology stiffness
A
- Feeling of difficulty moving a joint
- Ask
- Duration of early morning stiffness
- >30 mins- inflammatory arthritis e.g. RA or PsA
- If generalised more likely to be inflammatory
- Patients with ankylosing spondylitis typically have spinal stiffness in the early hours of the morning such that they have to get out of bed to ease it
- Duration of stiffness is an indicator of disease activity or how well its being controlled
- If localised to a joint then stiffness is likely to be mechanical
- Brief ‘inactivity gelling’ is common in knee OA
- Gel phenomenon is a condition that occurs when a joint has been too long at rest and the synovial fluid becomes thickened
- Duration of early morning stiffness
23
Q
rheumatology joint swelling and deformity
A
- How rapidly did the swelling come on? E.g. gout comes on in around an hour
- Any preceding injury?
- How long does it last ? if transient i.e. less than 24 hours then it is unlikely to be significant
- Is the swelling parallel to the joint line, indicating true joint swelling, or is it linear, crossing the joint line e.g. extensor tenosynovitis at the wrist seen in RA
- Is the swelling bony (Heberden’s and bouchardes in OA)
- Soft and tender? (clinical synovitis)
- Does the swelling extrude chalky material (tophi in gout)
- Does the swelling extrude hard yellowish lumps (calcinosis in systemic sclerosis)
24
Q
rheumatology fatigue
A
- Patients with fibromyalgia feel tired from the moment they wake up, so called ‘unrefreshed sleep’
- Inflammatory arthritis- fatigues after several hours into their days activity
- Distinguish between fatigue and depression
- Distinguish between fatigue and muscle weakness
25
Q
rheumatology weakness
A
- Many patients complain of dropping things and difficulty with grip
- Could be joint disease and pain on trying to do things with affected limb, or it may be neurogenic (e.g. foot drops S1 root compression due to intervertebral disc prolapse, or compression of the median nerve in carpal tunnel syndrome) or it may be muscular in origin (e.g. proximal weakness in polymyositis)
27
Q
rheumatology systems review part 1
A
28
Q
rheumatology systems review part 2
A
54
Q
abdominal pain locations
A
use SOCRATES
