History taking Flashcards
What types of communication can be used when taking a patients history?
one way
two way
open questions
closed questions
What barriers to communication could you come across, how could these be overcome?
language barriers
level of understanding
What is asked during the presenting complaint part of history taking?
Patients own words of what is wrong with them
What is asked during the history of presenting complaint part of history taking?
SOCRATES
What is asked during the previous medical and surgical history part of history taking?
Chronological order of any common medical conditions they might have or had, and any surgerys
What is asked during the drug history part of history taking?
What drugs do they take? to make it easier Is there a prescription list? Do they take everything on the list and is it updated?
Any other OTC, or illicit drugs?
What is asked during the family history part of history taking?
Any relatives die young, if so why?
Any medical history in CLOSE family members?
What is asked during the social history part of history taking?
Smoke, alcohol use
Sedentary?
Stress levels?
What is the order of sections under history taking?
Presenting complaint history of presenting complaint drug history family history social history
What does SOCRATES stand for?
Site Onset Character Radiation Associations Time Exacerbating and relieving factors Severity
What questions could be asked for the first S of Socrates (Site)?
Where is the pain?
Where is the main site of pain?
What questions could be asked for the O of Socrates (Onset)?
When did the pain start, was it sudden or gradual?
Is it progressive, regressive, intermittent?
What questions could be asked for the C of Socrates (Character)?
How would you describe the pain?
What questions could be asked for the R of Socrates (radiation)?
Does the pain radiate anywhere else?
What questions could be asked for the A of Socrates (associations)?
Any other signs or symptoms associated with the pain?
What questions could be asked for the T of Socrates (Time)?
How long has the pain been present?
Does it follow any pattern?
What questions could be asked for the E of Socrates (Exacerbating and relieving factors)?
does anything make the pain better or worse?
Does anything change the pain?
What questions could be asked for the last S of Socrates (Severity)?
How bad is the pain from 0-10?