History taking Flashcards
Introduce yourself carefully:
Name + status
Identification:
- Date of birth
- Sex
- Ethnicity
- (Weight and hight)
The presenting complaint:
O – Onset of event
P – Provocation
Q – Quality of pain
R – Region and radiation
S – Severity
T – Time/signs
Pain assessment model:
S - Site (What exactly is the pain?)
O - Onset (What were they doing when the pain started?)
C - Character (What does the pain feel like?)
R - Radiates (Does the pain go anywhere else?)
A - Associated symptoms e.g. nausea/ vomiting
T - Time/ duration (How long have they had the pain?)
E - Exacerbating/refactors (Does anything make the pain better or worse?)
S - Severity (Obtain an initial plan score)
Past medical history:
Medical history of the patient and maybe important family history.
Past surgical history:
If you have had any surgeries in the past years.
Sample:
S - symptoms
A - allergies
M - medication
P - pertinent medical history (previous)
L - last meal (last oral intake)
E - event leading to the injury or illness
Review of systems:
Brain - lightheadedness, dizziness
Upper body - pain in jaw, neck, arm, upper back
Chest - discomfort, pressure and pain
Lungs - shortness of breath
Stomach - nausea or vomit
Skin - cold sweat
Whole body - fatigue
Family information –>
Family tree
Family history:
- Collected family history can identify whether a patient has a higher risk for disease.
- Family history is considered important risk factors for health problems such as heart disease, stroke, diabetes, and cancer.
- Family tree
Social history:
The social history can provide vital early clues to the presence of disease. It can help you in understanding risk factors and background information that may be essential in formulating differential diagnosis.
- Smoking
- Alcohol
Alcohol equation:
Strength (%ABV) * (volume ml) / 1000 = number of units of alcohol.
Smoking equation:
Number of pack years = (packs smoked per day) * (years as a smoker)
