History Taking Flashcards
Example Q do start consultation
“could you tell me little bit about what brought you in today”
How do you start every history?
- Wash Hands
- “Hello my name is Olivia and I am a third yr medical student. Can I confirm your name and date of birth”
What does SOCRATES stand for
Site, onset, character, radiation, associated symptoms, timing, exacerbating and relieving factors, severity
PMH: what questions should you ask? (5)
- Do you have any other medical conditions that I should know about?
- Have you had any significant illness?
- Have you had any operations or durations in hospital?
- How is your mental health?
- Specific conditions
What specific conditions should you ask about in PMH? (7+1)
- Heart attack (MI)
- Hypertension/ high BP or heart disease
- Asthma/ COPD
- Diabetes
- High cholesterol
- Stroke
- Epilepsy
- TB
Drug History: what Qs (5)
- Do you take any medications?
- Do you taken OTC medications?
- If said yes to condition: is condition well controlled? compliance? side effects?
- Herbal medicine
- Allergies
Family history Qs? (2)
- Any disease that run in the family?
- ask about specific relevant conditions?
Social history Qs?
- Living conditions: live with anyone? any dependents? What accommodation?
- ADL? keeping up?
- Occupation
- Hobbies
- Pets
- Alcohol
- Smoking
- Recreational drugs
- Diet
- Sleeping
What ideas Q (ICE)
do you have any ideas about what this might be yourself?
What Concerns Q (ICE)
what are you concerned that it might be?
what Expectations Q (ICE)
what were you hoping to get out of this consultation?
What systems review questions?
- Headaches
- Numbness or tingling
- B symptoms (night sweats or weight loss)
- Fatigue
- Lumps
- Chest pain
- Breathlessness/sob
- palpitations
- Cough
- Abdo pain
- Nausea and Dominic
- change in bowel habit
- incontinence
- Periods
- paint, stiffness and swelling
Cardiovascular systems review (8)
- Chest pain
- Palpitations
- SOB at rest or on exertion
- Breathlessness on lying flat and how many pillows
- Breathlessness at night
- Ankle swelling
- Poor circulation
- Pain in calves when walking
Respiratory systems review (6)
- Cough
- Sputum
- SOB
- Wheeze
- Recent illness
- Fever
Gastrointestinal systems review (11)
- Nausea/ vomiting
- Appetite + diet or weight changes
- Swallowing difficulties
- Indigestion/ acid reflux
- Abdominal pain
- Jaundice
- Change in bowel habits
- Pain on defection
- Constipation, diarrhoea
- Blood/mucus/slime
- Incontinence
Neurological systems review (10)
- Headaches
- visual/ hearing/ speech disturbances
- dizziness/ vertigo
- faints/ fits/ blackouts
- Numbness
- Weakness
- Tingling
- Sleep disturbances
- Tremors
- concentration/ memory
Genitourinary systems review (9)
- Incontinence
- Frequency/ urgency
- Hesitancy/ dribbling
- Dysuria
- Nocturia
- Haematuria
- Genital rashes/ lumps
- Sexual history
- Periods, possibility of pregnancy
Endocrine systems review (10)
- Heat or cold intolerance
- Hair, nails + skin
- Fatigue/ energy levels
- Tremor
- Neck swelling
- Weight change
- polydipsia and polyuria
- Sleep + diet
- Periods
- Possibility of pregnancy
Skin systems review (7)
- Itch
- Rash
- Bruising
- Swelling
- Lumps
- Ulcers
- pigmentation changes
Haematological systems review (5)
- Night sweats
- Weight loss
- Bleed excessively
- Bruise easily
- Lumps (axially, neck + groin)
Musculoskeletal systems review (3)
- Joint pain, stiffness or swelling
- Recent trauma
- Skin rash
Mental health systems review (7)
- Mood
- Self harm + suicide
- Sleep and diet
- Energy levels
- Unusual beliefs/ delusions
- Memory problems/ cognitive impairments
- Learning difficulties
What are different causes of LOC (categories)?
- Neuro
- Cardiac
- Vasovagal
Questions to ask for falls history? What do you ask about before the fall?
- Was it witnessed
- Pre-syncopal symptoms; dizzy, light headed, palpitates
- What were you doing: getting up from lying down, toilet, walking
- How do you normally walk (walking aid)
Questions to ask for falls history? What do you ask about during the fall?
- Do you remember falling?
- Was it witnessed?
- Was there any LOC?
- Did you put out your hands to break your fall?
Questions to ask for falls history? What do you ask about after the fall?
- Any limb jerking?
- Urinary/faecal incontinence?
- How well orientated following the fall?
- Able to mobilise independently following fall?
- How long on the floor for?
What Qs to ask in Urinary history relating to sexual history? (5)
- Any new sexual partners
- Difficulty achieving or maintaining an erection
- (F: abnormal dryness)
- Any itching, redness or rash in genital region
- Any history of STIs (recently checked)
