History Taking Flashcards
What is the role of a doctor?
To make a diagnosis
To help the patient understand the cause of illness as well as its significance
Work with the patient to plan how to manage the illness
How does a doctor make a diagnosis?
Pattern of symptoms suggest a diagnosis
Is the patient a likely candidate for the diagnosis considering:
Age, lifestyle, risk factors, predispositions
What are symptoms?
What a patient complains of due to a particular disease
What is the structure of a history?
Name and age
Presenting complaint
History of presenting complaint
Past medical history
Medications and allergies
Family history
Social/Personal history
Review of systems
How would you ask for someone’s presenting complaint?
What brought you into hospital today?
How would you inquire for the history of the presenting complaint?
Can you tell me more about the problem that brought you into hospital?
What do we want to get from the history of the presenting complaint?
Temporal sequence
Full description of the symptom
Risk factors that the symptom suggests
In relation to temporal sequence, what are we looking for?
Mode of onset
Reason for seeking attention now (degenerative etc.)
Duration of the symptom
Similar symptoms in the past
What questions would fall under past medical history?
Have you been in hospital before?
Have you had any medical illnesses?
Have you had any investigations in the past?
Have you had any operations?
How would you ask about medications and allergies?
Are you on medications at present?
Are you allergic to any mediactions?
What questions can you ask about family history?
Are there any illnesses that run in your family?
Are your parents still alive?
Are your brothers and sisters well?
What would you ask under social/personal history?
Smoking
Alcohol
Social supports
Occupation
Type of accommodation
Education
Sexual activity
Travel
Diet
What is angina?
Narrowing of the coronary arteries due to atherosclerosis
Limits rate of blood flow through the coronary arteries to heart muscle especially during exercise
How do we confirm the diagnosis of angina?
Stress test and coronary angiography
