History Taking Flashcards
Components of history taking?
- presenting complaint
- history of presenting complaint
- review of other systems
- past medical history
- drug history
- allergies and intoxications
- family history
- social history
Patient particulars and source of history?
- Name
- Age
- Sex
- Occupation – current and relevant previous
- Place of residence
- Marital status
- Next of kin and phone number or contacts
- Mention the source of the history
Presenting complaint?
- Very brief but in patients own description eg Chest pain
- Duration: hours, days, months etc.
Note: If more than 1, then indicate in order of importance – 1, 2, 3
History of presenting complaint?
- Should be in patients own phraseology
- Indicate duration
- Should be chronological indicating the order in which symptoms presented
- More enquiry should be focused on the most likely system involved
For each complaint what should you address?
- nature of complaint
- location of symptoms
- time of onset, duration, frequency
- severity and effect on lifestyle
- what brings on or increases the symptoms and what relieves them
- associated other symptoms
- therapeutic interventions and responses
- patients beliefs about aetiology, diagnosis and prognosis
- what made the patient present now
- pertinent risk factors
What mnemonic do you use to describe pain?
SOCRATES
1. site
2. onset
3. character
4. radiation
5. associated factors
6. time
7. exacerbating/alleviating factors
8. severity
Which systems are reviewed?
- cardiovascular system
- respiratory system
- GIT system
- genitourinary system
- neurological system
- hematological system
- endocrine system
- musculoskeletal system
- head, ears, eyes, nose and throat + mouth
Review of Cardiovascular system?
- Breathlessness – at rest, on exertion, differences between night and day, precipitating factors, number of pillows, worse when lying flat (orthopnoea), worse when lying in bed at night (paroxysmal nocturnal dyspnoea)
- Chest pain – site, onset, character, radiation, severity, aggravating and relieving factors, accompanying symptoms e.g. N/V for GERD or breathlessness
- Dizziness
- Edema – or swelling of the feet/ abdomen/and other parts of the body
- Heart palpitations: note quality - (periodic) rapid beats or irregular beats, associated symptoms
- Peripheral vascular system – intermittent claudication (pain in calves, or buttocks – worse on exertion and relieved by rest), cold feet and hands (Raynaud’s phenomenon)
- passing urine at night (nocturia): how frequent
Respiratory system?
- Cough – duration, dry, wet or productive
- Sputum – color, frothy, bloody
- Breathlessness
- Wheeze
- Hoarseness of voice
- Chest pain
- Hoarseness
- Nasal discharge or obstruction
- Loss of weight
- Sweating
- Occupation
- Smoking - number of cigarettes per day/years = pack years
Gastrointestinal system?
- Pain – SOCRATES
- Appetite
- Difficulties in swallowing (dysphagia – solids vs liquids) vs pain on swallowing (odynophagia)
- Vomiting
- Diarrhea – duration, watery/ bloody, Volume, precipitating or relieving factors
- Flatus
- Jaundice
- Flatulence – discomfort caused by gaseous accumulation
- Weight loss
- Constipation
Central nervous system?
- Mental state – memory/ delusions/ hallucinations/ agitation/ intellectual capacity
- Loss of consciousness
- Headache
- Weakness or paralysis of part of the body
- Abnormalities of gait
- Numbness or pins or needles
- Dizziness/ giddiness
- Speech disturbances
- Visual disturbances
- Tremors
- Deafness
- Sphincters
Endocrine?
- Hair
- Weight
- Pigmentation of skin
- Flushes
- Sweating
Hematopoetic?
- Blood loss
- Sore tongue – signs of pernicious anemia
- Bruising
- Symptoms of anemia
Musculoskeletal system?
- Joint pains
- Swelling
- Stiffness
- Mechanical dysfunction
- Associated systemic symptoms
Past Medical/Surgical History?
- Previous Surgical procedures
- Previous admissions
- Important medical history – HIV/ DM/ HTN/ Epilepsy/ Asthma
- Vaccinations
- Obstetric and Gynae history
Drug history?
- Adverse effects
- Over the Counter medicines
- Doses of medicines
- History of recreation drug uses
- Traditional medicine use
Family and social history?
- Marital status plus number of children
- Genetic diseases
- Smoking
- Alcohol
- Occupation
Alcoholism screening?
CAGE
What are the CAGE questons?
- Have you ever felt you should Cut down on your drinking?
- Have people Annoyed you by criticizing your drinking?
- Have you ever felt Guilty about your drinking?
- Have you ever had a drink first thing in the morning (Eye opener)?
Interpretation of CAGE score?
- total score of 0 or 1 - low risk of problem drinking
- total score of 2 or 3 - indicates high suspicion for alcoholism
- total score of 4 - virtually diagnostic of alcoholism
How do you calculate alcohol units?
total volume of drink in ml x alcohol by volume % (ABV)/1000 = units
What are the normal alcohol units?
no more than 14 units of alcohol a week
- spread across 3 days or more
How do you calculate pack years?
number of cigarettes smoked per day/20 cigarettes x years smoked = pack years
What is considered binge drinking?
> 6 units a day in women
8 units a day in men
