History Taking Flashcards
What are the typical history taking tasks?
Take a focused history from the patient (role player)
Assess the severity of the condition based on discussion with patient/parent
Counsel the patient as to the possible causes for his/her presentation
Formulate an appropriate diagnostic workup or management/disposition/follow-up plan and communicate this to the patient
Answer the examiner’s questions regarding the differential diagnosis and further patient assessment.
Outline to the examiner the focused history you would obtain in order to diagnose a condition e.g. clinically clear the cervical spine
Give your differential diagnosis and clinical examination approach to the examiner
What are the elements of health advocacy that are assessed?
- Facilitates an adequate follow up plan
- Incorporates the patient’s chronic clinical state and their wishes when making decisions
- Implements strategies to prevent a patient ceasing their emergency care prematurely
- Provides understandable instructions for the patient on discharge, including likely progression of their clinical course, and reasons to return
- Explains to patients and/or their guardians the rationale for management decisions
- Integrates communication skills relevant to the patient’s culture to enhance delivery of health advice to patients
- Refugee Health - Identifies findings on assessment that increase the likelihood of a patient being vulnerable
- Tailors treatment and disposition decisions for a patient to account for the presence of vulnerability factors
What are some tips for history taking?
- The social history should always be explored as it often impacts the discharge advice and possible underlying cause of complaint
- Address all the tasks of the station (ie Hx, DDx, Ix and discharge)
- Pay careful attention to the role player, they will only give relevant information
- Apart from the initial open-ended question, used focused questions as the actors won’t volunteer information
Basic Psychiatric history taking? Further investigations
History
1- Explore reason/circumstances of presentation
2- Screen systemic symptoms (fevers, trauma, weight loss, infectious symptoms)
3- Past medical/Psych history
4- Illicit drug (ie meth) and medicine (ie anticholinergics) history
5- Orientation TPP
6- Basic MSE (hallucinations, delusions, homicidal/suicidal etc)
7- Social/forensic/sexual
Ix
- FBE/UEC, CK, LFT’s, ECG
- +/- CTB and CXR
- +/- LP
- +/- septic screen
- +/- drug/toxin panel (ie paracetamol level)
- +/- endocrine panel (ie TSH)
- +/- Bladder scan (ie anticholinergic delerium)
Delirium history approach and workup priorities?
Definition
- Disturbance in attention and awareness
- Develops over short period of time
- Fluctuant
- Not better explained by pre-existing pathology ie dementia, psychiatric disorder, neurocognitive disorder or coma
Causes
Substrate deficiency
- BSL, 02, CO2
- Thiamine, B12
Focal CNS pathology
- Stroke, SAH, tumour, bleed
- Hypertensive crisis
Toxidrome
- anticholinergic
- Paracetamol, salicylates, digoxin
- Psychotropics, anticonvulsants
- Diuretics
*Infectious cause
- Meningoencephalitis
- Other infections
Electrolyte derangment
- Hyponatraemia most common
- Hypernatraemia, hypercalcaemia
Metabolic/Endocrine derangment
- DKA, HHS, Uraemia, Azotaemia
- Hyper/hypothyroid
*Organ damage
- MI, PE, CCF, AKI, liver failure
Scoring Systems
MMSE
- for both delerium and dementia
- Score out of 30, needs pen and paper
- More for inpatient teams
bCAM
- Designed for ED delirium and concussion screening
- Altered mental status or fluctuating course? (yes = proceeed, no = stop)
- Innatention (name the months backwards from December to July) 2 or more errors then proceeed
- Altered level of consciousness? yes = delerium, no = proceed
- Disorganised thinking? (will a stone float on water? Are there fish in the sea? 1kg weigh more than 2kg? Does a hammer pound a nail? Hold up X fingers with each hand) If any errors then bCAM positive
General Management
Initial- Any specific antidotes and correct life threats ie low 02, hypoglycaemia, ABx etc
1- Admit to medics for further workup and psychiatric input if/when medical issue excluded
2- If patient lacks capacity then should be detained under a duty of care vs mental health act depending on scenario
3- May need 1:1 nursing +/- a nursing special dedicated to them, admit to appropriate area of hospital or ED
4- Specific workup goals ie septic and endocrine screen, CTB/LP etc
Depression History approach?
Suicide risk screening
- Determine if active Plans and the Means
- Previous Attempts
- what is the Lethality of their previous attempts and current plan
- Intoxicated, do they have capacity
- Features of psychosis, command hallucinations etc
- Detain under MHA if concerns about suicide on leaving
SAD PERSONS mnemonic for suicide
- See picture
- 0-4 is low risk
- 5-6 is medium risk
- 7-10 is high risk
SIDGECAPS for Depression
- at least 5 of the following features for > 2weeks needed to diagnose major depressive disorder (MDD
S- Sleep disturbance (insominia, excessive sleep)
I- Interest decreased (ie usual fun activities or interests)
D- Depressed mood/anhedonia
G- Guilt or worthlessness
E- Energy decreased
C- Concentration difficulties
A- Appetite disturbance or weight loss
P- Psychomotor alteration
S- Suicidal thoughts
Mental Health Act
- Appears to be mentally unwell
- This mental illness requires immediate assessment and Mx
- There is a perceived risk to the safety of the patient and others
- There is no less restrictive manner
DIfferentials
- Psychosis and mania
- Dementia
- Hypothyroidism
- CNS infection
- Autoimmune encephalitis
What is the PAIDEMS mnemonic for history taking?
Used to remember all the extra things needed to touch on apart from the presenting complaint
P- Past history (can include ante/perinatal in paeds)
A- Allergies
I- Immunisations (paeds, immunocompromised, returned traveller)
D- Developmental (growth, sleep/wake/feed cycle in paeds) Daily living (ADL’s in adults)
E- Ethanol and substances
M- Medications
S- Social (SHx in adults and NAI/depression screen in paeds)
How should a fever history be approached?
Life threats
- Meningitis, sepsis etc
- AMI, PE, ICH
- Thyroid storm, drugs, environment, NMS/SS/MH
- Seizures, transplant rejection, transfusion reaction, pancreatitis
HPC
- Onset, patterns, travel, localising symptoms
- How long for, previous infection (ie malaria)
- Weight loss, masses, input/output
- Sexual activity and STI’s, immobiliity, bed sores
PAIDEMS
- Indwelling lines, valves, joint replacements etc
- Immunocompromised, vaccination
- Medications, overdoses, chemo
- At risk populations (ATSI etc)
How should a chest pain history be approached?
Life threats
- AMI with cardiogenic shock
- Thoracic aortic dissection
- Rupturing AAA
- Pulmonary embolism
- Pneumonia
- Perforated duodenal ulcer
- Upper GI abdominal catastrophe
Red flags
- Tearing/ripping pain
- Sudden onset
-
History
- PERC/Wells/ADDRS
ECG’s
- Repeat ECG’s!!!
- Look at OLD ECG’s!!!
Investigations
- Blood gas
- Bedside CXR
- Bedside echo
- Trop and screening bloods
- Bilateral blood pressures
- radial-radial/femoral delay
Modified HEART score
- Prospectively validated in ED settings, modified has removed the troponin (ie for use before tests)
- Better validation than EDACS and not retrospective like TIMI score
H- History, high suspicion (typical symptoms) = 2 points
- Moderate suspicion (mixed atypical and typical) = 1 points
- Minimal/no suspicion (very atypical) = 0 points
E- ECG, STD = 2 points, non-specific changes = 1 point, normal = 0 points
A- Age <45 = 0 points, 45-64 = 1 point and >65 = 2 points
R- Risk factors, no RF’s = 0 points, 1-2 = 1 point, 3 or more = 2 points
- High risk if 4 or more points
T- Troponin, taken out of the modified score
- 0 points if no rise, slight to 3x rise = 1 point and >3x rise = 2 points
- Often patients with elevated troponins will be admitted anyway regardless of risk stratification
Low risk
- Discharge
- No objective testing required
Intermediate risk
- Serial ECG and troponins (3hrly)
- 2nd tropnin at at least 6hrs post pain starting
- Screen for other causes
- If normal then discharge with objective testing ie stress test
High risk
- Admit under cardiology
- DAPT +/- further therapy
Bilateral weakness DDx? How should they be addressed on history?
LOWER MOTOR NEURONE
AIDP/GBS
- Recent Gastro/virus
- Progressive ascending weakness with hypo or areflexia (diagnostic criteria)
- Hypotonia, neuropathic pain (more in kids)
- Autonomic instability, cranial nerve involvement
- Elevated CSF protein, N WCC
Botulism
- Neonates with honey, wound botulism, off canned food
- Descending flaccid paralysis
- Hypotonia, hyporeflexia
Tick Paralysis
Snake Bite
Hypokalaemic Periodic Paralysis
- PHx of HPP, unexplained weakness or hypo/hyperthyroidism
- Recent exertion or stimulant use
- Low K on blood tests
UPPER MOTOR NEURONE
Transverse Myelitis
- Recent virus/gastro
- Defined spinal cord segment with sensory/motor changes below this
- fasciculations, clonus below level
- No cranial nerve involvement
- Usually complete paralysis below level, loss bowel/bladder control
How should a travel history be approached?
Life threats
- Diving complications
- Altitude sickness
- Exotic infections
- Pulmonary embolism
History
- Pre-travel (ie Past history, meds etc)
- During travel
- Post travel
- Diving or altitude
- Exposure to animals, bug bites
- Eating
- Sexual adventure (STI’s), drug use, swimming in contaminated water
- Pre-travel vaccinations, prophylacitic medications, preventatives ie (mosquito nets)
- Exposure to animals, coral, dirty water
- Eating local food, non-bottled water
- Fever timing and severity (ie every 48hrs, 72hrs, random etc)
How should a diving history be approached?
Red flags
- Prolonged dive
- Diving to or beyond max depth
- Rapid ascent
- Inexperienced diver
- Equipment malfunction
How should a paediatric history be approached?
At least consider asking all the questions below
Birth history
- Antenatal care
- tests performed, GBS
- prematurity, PROM
- instrumentation, birth complications
- post birth NICU/special care
- vit K, baby check, heel prick testing
Development
- Ask for weight and height
- Can ask for the baby book, look at growth charts
- meeting milestones? arrest in development
Social history
- Who looks after the child
- Whos at home (parents, other children, relatives etc)
- Living environment, stressors
Meds/Allergies
PHx
What is the HEADS screening tool for adolescent/teenage social and mental health?
Social media use/abuse is another S at the end
What are some basic questions for sexual health assessment?
Key points/phrases
- This is confidential
- Give a warning shot (ie i understand these are sensitive/difficult topics)
- Follow up in sexual health clinic
- Discussion around informing the patients partner and the partners risk
- Abstinence or barrier condom while awaiting testing
Key symptoms/Signs
Gonorrhoea
- D/C, inguinal lymph nodes, rashes, joint swelling
Chlamydia
- Dysuria, dysmenorrhoea, dyspareunia, PID
Syphilis
- Chancre, rashes, soft tissue lesions
HIV
- Seroconversion illness
- On PrEP
HepB/C
- Immunized? IVDU, blood transfusion
Treatment
- Suggest treatment, shared decision making, dont force
- Gonorrhoea - Ceftriaxone
- Chlamydia - Azithromycin
- Syphilis - IM Benzathine penicillin
- Herpes - Aciclovir
Medicolegal
- If a patient knows they have HIV, and has unprotected sex with someone without informing them of this, they are liable for assault and can face jail time
Syncope history approach?
Most common (Mimics)
- Vasovagal (neurocardiogenic)
- Orthostatic hypotension, usually from dehydration
Most concerning Dx
- PE
- SAH
- Seizure
- Hypoglycaemia
- Tachydysrhythmia
- high grade AV block and sick sinus syndrome
- IHD
- Structural heart disease (HOCM, CHD, valvulopathy etc)
- Toxin/overdose induced
- Sepsis
Dysrhythmias in young people
- Brugada
- WPW
- HOCM
- ARVC
- Prolonged/shortened Qtc
Red Flags
- Exercise induced
- No prodrome (instant drop)
- Chest pain
- Sudden severe headache
- Palpitations
- Past cardiac history
- FHx sudden cardiac death or arrhythmias
History
- Previous episodes
- Tongue biting, intontinence
- seizure/myoclonic jerks/muscle soreness post event
- How long unconscious
- Precipitants (uncomfortable stimulus, dehydration etc)
- Postural symptoms
- Injury from the syncope
- Post ictal phase
- Family history and origin (ie south east asia and Brugada Syndrome)
- Nocturnal agonal breathing (brugada syndrome)
- Recent unwellness (increasing SOB, viral prodrome, intermittent chest pain etc)
- prescription meds, OTC meds, recreational drugs, overdose
San Franciscos Syncope Score
- CHESS mnemonic
- Any of the five makes patient not low risk
- C= congestive heart failure
- H= Haematocrit <30%
- E= ECG abnormal
- S= SOB
- S= SBP <90
Palpitations history approach?
Life threats
- Malignant arrhythmia
- Acute ischaemia
- Cardiac disorders (HOCM, WPW, Brugada, ARVC, MV prolapse)
- Pacemaker malfunction
- Endocrine (Hypoglycaemia, hyperthyroidism, phaeo)
- Sepsis/fever
DDx
- Psychiatric (Anxiety, stress, somatization, POTS)
- Ectopics
- Hypotension (dehydration, exercise)
- Pregnancy
- Anaemia
- Illicit drugs (cocaine, caffeine, alcohol, nicotine, ice etc)
- Medications (BB withdrawal, anticholinergics, sympathomimetics, vasodilators)
Red Flags
- Syncope
- Chest pain (particularly exertional)
- FHx cardiac disease/SCD
- Bleeding
- Oedema