HISTORY TAKING Flashcards
PC
- What the pt wants to discuss today!
HXPC
- What exactly happened?
- When did it start?
- How severe is it?
- What is the progression- has it got worse/better?
- Intermittent or continuous?
- Precipitating factors- what makes it better/worse?
- Any relieving factors?
- Associated symptoms
- Ever experienced anything like this before?- did it lead it hospital admission, medication or lasting effect?
- Any red flags?
Trauma HX
- when did it happen?
- Why did it happen?
- Whats the mechanism of the injury?
- Did they fall over on grass or concrete
- Where- work, is it safe?
- What they hurt- is there glass, metal involved?
- Who caused it?
- Was anyone present that witnessed it?
SOCRATES
- SITE
- ONSET
- CHARACTER
- RADIATION
- ASSOCIATED SYMPTOMS
- TIME/ DURATION
- EXACBERATING/RELIEVING FACTORS
- SEVERITY
- Any self care
ROS
General health:
- How do you feel compared to normal?
-How is your appetite- any weight gain/loss?
-do you feel more tired than normal?
Respiratory:
- Any breathlessness?
- Any coughs/colds/ wheezing/ sputum/colour?
Cardiovascular:
- Any chest pain or breathlessness?
- Any palpitations, dizziness, oedema?
CNS:
- Headaches, visual disturbances?
- Numbness or tingling?
- Any fits, balance problems, tremors?
- New speech or hearing problems?
Gastrointestinal/ Genitourinary:
- Any change in bladder/bowel?- frequency/blood
- d&v?, abdominal pain?
- Any change in frequency or urination/ burning/stinging?
Bone/ muscle/joints:
- Any new joint pain/stinging/altered sensation?
- Decreased mobility?
Endocrine:
- excessive thirst, sweating
- Intolerance to heat or cold
- Bleeding/bruising?, rashes?
- swollen lymph nodes
Dhx
- Allergies- what happens when they take it?- light headed, dizzy, rash, vomiting?
- Are they compliant with meds?
- OTC?- paracetamol, ibuprofen?
- Herbal medication?
- Alternative meds?
- Ilicit meds?
PMHX & FHX
JAM THREADS
JAUNDICE
ANAEMIA
MYOCARDIAL INFARCTION
TB
HYPERTENSION
RHEUMATIC FEVER
EPILEPSY
ASTHMA & COPD
DIABETES- Affects healing process
STROKE
* Any mental health conditions or cancer?
SHX
WHATS SACRED
- WORK/SCHOOL- will they cope with time off? What do they do for work?
- HOME- do they live alone?
- ALCOHOL/DRUGS- delays healing/ may cause bleeding!
- TOBACCO- cessation may cause pain/affect healing
- SEXUAL HEALTH- oral contraception- may have a huge effect on clotting, osteoporosis may be a symptom of menopause
- SLEEP- may be cause of headache if not getting enough
- ALTERNATIVE- weed/marujuana
- CAFFEINE - can cause anxiety, headaches
- ROAMING/TRAVEL- infection from another holiday?
- EXERCISE- do they do any, may help with healing
- DIET
Health promotion
- Will it affect activities of daily living especially in elderly
- Smoking can delay healing: pack years= packs smoked per day x years as a smoker
- Alcohol- can affect healing process, does pt need support
- Caffeine- are they consuming large amounts?
Paeds Hx
- Nutrition: is it good?
- Passive smoking, vaping
- Up to date with immunisation
- Meeting milestones?
- Are social services involved?
- Any behavioural changes?
- Prenatal/birth complications?
