History taking Flashcards
I want to take a history taking on a patient with respiratory problems, what should I consider asking the patient?
PC:
HPC: if pain then scoretes
what are the systemic symptoms to consider?
Fevers
Night sweats
Weight change
Fatigue
Cardiovascular symptoms to screen for?
Chest pain
Palpitations (They can make you feel like your heart is beating too hard or too fast, skipping a beat, or fluttering)
# Fast-beating, fluttering / poundind heart
Dyspnoea
Pre-syncope
Syncope
Orthopnoea
Peripheral oedema
What are the respiratory symptoms that need to be screened for?
Dyspnoea (SOB/out of breath)
Cough
Sputum
Wheeze
Haemoptysis
Pleuritic chest pain
what is pleuritic chest pain
sudden and intense sharp, stabbing, or burning pain in the chest
What are the gastrointestinal symptoms that need to be screened for?
Appetite change
Nausea
Vomiting
Dyspepsia
Dysphagia
Weight loss
Abdominal pain
Abdominal distension
Jaundice
Changes in bowel habit: constipation, diarrhoea, steatorrhoea, melaena (black, tarry stools), hematochezia (passage of fresh blood in stool)
What are the Genitourinary symptoms that need to be screened for?
Changes in urine output or colour: oliguria, polyuria, anuria, dark urine, haematuria
Infective symptoms: urinary frequency, dysuria, flank pain, offensive discharge, pelvic pain
Bladder control symptoms: urinary urgency, urinary incontinence
Obstructive symptoms: terminal dribbling, nocturia
Uraemic symptoms: fatigue, nausea, anorexia, pruritis
Signs that need to be screen off from a neurological conditions
Visual symptoms: blurred vision, changes in colour vision, sudden loss of vision, floaters
Headache: unilateral headache, bilateral headache, thunderclap headache
Motor or sensory disturbance: muscle weakness, numbness, paraesthesia
Loss of consciousness including seizures
Confusion (Abbreviated Mental Test 4 (AMT-4) / 4 A’s Test)
Ear, nose and throat symptoms to be screened off
Hearing loss/tinnitus
Otalgia
Facial pain
Persistent nasal discharge
Epistaxis
Dysphonia
Dysphagia
Odynophagia
Musculoskeletal symptoms to screen for.
Bone and joint pain
Muscular pain
Trauma
Dermatological symptoms to screen for
Rashes
Skin lesions
Skin colour changes
Ulcers
what are the order of the history taking orders for adults
***(no hesitation)
Presenting complaint
History presenting complaint
Past medical history
Past Drug history / Surgical history / Allergies
systemic review
Family history
Social history:
Drink
Smoke
Drugs
Occupation
Accommodation
Pets?
Summery and ICEs
what are the order of the history taking orders for kids
***(no hesitation)
IMMUNISATION
Presenting complaint
History presenting complaint
Past medical history
Past Drug history / Surgical history / Allergies
immunisations
systemic review
# NEONATAL HISTORY
# PREGNANCY HISTORY
#SPECIAL CARE REQUIRED?
Family history
Social history:
Drink
Smoke
Drugs
Occupation
Accommodation
Pets?
Travels?
Summery and ICEs
