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History Taking Flashcards

1
Q

Why take a history

A

First contact
Gather information
Provisional diagnosis
Affect on pt and carers

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2
Q

ICEE

A

Pt Idea of what’s wrong
Pts Concerns about what’s wrong
Effect of problem on pt
Pts Expectations

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3
Q

Structured history
(What to do - overarching areas)

A

Intros and wash hands
Check name and dob
Consent
History of presenting complaint (SOCRATES)
Past medical history
Medication history, prescription and non prescription and ALLERGIES
Social history
Family history
Review of systems
Ideas/expectations/concerns
Plan
Safety netting

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4
Q

SOCRATES

A

Site
Onset
Character
Radiation
Associated factors
Time
Exacerbating/relieving
Severity

Cause

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5
Q

Socrates

A

Site

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6
Q

sOcrates

A

Onset

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7
Q

soCrates

A

Character (type of pain)

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8
Q

socRates

A

Radiates

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9
Q

socrAtes

A

Associated factors

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10
Q

socraTes

A

Time

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11
Q

socratEs

A

Exacerbating/relieving factors

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12
Q

socrateS

A

Severity
Plus pain score and cause

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13
Q

Past medical history
JAMTHREADS CA

A

Jaundice
Anaemia/haematological disorders
Myocardial infarction/heart disease
TB/thyroid
Hypertension
Rheumatoid disease
Epilepsy
Asthma/COPD
Diabetes
Stroke/surgery
Cancer
Anything else?

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14
Q

Jamthreads ca

A

Jaundice

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15
Q

jAmthreads ca

A

Anaemia and haematological disorders Myocardial infarction

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16
Q

jaMthreads ca

A

Myocardial infarction/heart attack

17
Q

jamThreads ca

A

TB and thyroid issues

18
Q

jamtHreads ca

A

Hypertension

19
Q

jamthReads ca

A

Rheumatoid disease

20
Q

JamthrEads ca

21
Q

JamthreAds ca

A

Asthma COPD

22
Q

jamthreaDs ca

23
Q

jamthreadS ca

A

Stroke and surgery

24
Q

jamthreads Ca

25
Q

jamthreads cA

A

Anything else

26
Q

Medication history

A

ALLERGIES + reaction
prescription meds, are you compliant?
Over the counter
Internet meds
Illegal
Homeopathic

27
Q

Social history

A

Smoking, be specific if yes
Alcohol units
Housing situation
Social circumstances, where living with who
Employment, present and past
Functional abilities re ADL
Travel
Pets
Hobbies
Anything else

28
Q

Family history

A

Do Jamthreads ca

29
Q

Review of systems

A

Cardiac
Respiratory
Gastrointestinal
Genitourinary
Neurological
Endocrine
Musculoskeletal
Mental state

30
Q

ROS cardiac

A

Chest pain/tightness
Wake up in night short of breath
Stop you from exercising
Worse after a meal

31
Q

ROS respiratory

A

Short of breath
Cough, cough anything up
Colour of phlegm
Blood in phlegm
Wheeze
Exercise tolerance

ACP (1 decks)

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