history taking Flashcards
1
Q
what would you ask in a respiratory history
A
cough wheeze sputum haemoptysis exercise tolerance SOB pain weight loss
2
Q
cardiovascular history
A
chest pain SOB PND/orthopnoea/ number of pillows slept with exercise oedema palpitations faintness/ syncope intermittent claudication
3
Q
gastrointestinal history
A
abdo pain weight loss dysphagia indigestion bloating/ cramping anorexia nausea/vomiting diarrhoea/ constipaiton obstipation haematemesis blood in stools and duration black stools change in stools/ bowel habits mucous/ water malaise/ lethargy
recent travel family hx diet, foods that are associated recent use of antibiotics or laxatives, NSAIDS, warfarin has this ever happened before lethargy joint pain, skin lesions, mouth ulcers, worsening/ continuous/ intermittent blood clotted or liquid on outside of stool or mixed in
4
Q
urinary
A
incontinence pain haematuria nocturia polyuria hesitancy dribbling urgency change in stream
5
Q
female
A
discharge dysparaenia menses dysmenorrhoea urinary menarche/ menopause contraception smear Sti tests gravity/ parity/ abortus
6
Q
additional important questions for respiratory
A
travel smoking and cannabis chest pain and what causes it home leisure pets occupation what can you do before getting breathless? can you dress yourself allergies- hayfever, ezcema onset- gradual or sudden exacerbating factors time of day/ gets worse/better? relieving factors recent possible exposure to allergens/ asbestos etc leg swelling/ hot/ red night sweats/ horseness diziness/ palpitations
7
Q
history taking
A
presenting complaint history of presenting complaint past medical history and recent illnesses/ trips to hospital systems review family hx social history including occupation, travel, living situation, leisure and pets, marriage and children medication and allergies smoking, drugs, alcohol, diet ideas, concerns and expectations summary
contact with anyone unwell
8
Q
SOCRATES
A
site onset character radiation associations time of day exacerbations or relieving fx severity
9
Q
additional questions for cardiovascular history
A
associated fx exacerbating fx type of pain (socrates) relieving factors recent illnesses blood clots legs swollen/ hot/ red chest pain worse when cold test for diabetes/ blood pressure/ cholesterol
