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FoCM > History Taking > Flashcards

History Taking Flashcards

1
Q

What are the sections of the clerking process?

A
  1. Presenting complaint
  2. History of Complaint
  3. Patients Perspective
  4. Past Medical History
  5. Drug and Allergy History
  6. Family History
  7. Social History
  8. Systematic Enquiry
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2
Q

What is covered in the stage of the presenting complaint?

A

Identify the main problem or reason for attendance.

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3
Q

What pieces of information should be gathered for the History of Complaint?

A 
Site
Severity
Radiation
Character
Onset
Duration
Pattern, recurrence, progression
Exacerbating factors
Associated symptoms
Functional Consequences

Also - any other relevant symptoms from the same area

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4
Q

How do you assess pain in the history of complaint?

A

Socrates

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5
Q

What does SOCRATES stand for?

A 
Site
Onset
Character
Radiation
Associated symptoms
Timing
Exacerbating and relieving factors
Severity
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6
Q

What comes after History of presenting complaint?

A

Patients Perspective

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7
Q

What is discovered in the patients perspective?

A

Ideas, concerns and expectations

Ask appropriate questions and summarise what you think the patients perspective is.

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8
Q

What is discussed after the patients perspective?

A

Past medical History

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9
Q

What is discussed in the past medical history?

A

Past Medical and Surgical Problems

Take a list of operations and illnesses requiring hospitilisation as well as any chronic illness in CHRONOLOGICAL order.

Any problems associated with previous treatment

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10
Q

What is discussed after the past medical history?

A

Drug and Allergy History

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11
Q

What is discussed in the Drug and Allergy History?

A

Find out the prescribed medicines the patient is taking :

  • Name
  • Dose
  • Method of Delivery
  • Frequency

Non-prescribed medicines - painkillers, herbal remedies

Contraceptive pills and hormone replacements!

Drug allergies - ask them what their adverse reaction was

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12
Q

What is discussed after the Drug and Allergy History?

A

Family History

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13
Q

What is discussed in the family history?

A

Illness which runs in the family

You are primarily interested in the first degree relatives

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14
Q

What is discussed after family history?

A

Social History or lifestyle

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15
Q

What is discussed in social history or lifestyle

A 
Habits (duration and amount) - Includes, drinking, Alcohol and recreational drug use
Exercise
Social circumstances
Household members
Work circumstances
Hobbies
Pets
Overseas travel
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16
Q

What follows the social history or lifestyle?

A

Systematic enquiry

17
Q

What is the purpose of the systematic enquiry?

A

Highlight a list of important symptoms that may have been missed (any other concerns)

18
Q

What sections of the history taking do you perform when it is shortened?

A

History of presenting complaint
Family History
Social History
Patients perspective

FoCM (7 decks)

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