History Taking Flashcards
1
Q
Order of headings
A
Presenting complaint History of presenting complaint Previous medical history Drugs/ Allergies Family History Social History
(Systematic enquiry)
2
Q
Presenting Complaint
A
“What can I do for you?”
3
Q
History of Presenting Complaint
A
Details of symptom + Patient’s perspective
Site Onset Character Radiation Associated symptoms Timing Exacerbating/ Relieving factors Severity (Functional consequences)
4
Q
Previous Medical History
A
“Have you ever been in hospital before?”
“Do you see your GP for anything?”
5
Q
Drugs/ Allergies
A
Drugs:
name, dose, frequency, route of admisistration
prescription/ OTC/ alternative/ (recreational)
Allergies:
allergen, effect
6
Q
Family History
A
parents, children and siblings
- age/age of death
- current health/ cause of death
if a strong FH, ask for extended family
7
Q
Social History
A
social circumstances household members (if relevant) work smoking (duration + amount) Alcohol (amount + type) Recreational drugs (if not covered in drugs) Exercise (time spent per week) Diet (typical food eaten in a day) Hobbies Pets Overseas travel
8
Q
General Systematic enquiry
A
fatigue malaise fever/ rigors (chills/ shaking) skin: rashes, bruising, bleeding sleep disturbance night sweats thirst pruritus (itching) neck swelling/ lumps
