History Taking Flashcards
Ask
Name, age, occupation
Background
Why are they here?
Presenting complaints
1, 2, 3
Identify main problem in their words
Use open questions and clarify responses
Systems review to assess general health
History of presenting c/o
Go through history for each symptom
Maintain chronology
Investigations within hospital and treatments received
Who are current teams?
Past medical history
Complete rest of history WWWW Negatives e.g asthma, angina, MI Ask about surgical procedures Any problems with anaesthesia?
Drug History
Ask if they have Px Compliant? Knowledge of drug action? Responses to medications Allergies
Family history
First relatives?
Any hereditary diseases
Social history
Smoking/alcohol Any dependants Impact of illness on family? Mood and outlook on disease Modifications in lifestyle Occupational hazards
Ex-smoker/drinker
When How much before giving up and for how long for? How many units Diet Recreational drugs?
Systems review
Set of screening questions
Adapt these qs accordingg to patients age and history
Closing history
Anything else to add?
Examination
General Vital observations System by system Go through main system first Examine other relevant system
Generating diagnoses
Think of differential diagnosis
Provisional diagnosis
Presenting exam findings
Present in order of examination
Remember positives
Summarise
Do not repeat findings in great detail
Mention important/relevant features
Risk factors
Current ongoing issues
Social
Familial
