History taking Flashcards
How should a history be initiated?
Wash hands
Introduction
Patient consent
Explanation
What should be covered in presenting complaint?
Mode of onset Progress SQITAS Systems review Red flags
What is SQITAS?
Site Quality Intensity Timing Aggravating/ alleviating factors Associated symptoms
What are the red flag symptoms?
Lumps/ bumps Bleeding Change in bowel habits Change in weight or appetite Nausea/ vomiting Fever Mood/ fatigue
What are the cardiovascular cardinal symptoms?
Chest pain Palpitations Dyspnoea (and tolerance) Paroxysmal Nocturnal Dyspnoea/ Orthopnoea Peripheral oedema Pain in legs on walking/ cold limbs
What are the respiratory cardinal symptoms?
Shortness of breath (and tolerance)
Cough (?sputum, blood)
Pleuritic pain
Noisy breathing (wheeze, stridor)
What are the gastro-intestinal cardinal symptoms?
Difficulty/ pain when chewing/ swallowing Mouth ulcers Nausea/ vomiting (?blood) Indigestion/ heartburn Abdominal pain/ mass Change in appetite/ weight Change in bowel habits (?blood)
What are the neurological/ psychiatric cardinal symptoms?
Headache Fits Faints/ dizziness/ blackouts Numbness/ change in sensation Weakness in limbs Changes in vision (double vision), hearing (deafness, tinnitus), speech, taste, smell Changes in mood
What are the genito-urinary cardinal symptoms?
Pain/ difficulty passing urine Nocturia Hydration Genital discharge/ lesions Menstrual changes
What are the endocrinology cardinal symptoms?
Polyuria (urinating more) Polydipsia (drinking more) Weight loss/ gain Blurred vision Thrush Temperature intolerance Neck swelling Change in appearance Sweating Energy/ libido changes Erectile dysfunction
What are the musculoskeletal/ skin cardinal symptoms?
Pain/ stiffness in joints Pain/ stiffness in muscles Carpal Tunnel syndrome Falls/ difficulty walking Limiting activities of daily living Skin lesions/ rashes/ ulcers etc.
What should be covered in past medical history?
Operations
Serious/ chronic illnesses
Medication (prescribed, OTC, recreational)
Allergies
What should be covered in social/ family history?
Smoking/ alcohol intake (signpost if necessary)
Occupation/ home circumstances (effect on ADL)
Family history
How should the consultation finish?
Ideas, Concerns, Expectations
Any further information
Questions
How do you summarise findings?
General findings
Important positive findings
Negative findings
Clinical conclusion
