History Taking Flashcards
1
Q
Presenting Complaint
A
Allow the patient time and space to tell their story
2
Q
History of Presenting Complaint (3)
A
SOCRATES
Symptoms- associated symptoms
Onset
3
Q
Respiratory System (6)
A
Wheeze Cough Sputum Haemoptysis Chest pains SOB
4
Q
Cardiovascular System (6)
A
Palpitations Claudications (leg cramp) Chest pains Oedema SOB Varicose veins
5
Q
General Systemic Enquiry (9)
A
Malaise Rigors Weight Loss Skin rash Sleep disturbances Thirst Itch Neck Lumps Night Sweat
6
Q
Patience Perspective (4)
A
Ideas
Concerns
Expectation
Function
7
Q
Past Medical History (6)
A
Seeing GP Ongoing illnesses Hospitalised Surgery (reaction to anaesthetic) Taken time off work due to ill health JAMTHREADS
8
Q
Drug and Allergy History (6)
A
Prescribed Medication Non-prescribed Over the counter Vitamins/Minerals Herbal Recreational drugs
9
Q
Drugs and Allergy History investigations (8)
A
Name Dose Method of delivery Frequency Whats it for How long have they been taking it Any problems Any allergies
10
Q
Family History (3)
A
Parents
Siblings
Children
11
Q
Social History or lifestyle (9)
A
Smoking- how many, for how long Drinking- how much (weekly) Diet Exercise Housing Hobbies Pets Work Travel
