History Taking Flashcards
What’s the full meaning of SOCRATES?
Site Onset Character Radiation Association Time Course Exacerbating / Relieving Factors Severity
What is the ultimate goal of a Medical History?
To reach a diagnosis or a differential diagnosis
What is the content of History taking ?
Rapport Demographics Presenting complaint History of presenting complaint Past medical histories Drug history Family history Social history Systemic enquiries Synthesis Summary
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Aims of history taking
- To identify the relevant organ system(s) responsible for symptoms
- To clarify the nature of the pathological processes at play
- To characterize the social context of patients’ illness, their concerns, and interpretation of symptoms
Ways of showing the patient you’ve been listening to the content of their problem
- Facilitating(e. g. Nodding, “uhuh”, “go on” etc.)
- Rephrasing
- Clarification and Elaboration
- Further questioning
- Summarizing periodically
most important and crucial part of history taking
History of Presenting Complaints(HPC)
Mention 5 characteristics of symptoms that are “fluid in nature” (bleeding, vomiting, loose bowel movements)
- Frequency/# of episodes
- Volume/amount
- Color
- Content
- Consistency
“CAGE” questions for a patient who consumes alcohol
- “Have you thought about Cutting down?”
- “Have you ever gotten Annoyed when people talk to you about your drinking?”
- “Have you ever felt Guilty about your drinking?”
• “Do you ever have a drink first thing in the morning (Eye opener)?”
NB: An affirmative answer to 2 or more CAGE questions has a sensitivity and specificity of > 90% for alcohol dependence.
Doctors make diagnosis by
- History taking
- Physical examination
- Investigation
Mention 3 egs of symptoms that are fluid in nature
bleeding, vomiting, loose bowel movements
burning substernal chest pain is more likely to be due to
esophageal reflux
squeezing or crushing chest pain is more likely to be
angina or myocardial infarction
What does the patients ICEs mean?
ideas, concerns and expectations
An example of an expected side effect of morphine
Itching
Give one adverse reaction from taking aspirin
Gastric bleeding
What is pruritus
Itching
What is Malaise?
a feeling of weakness, overall discomfort, illness, or simply not feeling well
What is Odynophagia?
Painful Swallowing
What is Tinnitus?
Ringing or buzzing noise in one or both ears that may be constant or come and go, often associated with hearing loss
Immune thrombocytopenia (ITP)
A disorder that can lead to easy or excessive bruising and bleeding. The bleeding results from unusually low levels of platelets, this usually happens when your immune system mistakenly attacks and destroys platelets.
What is Colonoscopy?
the endoscopic examination of the large bowel and the distal part of the small bowel with a CCD camera or a fiber optic camera on a flexible tube passed through the anus
Doctors can not practice medicine without
effective communication skills
Poor communication causes
a lot of medicolegal and ethical problems
A doctor’s primary goal is to
- make a diagnosis
- treat and cure where possible
- bring relief in suffering
- help the patient cope with illness, disability and death
Patients management include
- Pharmacological
2. Non-pharmacological
Past medical history to inquire of an adult?
hypertension stroke diabetes heart disease tuberculosis sexually transmitted infections cancer asthma hepatitis B/C
Drugs that can cause GI bleeding
NSAIDs
Is an alcoholic the same as a chronic alcohol abuser?
If yes, what is the difference?
They are not the same.
An alcoholic is dependent on alcohol but a chronic alcohol abuser is not.
An alcoholic will therefore have withdrawal symptoms when he tries to stop.
A chronic alcohol abuser can stop drinking without any withdrawal symptoms.
What is Mallory Weiss Syndrome?
It refers to a tear or laceration of the mucous membrane of the stomach, commonly the gastroesophageal junction. This is mostly due to retching or violent coughing.
In history taking its presentation is this: vomitus will initially be gastric contents , later it will contain blood.
When clerking patients with a symptom of pain….
If the patient is presenting with a disease of the GIT, for T (Socrates) - always ask for its relationship with food, ie, whether the pain is worsened or better with food.
2 tiny very important things to note in history taking
- Give the patient an assurance of CONFIDENTIALITY.
- Always show EMPATHY especially when the patient makes mention of bad news, extreme pain etc.
Eg. oh I’m so sorry, so what happened next.
3 reasons for history/ 3 important questions to be answered in one’s history
- To find a working diagnosis
- To find the risk factors associated with the disease condition.
- To find out whether the patient has developed complications or not.
What are the questions for the general review of system?
- Usual state of health
- Fever
- Chills
- Night sweats
- Appetite
- Sudden weight change
- Fatigue
- Malaise
- Sleep pattern
- Pruritus
What are the questions for the review of the cardiovascular system?
- Chest pain
- Palpitations
- Shortness of breath (dyspnea) - on exertion, orthopnea, paroxysmal nocturnal dyspnea
- Pedal swelling
- Intermittent claudication
What are the questions for the review of the respiratory system?
- Cough
- Sputum production
- Hemoptysis
- Chest pain
- Dyspnea
- Wheezing
What are the questions for the review of the of the gastrointestinal system?
- Appetite
- Nausea
- Emesis
- Hematemesis
- Coffee ground emesis
- Dysphagia
- Odynophagia
- Dyspepsia
- Abdominal pain
- Abdominal distension
- Jaundice
- Change in stool color/caliber
- Constipation/Diarrhea
- Melena stools
- Hematochezia
What are the questions for the review of the of the Neurological system?
- Limb weakness
- Numbness or tingling of hands/feet
- Tremors
- Loss of memory
- Confusion
- Sleep changes
- Nervousness
- Speech disorders
- Poor balance (ataxia)
- Seizures
- Blurred or loss of vision
- Double vision (diplopia)
- Light-headedness
- Dizziness
- Fainting
- Loss of smell or taste
- Headaches
- Neck pain/stiffness
- Tinnitus
Differential history of a “breast patient”
Traumatic fat necrosis
Chronic breast abscess
Tuberculosis of the breast
Breast lymphoma
3 main symptoms a “breast patient” presents with
Pain
Lump
Nipple discharge
This is a current health concern that acts as the reason for the health care visit.
Presenting/Chief Complaint
This is additional information that is collected to understand the full picture of the chief complaint.
History of Present Illness
General State of Health per patient, Significant adult or childhood illnesses or injuries, Psychiatric illnesses, Past hospitalizations, surgeries or long-term treatments are elements of
Past Medical History
The chief complaint is best derived from:
- The patient, either verbally or nonverbally
- The initial radio dispatch
- The scene size-up
- Medical records
- The patient, either verbally or nonverbally
MNEMONIC for causes of clubbing
C-Cyanotic heart disease, cystic fibrosis L-Lung cancer, lung abscess U- Ulcerative colitis B-Bronchiectasis B-Benign mesothelioma I-Infective endocarditis, Idiopathic pulmonary fibrosis N-Neurogenic tumour G-Gastrointestinal disease
Causes of splinter haemorrhage
Bacterial endocarditis Rheumatoid arthritis Vasculitis Trauma Sepsis (from any source)
Working Diagnosis
The leading contender in a list of 2 or more potential diagnosis
What is the most common cause of deep pulmonary embolism?
Deep Vein Thrombosis(DVT)
