History taking and examination Flashcards
What to do when meeting a pt?
Introduce self Identify pt (name, DOB, consent) Sit at pt eye level Polite Smile Wash hands Explanations, clarity in questions
What to ask the pt?
Name, age, occupation
Background/serious medical conditions
Why in hospital?
How to record a pt complaint?
Identify pt main problem in their won words
Use open questions and clarify pts responses
- Go through history of presenting complaints for each symptom
- Ask q’s related to each system
- Chronological order
- Investigations within the hospitals and treatments received
- Find out their current doctor
How to take a drug history?
Ask if they've brought a prescription Compliance? Does the pt know what the drugs do? OTC/alternative meds or treatments Ask about responses to medications Allergies - what sort of allergic reactions
Family history?
Ask about the 1st degree relatives
Does disease run in family?
Social history?
Smoking, alcohol, living circumstances Do they have any dependents Impact of illness on pt and family Consider mood and outlook Any modifications in lifestyle, activities of daily living Occupation hazards/exposure Change in occupation
What to do if the pt is an ex-smoker or has given up alcohol?
Ask them when they gave up
How much did they smoke and how long for
How many units they drank
Ask about diet and recreational drugs
How to close the history?
Is there anything else you would like to add or tell me?
Examination steps?
General Vital observations System by system Main system 1st Then examine other relevant system
What to do after the examination?
Thank pt
Cover pt or let them dress themselves
Wash hands
Document and report findings
Think of differential and provisional diagnosis
Think about possible questions that may arise from pt and how to answer them
How to present examination findings?
Present in order you examined
Remember all positives, not too any negatives
What to mention in the summary at the end?
The important and relevant features from the pt complain, HOPC and examination
Steps to taking a history? (structure)
Name
Age
Occupation
Background - medical
The condition the pt feels is the biggest problem
The 2nd and 3rd problems
Systems review - Gen, CVS, RS, GIT, GUS, NS, MS
PMH
Other important PMH
Who/When/Why/Ops
Follow up
Dental History including OTC
Allergies
Family History
Social history
Impact of the illness on the pt
Risk factors
General exam
Vitals - BP/HR/RR/Temp
System by system Most appropriate system 1st RS CVS GI
Neuro
MSK
Summary
Problem list
