Introduction to History Taking Flashcards

1
Q

80% of diagnosis is made from the history

A
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2
Q

General Advice

A

When on wardsm look smart and remember PPE, wash your hands and alcohol gel after you have seen your patient

ID badge should be visible, ensure patients know you are medical students, introduce yourslef

Listen to your patient, use active listening skills

Don’t be afraid to get them to repeat or clarify

If they are giving you a lot of information, ask them to slow down and break it into smaller parts, ask them to stop or pause

Summarise/repeat it back to clarify

Write down key notes, but tell patient if you are

Treat all information as confidential

Try to follow a structure, it will also help you remember all parts that need to be covered

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3
Q

Communicating with patients

A

Be aware of any sight, hearing or communication difficulties with your patients

Never shout at a patuent with hearing impairments; try to be clear, stand closer to them so you can talk closer to their ear or other patients may prefer you to stand directly in front of them. Ask what is best for them

Give a patient with a visual impairment more information

Someone with a communication difficulty may struggle to understand or express to you, slow your communication down, break setences up, gesture, write things down, use pictures. Get them to write down. If you don’t know, don’t assume.

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4
Q

Communicating with patients

A

Main aim in history is to elicit; the patients main problems, the patient’s perceptions of these and the physical, emotional, and social impact of the patient’s problems on the patient and family

Tailor information to what they want to know; check their understanding

Hollistic thinking - how is this issue affecting this patient?

Talk to your patient - give them the information, answer the specific question if you feel you’re able

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5
Q

No equipment needed

A

Question style - (open/closed)

Active listening

Facilitative responding

Cues

Clarification

Time-framing

Appropriate language¬

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6
Q

Patient encounter

A

History –> Examination –> Investigation –> Management

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7
Q

Introduction to history taking

A

Introduce yourself
Gain consent
Confirm patient’s name, age, DOB
Occupation
Main presenting complaint
History of presenting complaint - sequence of events, symptom detail and any associated symptoms
Systems review - how have they been in other aspects of their health?
Past medical/surgical history
Drug History - Prescribed/OTC, illicit use? Smoking, Alcohol?

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8
Q

Introduction to history taking slide 2

A

Allergies

Family history
Travel History
Social History - where do they live? Can they care for themselves? Are they mobile? Do they have any mobility aids? Do they have carers? Do they have children
Effects on patient
 - Physical, psychogical, social
Patient's perspective/ICE
Summarise back to patient
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9
Q

Presenting complaint

A

The key is asking this as an open ended question, you’re asking your patient to tell you in their own words. Record and feedback how the patient has described things in their own words. Be aware there maybe more than one complaint, e.g. Ankle swelling and a fall

“What has brought you to hospital?”
“What has been the trouble/problem recently?”
“How can we help you today?”

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10
Q

SOCRATES

A
Site
Onset
Character
Radiation
Associated symptoms
Time course
Exacerbating/Relieving factors
Severity
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11
Q

History of Presenting Complaint

A

Chronological and more detailed account of the presenting complaint

Open question initially

Let the patient talk (active listening - show them, ‘right’, ‘mm’, nod your head)

Closed questions to clarify points - (So can I just confirm as you have told me lots of important questions)

Specific questions related to the relevant system

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12
Q

Past medical history

A
Medical Illness:
A - Asthma
B - Blood pressure
C - CVD/CVA
D - Diabetes
E - Epilepsy
TB, Jaundice, Rheumatic fever

Drug history can be telling

Surgical procedures
Childood illnesses
When and where

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13
Q

Systems review

A

CVS - Chest pain / SOB / Orthopnoea / PND / Oedema / Palpitations

Respiratory - SOB / Cough / Haemoptysis / ET / Chest pain

GIT - Weight loss / N&V / Dysphagia / Bowe lhabit / Passing blood

GU - Dysuria / Hestitancy / Poor stream / Nocturia / Blood

CNS - Headaches / Fits/ Faints / Blackouts / Weakness / Clumsiness / Memory problems

MSK - Painful joints / Stiffness / Rashes / Swelling

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14
Q

The last few parts

A

Summarise the issues
Anything missed?

Any questions?

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15
Q

ICE

A

Ideas - Do you have any idea what this could be
Concerns - What are your main worries?
Expectations - What are you hoping we can help you with

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