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SKILLS LAB > L1 HISTORY TAKING > Flashcards

L1 HISTORY TAKING Flashcards

1
Q

What are the initial 6 steps of patient interaction?

A
  1. Introduce Yourself
  2. Explain Process
  3. Gain Consent
  4. Demographics- name, age, occupation, address
  5. Presenting Complaint(PC)
  6. History of Presenting Complaint (HPC)
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2
Q

What does Presenting Complaint (PC) entail?

A

In patient’s own words.

Ask open ended question e.g. what brings you in today?

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3
Q

What does History of Presenting Complaint (HPC) entail?

A

Obtain body of History

Questions pertaining to
complaint and any associating symptoms.

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4
Q

What is the acronym for pain assessment?

A

SOCRATEs

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5
Q

What does the S in SOCRATEs represent?

A

Site

Where is the pain?

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6
Q

What does the O in SOCRATEs represent?

A

Onset

When did it start?

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7
Q

What does the C in SOCRATEs represent?

A

Character

What type/nature of the pain?

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8
Q

What does the R in SOCRATEs represent?

A

Radiation

Where else does it go?

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9
Q

What does the A in SOCRATEs represent?

A

Associating factors

Any accompanying symptoms

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10
Q

What does the T in SOCRATEs represent?

A

Time

What time of day does it occur?

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11
Q

What does the E in SOCRATEs represent?

A

Exacerbating
What makes it worse?

Alleviating factors
What makes it better?

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12
Q

What does the s in SOCRATEs represent?

A

Severity
Utilize a scale from 0 to 10.
0 is no pain & 10 is the worse pain ever experienced.

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13
Q

What are the 7 systems that need to be reviewed?

A
  1. CNS (central nervous system)
  2. CVS (cardiovascular)
  3. RESP (respiratory)
  4. GU (Genitourinary)
  5. GI (Gastrointestinal)
  6. MSS (musculoskeletal)
  7. General
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14
Q

What are common symptoms associated with CNS?

A

Headaches, dizziness, loss of consciousness, visual

problems

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15
Q

What are common symptoms associated with CVS?

A

chest pain, shortness of breath

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16
Q

What are common symptoms associated with RES?

A

flu like symptoms, cough

17
Q

What are common symptoms associated with GI?

A

Abdo pain, diarrhoea /constipation, blood in stools

18
Q

What are common symptoms associated with GU?

A

Dysuria- burning or difficulty when passing urine Hematuria- blood in the urine
Increase frequency

19
Q

What are common symptoms associated with MSS?

A

Rashes, Joint pain

20
Q

What are common symptoms associated with any body system?

A

fever, weight loss, loss of appetite

21
Q

What does Past medical history (PMHx) entail?

A

What existing conditions/ illnesses the patient has.

Does the patent attend a clinic?

Who diagnose?

Any follow up?

22
Q

What does the acronym HIDEABC stand for?

A

Hypertension, Ischemic heart disease, Diabetes, Epilepsy, Asthma, Blood conditions (eg sickle cell disease),
Cancer

23
Q

What does Past Surgical History (PSHx) entail?

A

Any surgeries, complications

24
Q

What does Drug History (Rx) entail?

A

Any meds? : over the counter meds, herbal remedies

25
Q

What does Family history (FHx) entail?

A

Any medical conditions of family members

26
Q

What does Allergy history entail?

A

Food or drug.

What reaction after consumption/ use.

27
Q

What does Hospitalization History entail?

A

when, why, how long stay, diagnosis, treatment

28
Q

What does Social History entail?

A

Cigarette smoking – how many per day for how long

Alcohol consumption – how often, what do they drink, how much

Recreational drugs- marijuana, cocoaine, etc

Occupation

Exercise

Diet

Sleep History

29
Q

What are the different categories that need to be considered when taking a patient’s history?

A
  1. History of Complaint
  2. History of Body Systems
  3. Past Medical History (PMHx)
  4. Past Surgical History (PSHx)
  5. Allergies
  6. Hospitalization
  7. Family History (FHx)
  8. Social History
  9. Travel History
  10. Gynecological History and Obstetric History
  11. Sexual History
30
Q

What is done after a complete history is taken?

A

Thank Patient

Summarize – positives and significant negatives

SKILLS LAB (2 decks)

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