Medical History Flashcards
What are the components of a full history
complaining of
history of presenting complaint
past medical history
past dental history
social history
What do we ask when noting the complaining of
What brings you in today?
We want to know the presenting issue
What is the history of presenting complaint
We want to know how it has happened, when it has happened, how long has it been bothering the patient, have they tried to do anything about it?
If there is pain then take a pain history
What do we use when taking a pain history
SOCRATES
What does socrates stand for
site
onset
character
radiation
associated symptoms
time
exacerbating factors
severity
What is meant by the site of pain
Where
What is meant by the onset of pain
when did it start
What is meant by the character of pain
sharp or dull
What is meant by radiation of pain
does it extend anywhere
What is meant by associated symptoms
any other symptoms that are linked to the pain
e.g swelling, nausea etc
What is meant by time regarding pain
how long does the pain last
What is meant by exacerbating factors
anything made it worse?
also good time to ask if px has tried analgesics or any other meds
What is meant by severity
scale 1-10
good time to ask if pain keeps px up at night
When taking a medical history what should we ask about
Address systems first
- CV
- Respiratory
- GI
- Blood
- Muscular, hormonal and neurological problems
Ask about diabetes and epilepsy
Ask for any other medical conditions px is aware of
Any medications - including OCP
Any allergies
What are common cardiovascular conditions we can ask about
- blood pressure
- stroke
- heart attack
- angina
