Medical history

Question 1

what are the 8 steps of taking a medical history

Answer 1

introduction
complaining of 
history of present complaint
past medical history
past dental history 
current medications
social history 
family history

Question 2

what do we do in the introduction

Answer 2

introduce yourself to patient
find out their name, age and where they are from
ask for patients consent for you to speak to them

Question 3

what do we find out in complaining of

Answer 3

we are trying to find out the presenting issue is
must be an open question
what has occurred to necessitate them coming to hospital

Question 4

what do we do in history of present complaint

Answer 4

we want to get as much information as we can about the specific complaint
it should be done in the patients words
ask appropriate questions to prove around
take a pain history

Question 5

how do we take a pain history

Answer 5

SOCRATES

Question 6

what does SOCRATES stand for

Answer 6

site
onset
character
radiation
associations
time
exacerbating factors
severity

Question 7

what are the 3 systems we look at in past medical history

Answer 7

cardiovascular
respiratory
gastrointestinal

Question 8

what do we look at in cardiovascular past medical history

Answer 8

heart issues e.g blood pressure
stroke
cardiac problems e.g angina, heart attack (any treatment?), valvular disease

Question 9

what do we look at respiratory past medical history

Answer 9

respiratory infections e.g pneuomina
airflow obstructions - asthma, COPD 
gas exchange failure - fibrosis 
obstructive sleep apnea
tumors?

Question 10

what do we look at in gastrointestinal past medical history

Answer 10

stomach - acid reflux?
bowel problems - crowns, ulcerative colitis
liver problems - alcoholic liver disease, cirrhosis

Question 11

what are the other systems in past medical history

Answer 11

endocrine
musculoskeletal
neurological
blood disorders

Question 12

what other questions should we ask in past medical history

Answer 12

are they diabetic/epileptic?
any other medical conditions?
any previous hospital admissions?
any previous surgery?

Question 13

what do we ask in past dental history?

Answer 13

regular attender?
any phobias?
good oral hygiene?
fully dentate?
bleed after extraction?

Question 14

what do we ask in current medications

Answer 14

are they taking any prescribed medications
topical drugs or inhalers?
oral contraceptive pill?
any allergies to drugs?

Question 15

what do we ask in social history

Answer 15

alcohol - quantity
smoking - quantity 
occupation 
exercise
recreational drug use
living situation

Question 16

what do we ask when asking about living situation

Answer 16

house/flat?
who is at home?
mobility?
carers?
are they managing activities of daily living?

Question 17

what do we ask when asking about family history

Answer 17

we are looking for risk factors - does anyone have any cardiovascular disease at young age?
are parents in good health?