Medical History Taking Flashcards
What should be asked under Presenting Complaint?
Name
DOB
Purpose of Visit
When can SOCRATES be used?
In History of Presenting Complaint if the patient has pain
What does the first S in SOCRATES stand for?
Site - where is it
What does the O in SOCRATES stand for?
Onset/duration - when did it start, how long does it go on for
What does the C in SOCRATES stand for?
Character - ache, sharp, throbbing
What does the R in SOCRATES stand for?
Relieving/exacerbating factors - anything you do that makes it better/worse eg - pain meds
What does the A in SOCRATES stand for?
Associated - any other symptoms associated with it
What does the T in SOCRATES stand for?
Timing - how often does it last, is it worse in the morning
What does the E in SOCRATES stand for?
Effects - does it affect you in daily life, at work etc
What does the second S in SOCRATES stand for?
Severity - 1-10
What should be asked under Past Medical History?
Medical conditions
Any problems they feel may be relevant
Are they seeing a specialist for anything
Past hospital admissions
What should be asked under Past Dental History?
Dental attitude
Anxiety
Experience of local anaesthetic
How often do they attend the dentist
What should be asked under Past Drug History?
Medications they are on
Dosage
What for
What should be asked for Social History?
What is their occupation? Do they smoke (packets) Do they drink (units) Do they take recreational drugs Do they exercise
What kind of questions should be used in History of Presenting Complaint?
Open questions
What are notable drugs that many patients are on?
Anticoagulants
Antiplatelets
Bisphosphonates - alendronic acid for osteoporosis
Steroids in the past 2 years - prednisolone for adrenal crisis
What systems should Past Medical History be split into?
Cardiovascular Respiratory Gastrointestinal Neurological Endocrinology Musculoskeletal Blood Disorders
What should be covered under Cardiovascular in Past Medical History?
Blood pressure CVA Angina MI - Medical treatment - stents or CABG Valvular disease
What should be covered under Respiratory in Past Medical History?
Infections - pneumonia Airflow obstruction - asthma, COPD - chronic bronchitis, emphysema Gas exchange failure - fibrosis Obstructive sleep apnoea Tumours
What should be covered under GI in Past Medical History?
Stomach reflux
Bowel - Crohn’s or ulcerative colitis
Liver - alcoholic liver disease, cirrhosis
What should be covered under Neurological in Past Medical History?
Fits - seizure control, precipitating factors, change in meds
Faints
Headaches
What should be covered under Endocrinology in Past Medical History?
Diabetes: type 1 - insulin deficiency, type 2 - insulin resistance
Thyroid dysfunction
What should be covered under Musculoskeletal in Past Medical History?
Pain, swelling, stiff joints
Arthritis
Joint prosthesis
Osteoporosis
What should be covered under Blood Disorders in Past Medical History?
Generic: Do you bleed for a while after a cut, any issues with tooth extractions in the past, any blood disorders Focused: Hep B, Hep C, HIV Haemophilia A and B VW disease
