Module 2_Basic Medical History Flashcards
What is the first step that should be undergone in taking a medical history?
Observations on first sight
- Do they look their age
- Any obvious deformities
- Bruises, cuts, jaundice?
What setting should a medical history be taken in?
- Comfortable neutral setting
- Desk and ordinary chair
- Maintain eye contact
- No large desk between you and patient
- If no desk and chair use dental chair in upright position with minimum equipment out
- Sit close to them without invading their space, again maintaining eye contact
*Do not interview in surgical scrubs, especially masked
What should you do with EVERY positive/yes response to MHx questions?
-Follow it up
Why is the name, address and telephone of pt’s medical practitioner essential?
- Manage patient emergencies (e.g. collapse)
- If no medical practioner or severl then indicates health attitude
What is implied if a patient has multiple health practitioners?
-Probably abuse analgaesics or other medications
Why is the name of conttact person, address and phone number asked?
- In case of emergency
- In case pt can’t give consent (e.g. underaged)
What kind of medical history questions can you ask?
Have you ever stayed in hospital or hand an operation asked?
- Ask this question first to open and set the scene
- If yes, ask what was it for
- Routine or run into complications (especially surgical/anaesthetic)?
Do you have any allergies?
- If yes, what to and what is the nature of the problem?
- Particularly ask about penicillin allergies
Have you ever had any type of heart disaese, high blood pressure or rheumatic fever?
- If yes, find out the nature of the problem and how long ago it was
- If vauge either clarify with patient or contct medical practitioner
Have you ever had any type of heart dsiease, high blood pressure or rheumatic fever?
-If blood pressure stable and if taking any medications
Do you have diabetes
- Type I or II
- How currently managed
- Labile or stable?
- Is there a family history of diabetes
Have you ever had TB, asthmma, obstructive sleep apnoea or any other form of lung disease?
- Affects 25% of all Australian children have some disease
- If positive/yes answer, type and effect of disease needs to be known
- Also important to take into account for sedation/anaesthesia
- Even if answers no, assess whether short of breath and how long can thye keep excerising before feeling breathless
Have you ever had hepatitis or any other liver disease?
- If unsure, good prompt is: have you ever felt sick and has your skin go yellow?–> determine precisely what was happening if positive
- Relates to patient’s ability to metabolise drugs, bleeding, blood borne virus
- More common in alcoholics and drug abusers
- Especailly important for analgaesics
Have you ever had any kidney problems?
- Determines pt’s bility to metabolise many medications
- If kidney transplant will also be immuno suppressed
- If renal dialisis then health will vary depending on last dialysis
Do you have any bleeding problems or blood disorders?
- Ask why anti-coagulated and how long been on anticoagulants
- How well controlled?
- Need to specifically instruct pt or they may cease medication
- Be observant: is pt’s body bruised even if she has no scabs/cuts etc-. need to recheck
Have you had an HIV test?
-If decline to answer consider response is positive
Are you pregnat?
- Prime danger to fetus from any drugs you may prescribe is in first few weeks after conception
- If positive/yes response: ask on the current stage of pregancy, and how many times tehy’ve been successfully pregnat
Do you have any other medical problems?
-Check question which covers other conditions and also cross check q1 and 2.
What medications are you taking?
- Each drug needs to be recorded for type, dose and regiment
- If pt unsure ask to bring all their tablets at the next appointment
What type of people are vulernable to rheumatic fever?
- Current Australians over 60
- Indigenous
- Patients born overseas
When should you really ask a patient about sleep apnoae
Patinet if overweight
What should all medical history records include?
-Printed name, status, signature
What should you do if you’ve had difficulty obtaining history? (e.g . if patients confused)
Add this to notes and say MHx may be unreliable
T or F?
Pt consent must be acqured prior to contacting patinet’s medical practitioner?
True
When sent a medical history by a doctor, how are the medications ordered and are they all current (e.g. is pt currently taking them all)?
Ordered in the order they were prescribed to patient
Not all medications are current (depending on when it was updated, might have drugs on it that pt was meant to take for short term e.g. 5 days)
In non-urgent cases, how should you communicate with pt’s GP? What should be included in said communication?
- Your name and position
- Patient’s name, DOB, address for ID
- State procedure, give indication whether it will be brief or full surgical with bone removal
- State what you understand of patient’s medical problem and specific medical issue for confirmation or advice
In urgent cases, how should you contact pt’s GP?
Ring them (However, if emergency don't bother, managing emergency takes priority)
