Patient history Flashcards
Template for history
-Name
- Age
- Occupation
- Presenting complaints: 1,2,3
- Which presenting complaint is their biggest problem?
- Why are they in the hospital?
History of presenting complaint
- What happened?
- The story in chronological order?
- Systems review
- PMH
- Drug history
- Family history
- Social history
- Risk factors
What do you do after examinations?
- Vitals - HR/ BP/ RR/ TEMP
- Physical examinations - system by system - resp, CVS, GI, Neurological, MSK, Summary
- Problem list
What to ask?
Name, age, occupation
Background/ serious medical conditions
Why are they in the hospital
What to do with presenting complaints
Identify patients main problems in own words
Use open questions and clarify patients responses
History of presenting complaints?
Go through HPC for each system
Ask questions related to each system
Maintain a chronological order
Past medical history
Who diid they see/ When/ Why/ Whats happened sicne
Any more important negatives - dm, asthma, angina, MI
Ask about surgical exposures/ operations
Any anaesthetic problems
Drug history
Ask if they brought their prescription
Compliance - are they OK with medicines, do they take them regularly as prescribed, do they struggle
Does the patient know what the drugs are for
Ask about over the counter or alternative meds
Ask about any responses to medications
Allergies
Family history
Ask about first degree relatives
Social history
Smoking
Alcohol
Living circumstances - accomodation
Do they have any dependents
Impacts of illness on patietns or family
Consider mood and outlook
ANy lifestyle odicatiocons
Any occupational hazards
Change in mood
What do you ask if a patient says they are an ex smoker or have given up an alcohol?
Ask them when did they give up
How much did they smoke and how long for
How many units did they drink or used to drink
Diet
Recreational drugs
Systems review
Series of screening questions
Closing the history
Ask - is there anything else you would like to add or tell me?
Examination
