PMHP-Medical history taking Flashcards
What are the steps of medical history taking?
- Introduction
- Complaining of
- History of present complaint
- Past medical history
- past dental history
- current medications and allergies
- social history
- family history.
If you find out that what the patient is complaining of is due to a fall. You ask?
- What were they doing?
- did they trip?
- did they collapse?
- was there any loss of conciousness?
- did they recieve a head injury?
- did they become dizzy or light headed?
- was there associated chest pain?
- did they stand up after? if so how?
- how long did they lie for?
- Have they had previous eppisodes?
How do we find out about the pain history?
S- Site of the pain
O- onset
C character
R radiation
A associated symptoms
T time
E exacerbating factors
S severity
How do we complete a past medical history
We cover these full systems:
- Cardiovascular
- Respiratory
- Gastrointestinal
Also briefly:
- Endocrine
- Musculoskeletal
- Neurological
- Blood disorders
Any other medical conditions not mentioned
Plus the patients past experiences to a hospital
How do we cover the cardiovascular medical history?
Have you/ do you have any heart problems?
- High blood pressure
- strokes
- angina
- MI in the past
- Valvular disease
- Have you had any medical interventions (bypass?stent?)
How do we cover the Respiratory medical history?
Do you have/have you had any respiratory problems?
Infections
Airflow obstructions
gas exchange failure
OSA
Tumours.
How do we cover the Gastrointestinal medical history?
Have you had any stomach or bowel problems?
- Stomach (reflux?)
- Bowel (Crohn’s disease / Ulcerative colitis?)
- Liver (Alchoholic liver disease? or Cirrhosis?)
How do we briefly cover the other systems in a patient’s past medical history?
Endocrine- are they diabetic?
Musculoskeletal- Do they have arthritis?
Neurological- are they epileptic?
Blood disorder- are they anaemic?
What questions should you ask for the past dental history?
Are they a regular dental attender?
Are they afraid of the dentist?
Oral hygiene (TOFF
Type of brush?how Often? Fluoride toothpaste? Floss?)
Are they fully dentate?
Do they bleed excessively after extractions?
What should you ask when finding out about a patients current medications and allergies?
Are you taking any medications prescribed or otherwise?
Any medications that are inhaled or topical preparations
The oral contraceptive pill?
Any homeopathic remedies?
What can you not take? and ask what happens if you do.
What should you ask about a patients social history?
Alcohol- What are they drinking and how much per week?
Smoking- How many cigarettes are they smoking per day?
occupation-
Exercise?
Recreational drug use?
What should you ask about a patient’s family history?
- Is there a risk of cardiovascular disease at a young age?
- Are the parents still in good health?
