PRIMARY HEALTHCARE Flashcards
Structure to History Taking?
Intro [WIPE]
Body [CHAMP FRIES]
Closure [SETIP]
Structure to Introduction [History Taking]?
WIPE
Wash Hands
Introduce Self + Identify Pt
Pain?
Explain Process
Structure to Body [History Taking]?
CHAMP FRIES
Complaint
History Presenting Complaint
Allergies
Medication
Past Medical History
Family History
Red Flags
ICE
Every System
Social History
Structure to Closure [History Taking]?
SETITP
Summarise
Examination
Tests
Impression
Plan
Examples for Introduction [History Taking]
WIPE
W: Wash Hands
I: Hi There, I am Ollie the Doctor, can I please confirm your name and service number?
P: Are you comfortable? Do you need any painkillers?
E: I will try to find out whats has been going on, and will ask some more general questions about you - would this be ok?
Examples for Body [History Taking]?
CHAMP FRIES
C: How can I help you today?
H: OLD CARTS = When did this start? // WHere exactly is the pain? // How long has this been going on for? // How would you describe the pain? // What makes it better and what makes it worse? // Does it spread anywhere? // Is it constant? // How would you score it out of 10?
A: Do you have any allergies?
M: Do you take any regular medications?
P: DAS = Do you see a Doctor regularly for anything? // Ever been admitted to hospital? // Ever had an operation?
F: Anything medical or surgical run in the family?
R: FLAWS = Any fever? // Any extra tiredness? // Any change in appetite? // Any unexpected weight loss? // Any night sweats?
I: ICE = What do you think may be going on? // What is it you are worried about? // What are you hoping we can do for you?
E: Any headaches or blurred vision? // Any chest pain? // Any SOB or cough? // Any tummy pain? // Any problems pissing or pooing? // Any aches or pains in your arms or legs? // Any lumps, bumps or rashes?
S: WHASO = What do you do for work? // Who lives at home with you? // Do you drink alcohol? // Do you smoke? // Do you take any other recreational drugs?
Examples of Closure [History Taking]?
SETIP
S: I am now going to summarise back to you - please correct me at any point!
E: I would now like to perform an examination of XYZ, it will involve me having a look/listen/feel and performing some movements and special tests of XYZ - would this be ok?
T: I would like to perform XYZ to help us find out a bit more
I: I think XYZ may be causing this, but there are other things we need to rule out.
P: My plan is XYZ
Structure to History of Presenting Complaint [History Taking]
OLD CARTS
Onset
Location
Duration
Characteristic
Aggrevating / Alleviating Factors
Radiation
Timing
Severity
Structure to Past Medical History [History Taking]?
DAS
D: Do you see a Dr regularly for anything?
A: Have you ever been admitted to hospital?
S: Have you ever had surgery?
Structure to Social History [History Taking]?
WHASO
W: What do you do for work?
H: Who lives at home with you?
A: Do you drink alcohol?
S: Do you smoke?
O: Do you take any other recreational drugs?
Structure to Cranial Nerve Exam?
Look
Feel
Listen
Move
Special Tests
Further Tests
LOOK [Cranial Nerves]
HAPS
Hearing Aid
Asymmetry
Ptosis
Spectacles
FEEL [Cranial Nerves]
Facial Sensation > Forehead / Cheek / Chin
[CN 5 > Trigeminal]
LISTEN [Cranial Nerves]
Hearing > Whisper + Weber + Rinne Test
[CN 8 > Vestibulocochlear]
Voice > Speech + Cough
[CN 9 + 10 > Glossopharyngeal + Vagus]
MOVE [Cranial Nerves]
Eyes > H Test
[CN 3/4/6 > Oculomotor + Trochlear + Abducens]
Facial Muscles > Eyebrows / Eyes / Cheeks
[CN 7 > Facial]
Shoulder Shrug + Neck Turn
[CN 11 > Accessory]
Tongue > Lateral Movement
[CN 12 > Hypoglossal]
SPECIAL TESTS [Cranial Nerves]
Vision > AFROCA
Acuity = Snellen Chart
Fields = Finger Wag
Reflexes = Light Reflex
Ophthalmoscope = Optic Disc
Colour Vision = Ishihara Plates
Accommodation = Near > Far
[CN 2 > Optic]
Taste/Smell > Smelling Salts
[CN 1 > Olfactory]
FURTHER TESTS [Cranial Nerves]
Full History
Full Observation
Neuro Examination
Bloods
?CT/MRI
Structure to Neuro Exam?
Look
Feel
Move
Special Tests
Further Tests
