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Yr 3 Human Disease > Taking a history > Flashcards

Taking a history Flashcards

1
Q

What order should you do things in?

A
  1. wash hands and introduce yourself, confirm patients name and age etc.
  2. presenting complaint
  3. history of presenting complaint
  4. medical history
  5. drug history
  6. social history and family history
  7. systems review
    Pulling hair means doing something silly
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2
Q

How do you ask about 2. the presenting complaint?

A

What has brought you here today?

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3
Q

What do you ask about 3. history of the presenting complaint?

A
  • Start with open questions
  • When did it start?
  • Have you ever had this before? how does this time compare?
  • Has it changed/stayed the same? improving/worsening? over what time period?
  • Are there any other associated symptoms?
  • When did you last feel well?
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4
Q

If in pain what is the pneumonic?

A

SOCRATES

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5
Q

What does the first S in SOCRATES stand for?

A

Site -> where is it and has the position changed?

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6
Q

What does the O in SOCRATES stand for?

A

Onset -> when did it start? gradual/sudden? precipitating factors?

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7
Q

What does the C in SOCRATES stand for?

A

Character -> How would you describe it? is it sharp/dull/stabbing?

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8
Q

What does the R in SOCRATES stand for?

A

Radiation -> does it spread anywhere?
e.g. pancreatitis = radiates to back, MI = radiates to arm, aortic dissection = tearing pain radiating towards back, kidney stones = from loin to groin

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9
Q

What does the A in SOCRATES stand for?

A

Associated factors e.g. nausea, vomiting, sweating, palpitations, diarrhoea, shortness of breath

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10
Q

What does the T in SOCRATES stand for?

A

Timing -> constant/ intermittent, if intermittent how long does it last and is there recovery in-between?

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11
Q

What does the E in SOCRATES stand for?

A

Exacerbating and relieving factors -> anything that makes it better/worse, e.g. movement, pain relief, vomiting, food, position, exercise

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12
Q

What does the second S in SOCRATES stand for?

A

Severity -> scale 1-10

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13
Q

What do you ask about 4. Medical history?

A
  • Have you seen the GP for anything recently?
  • Do you see the GP for anything regularly?
  • Any previous operations, hospital admissions, serious illnesses?
  • Have you had: JAM THREADS
  • Have you travelled abroad recently?
  • Are you pregnant?
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14
Q

What does the J in JAM stand for?

A

Jaundice

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15
Q

What does the A in JAM stand for?

A

Anaemia

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16
Q

What does the M in JAM stand for?

A

MI

17
Q

What does the T in THREADS stand for?

A

TB

18
Q

What does the H in THREADS stand for?

A

Hypertension

19
Q

What does the R in THREADS stand for?

A

Rheumatic fever

20
Q

What does the E in THREADS stand for?

A

Epilepsy

21
Q

What does the A in THREADS stand for?

A

Asthma/COPD

22
Q

What does the D in THREADS stand for?

A

Diabetes

23
Q

What does the S in THREADS stand for?

A

Stroke

24
Q

What do you ask about 5. Drug history?

A
  • Do you take any medication for anything? (frequ, dose)

- Any allergies? To what? What happens?

25
Q

What do you ask about 6. Social history?

A
  • Smoking, alcohol, drugs -> quantity and frequency
  • Who is at home? (help from carers?)
  • What kind of accommodation do you live in?
  • Stairs?
  • Daily activities -> who does the cooking, cleaning and shopping etc., do they have help?
  • How do you get around? Drive, walking aids etc?
26
Q

What do you ask about 6. Family history?

A
  • Any medical conditions in the family? Age of onset?

- Enquire health of parents -> cause of death if appropriate?

27
Q

What different systems do we review in 7. Systems review?

A

CVS, Resp, GI, GU, Neuro, General

28
Q

What questions do we ask for CVS?

A
  • Chest pain?
  • Palpitations?
  • Leg swelling?
  • Calf pain?
29
Q

What questions of we ask for Resp?

A
  • Shortness of breath (SOB)?
  • Cough? ->productive, blood?
  • Wheeze?
  • Orthopnoea -> lay flat without SOB, how many pillows do they sleep with?
  • Paroxysmal nocturnal dyspnoea -> wake up gasping for breath?
30
Q

What questions do we ask for GI?

A
  • loss of appetite?
  • problems swallowing?
  • nausea/vomiting?
  • weight loss?
  • change in bowel habits?
  • bleeding from ‘tail end’?
31
Q

What questions do we ask for GU?

A
  • pain/burning/stinging when passing urine?
  • increased frequency?
  • any blood in urine?
32
Q

What equations do we ask for Neuro?

A
  • fits/faints/funny turns?

- new onset headache/tingling/numbness of arms/legs

33
Q

What questions do we ask for general?

A

fevers/shakes/chills

Yr 3 Human Disease (1 decks)

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