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Yr 3 examinations > Taking a history > Flashcards

Taking a history Flashcards

1
Q

order of a history

A 
introduce self and pt - name age sex and occupation (present occ right at start!!)
PC
HPC - get the detail
PMH
DH
FH
SH
system review
habits
summarise
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2
Q

how to get PC

A

‘what brought you to GP/Hospital’
golden minute
if pause ask them to expand

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3
Q

acronyms to help with HPC

A

socrates

ICE

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4
Q

summarize SOCRATES

A 
site 
onset - time, type (rapid/gradual etc)
character 
radiation 
association - look for red flags 
time - of that incident and how long been occuring 
exacerbating/alleviating factors 
severity - 1-10
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5
Q

purpose of ICE

A

make sure on the same page

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6
Q

how do you investigate the PMH

A

‘do you have any medical conditions for which you see your GP’
take inhalers
ever needed to be admitted to hospital
MJTHREADS

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7
Q

what is MJTHREADS

A 
acronym for conditions to check in PMH (make clear routine qns): 
MI
Jaundice
TB
Hypertension
Rheumatic fever
epilepsy 
asthma
dm 
stroke
PE
DVT
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8
Q

how do you investigate DH

A

check allergies - and what happens in reaction - is it minor/life threatening means can determine if can take similar drugs. Might just be SE
what med are you taking - dose and freq
herbal (eg st John’s wort messes with other drugs)
alternative medicines eg chinese herbs (can have steroids in) and homeopathy
over the counter
vaccines
contraceptive pill
SE from drugs
compliance

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9
Q

investigate FH

A 
any medical conditions run in the family 
are your parents still alive 
if not how and when die
any sig illnesses
any autoimmune
stick to 1st degree relatives
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10
Q

investigate SH

A

occupation for pulmonary disorders
exercise and exercise tolerance
any travel in the last yr, ever lived abroad, appropriate vaccines, were you ill when away
smoke - give cessation advice, have you ever smoked
alcohol - CAGE questionnaire, units
recreational drugs
pets - resp problems, allergy, farmers
home circumstances - need help with activities of daily living
married/partner/children - who is at home
are they from a nursing home or residential home
do they use social services - meals on wheels
religious beliefs

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11
Q

how do you calculate pack yrs - smoking

A

(pack/day)*yr

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12
Q

how do you do a systems review

A

SEE SLIDE
always ask general, dizzyness, loss of consciousness, chest pain, SOB, headache, GI, prostate
tailor to pt

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13
Q

how to present

A

SBAR - site, background, assessment, recommendation

rule out negatives (ie say no weight loss)

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14
Q

what should be in a ddx

A

most serious differential

most common ones

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15
Q

what is a PC

A

it is the symptom - not the diagnosis

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16
Q

what can you include when presenting a PC

A

any immediately relevant medical history eg known ischemic heart disease, COPD - only when confident

17
Q

other relevant info to HPC

A

recent travel
new medication
trauma
recent admission

18
Q

resp systems review

A

SIB

pleuritic chest pain

19
Q

CVS systems review

A

chest pain
syncope
palpations
ankle swelling

20
Q

GI systems review

A

change in bowels
vomiting
dysphagia

21
Q

CNS systems review

A

headache
photophobia
meningism

22
Q

GU systems review

A

dysuria
frequency
urgency

23
Q

skin systems review

A

rash

swellings

24
Q

musculoskeletal systems review

A

pain, aches, trauma, joints

25
Q

other systems review

A

fever
night sweats
weight loss
recent stressors

26
Q

presenting PMH

A 
1st list those most relevant to the PC 
then list in chronological order
give dates for major procedures 
are they under follow up by GP or specialist 
where? when? is the next appointment

allows you to see the significance of the problem

27
Q

what do you check allergies for

A

drugs
contrast agents
plasters

what happens - is it allergy or just an intolerance - if throat swell and couldnt breath = anaphylaxis
if just funny tummy - fine

Yr 3 examinations (10 decks)

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