Taking Histories Flashcards
What are the key topics to cover in a Paediatric history
- History of presenting complaint - explore each symptom and systems review if necessary
- Birth history - any problems during the pregnancy? Any abnormal scans? Any complications during birth or as a neonate?
- Feeding - breast/bottle, any feeding difficulties, frequency of wet nappies and stool
- Growth - Weights (Red Book), puberty
- Development - school progress and attendance, developemental screen
- PMH
- DH - immunisations, allergies
- FH - anyone else in the family ill?
- SH - family unit, smoking in the family, social services
- ICE
What are the components of the paediatric developmental screen
- Smiling by 6 weeks
- Turns to sound by 6 months
- Sitting by 9 months
- First words by 18 months
- Walking by 18 months
- Short sentences by 3 years
What would you ask if a child has failure to thrive/weight loss?
Ask to see growth chart
- Input (feeding history, diet)
- Use (energy, activity level)
- Output (wet nappies, stools)
Also any chronic cough (CF), recurrent infections, breathlessness (cardiac)
What would you ask if a child presents with walking/sitting delay
- Ages of other milestones
- General mobility
- Hand domianance
- Balance problems
- Behavioural problems
- Neurological symptoms (weakness, incontinence, seizures, stiffness)
What would you ask with a child that presents with speech delay?
- Age of other milestones
- Senses: vocals, hearing, vision
- Communication: can they follow commands, respond to voice, non-verbal communication (pointing, gestures)
What would you ask in a child that presents with early/late puberty, primary amenorrhoea or short stature
- Pubertal developemental review - testes, brest development, menarche, pubic/axillary hair, height, acne, mood changes
- Raised ICP symptoms - visual problems, headaches
- Family pubertal/stature history
- Symptoms of other diseases - CF, Thyroid, anorexia, Crohn’s)
What are the key topics to cover in a Gynae history?
- HPC - explore each symptom, systems review (gynae 4 P’s, gastro, urological)
- Menstrual history - 1st day of last period, regularity and cycle length, duration of periods (3-7 days), character of periods
- Obs History - Gravida/Parity, miscarriages/ectopic pregnancies/terminations, any previous pregnancy or delivery problems
- Sexual history - history of sexual partner, intercourse (pain, discomfort), subfertility
- Contraception and Smear - contraception (current and previous), smears (date of last smear and results)
- PMH, DH, FH, SH - all same as normal
What are the 4 P’s when taking a Gynae history
- PV bleeding
- PV discharge
- Pain: pelvic, dysmeorrrhoea, dyspareunia
- Pregnancy (chance of pregnancy)
What are the key topics to cover when doing a sexual health history
- HPC - explore each symptom, systems review (discharge, dysuria, swelling/growth/ulcers, pain, PV bleeding)
- Partners - sexual orientation, current partners (casual/regular), contraception use, type of sex, high risk encounters for HIV (MSM, sex workers, needle sharing)
- PMH - previous STIs and testing, HIV & Hepatitis B/C status
- DH - contraception and adherence
- SH
What are the key topics to cover when taking a fertility history?
- General- how long been trying? any prev investigations? any medical treatments? previous IVF attempts?
- Sex - frequency, difficulties, relation to fertile days (12-14 days before next period), pain
- The partners - consider each separately: age, occupation, previous children (same or different partner), smoking and alcohol, current medications, PMH, FH
- Gynae history - Menstrual history, Obs history, Sexual history, Cervical smears & contraception, PMH (PCOS symptoms, discharge, pain, bleeding)
What are the key topics to ask about in a Psychiatric history
- HPC - explore each symptom, who prompted them to come in?, systems review (psychosis screen, depression screen, RISK to self or others)
- PMH - past psych history (how many episodes and admissions, previous self-harm/suicide, mental health worker), Normal PMH
- DH - check compliance
- FH - family psych history, family history of suicide
- SH - alchohol and drug use, living situation, relationships, dependents (children), occupation, personal upbringing history (child abuse), forensic history
What symptoms would you ask about in a psychosis screen?
3rd person auditory hallucinations, running commentary auditory hallucinations, delusions of thought/control/perception
What symptoms would you ask about in a dperession screen?
Mood, anhedonia (inability to feel pleasure), sleep, energy, hopelessness feelings towards the future, suicidal/self-harm thoughts
What are the key topics to ask about in a Obstetric history
- HPC - explore each symptom, relevant systems review (Gynae 4 P’s, gastro, urological)
- Current pregnancy - 1st day of last menstrual period and when +ve pregnancy test, Scans so far, investigations (rhesus, Down’s syndrome), any other problems/admissions with current pregnancy, vomiting/hydration
- Obs History - Gravida & Parity, miscarriages/ectopic pregnancies/terminations, any previous pregnancy or delivery problems with previous pregnancies, type of delivery with prev pregnancies
- PMH, DH, FH, SH
What are the things you actually need to ask about in a MSE?
- Ask about mood: how are you feeling? What is your mood like? Have you felt low/anxious recently?
- Ask about delusions: Any strange thought, or thoughts that others find strange? Can anyone interfere with or hear your thoughts? Do you feel you are in control of your actions? Are there any actions you feel you need to do repeatedly?
- Ask about risk to self and others (some people in your situation feel like harming themselves or taking their own life, have you had such thoughts?) Never forget to ask about risk to self/others!!
- Ask about hallucinations: Have you ever heard or seen anything you can’t explain? Have you ever heard people commenting on what you do? Do you see things that other people can’t?
- Assess insight - awareness of illness and understanding of the need for medical help
