Week 21

Question 1

what are the 8 stages of history taking?

Answer 1

introduction
presenting complaint
history of presenting complaint
past medical history
family history
social history
drug history
system review

Question 2

what should be included in the introduction?

Answer 2

• Wash hands / don correct PPE
• Introduce yourself (name, job role)
• Identify you are speaking to the correct individual (name, address / dob)
• Purpose / permission: explain the purpose of the consultation / history taking
• Position: eye level with the patient, 1m away (2m to help with social distancing)

Question 3

what questions should be asked when asking about a presenting complaint?

Answer 3

• “What has brought you into hospital today?”
• “What can I help you with today?”
• “What seems to be the problem”

Question 4

what questions should be asked for finding out about the history of the presenting complaint?

Answer 4

SOCRATES
-site
-onset
-character
-radiation
-associated symptoms
-time
-exacerbating or relieving factors
-severity

Question 5

what questions should be asked about past medical history?

Answer 5

• “Do you have any medical conditions”
• “Have you ever had surgery”
• Useful to cross match the PMHx and DHx
  M J T H R E A D S Ca
• Myocardial infarction
• Jaundice
• Tuberculosis
• Hypertension
• Rheumatic fever
• Epilepsy
• Asthma
• Diabetes
• Stroke
• Cancer

Question 6

what are the different diagnostic tests available?

Answer 6

blood pressure
heart rate/ pulse
respiratory rate
temperature
oxygen levels/saturations
ear examination/ visualisation
BMI/weight
blood sugar monitoring
peak flow
throat swabs
urine dip tests
pregnancy test

Question 7

what is a supplementary prescriber?

Answer 7

Prescribe under a specific Clinical Management Plan (CMP) set out
under a doctor stating what can and can’t be prescribed and under what
circumstances. The Doctor is the overall responsible clinician accountable for care of
the patient(s)

Question 8

what is an independant prescriber?

Answer 8

Can prescribe any medication independently for any condition within
scope of practice and competence. EXCEPT Cocaine, diamorphine and dipipanone for
addiction. Pharmacist is accountable clinician for care of the patient.

Question 9

what are the principles of prescribing?

Answer 9

be clear in the reasons for prescribing
consider patient medication Hx before prescribing
consider factors that might affect benefit and risk of treatment
consider patient ideas, concerns, beliefs and expectations
use safe, effective, cost effective, evidence based treatments
prescribe in accordance with National and local guidelines/ formularies
write clear, unambiguous legal prescriptions
mo nitor beneficial and adverse effets of treatment
communicate and document prescribing decisions and reasoning for them
prescribe within limits of knowledge, skills and experience