WEEK5- History taking & communication tools

Question 1

what is history taking

Answer 1

gathering information on what is making the patient unwell/ill. This will help with working out the working diagnosis

Question 2

whats step 1 of the history taking

Answer 2

establish a presenting complaint:
presenting complaint= symptom the patient is presenting with

Question 3

whats step 2 of the history taking

Answer 3

the history of the presenting complaint.
collect info using SOCRATES

Question 4

what does socrates stand for

Answer 4

site
onset
character
Radiation
associated symptoms
timing
exacerbating factors
severity score

Question 5

explain s in socrates

Answer 5

site:
wheres the pain/problem.
ask patient to point where pain is

Question 6

explain o in socrates

Answer 6

onset:
when did pain come on, how long ago.
how quickly did it come on
was it a sudden onset (over minutes) or gradual (over few hours/days)

Question 7

explain the c in socrates

Answer 7

character:
ask the patient to describe what symptoms/pain feels like

Question 8

explain the r in socrates

Answer 8

radiation:
does the symptom/pain travel anywhere else around the body

Question 9

explain the a in socrates

Answer 9

associated symptoms:
what other symptoms does the patient have that could associate the presenting complaint

Question 10

explain the t in socrates

Answer 10

timing:
how does the symptom/pain present
is the pain continuous/come in waves

Question 11

explain the e in socrates

Answer 11

exacerbating factors:
what makes the symptoms better/worse
does anything change the pain

Question 12

explain the s in socrates

Answer 12

severity score:
ask patient to score pain out of 10, 1=little/no discomfort
10=worst pain imaginable

Question 13

whats step 3 in history taking

Answer 13

focused patient questioning:
ask relevant questions relating to presenting complaint which can help distinguish between multiple different diagnosis’

Question 14

what are some questions that may be asked for cardiovascular focused patient questioning

Answer 14

1. pain relieved by moving forward (pericarditis)
2. ever had this pain before (chronic chest pain-angina/ acid reflux)
3. what was you doing when the pain came on (stable angina-movement unstable angina- rest
4. any burping/vomiting/belching (acid reflux/mi)
   any shortness of breath (mi)

Question 15

what are some questions that may be asked for respiratory focused patient questioning

Answer 15

1. is pain pinpoint (PE)
2. is there a cough (breathing condition, chest infection)
3. coughing up blood- haemopatsis (cancer or PE)
4. shortness of breath worse lying flat (heart failure)
5. recent calf pain,swelling,redness (PE)

Question 16

what are some questions that may be asked for neurological/endocrine focused patient questioning

Answer 16

1. headaches (migraine,meningitis,stroke)
2. neck stiffness (meningitis)
3. confusion (stroke)
4. changes to mobility (had a stroke)
5. recent history of head injury (intracranial bleed)
6. changes to vision (stroke,aura migrane)
7. all symptoms resolved (tia)

Question 17

what are some questions that may be asked for gastrointestinal focused patient questioning

Answer 17

1. changes to menstrual cycle (endometreosis,pregnancy,pelvic inflammatory disease)
2. pregnancy (could be ectopic)
3. vomited (gastroenteritis, acid reflux, appendicitis, bowel obstruction
4. blood in vomit (red blood- peptic ulcers, dark brown blood- bleed lower down the gastrointestinal tract
5. pain worse when you cough (indicative of appendicitis

Question 18

whats step 4 of history taking

Answer 18

patients’ medical history:
past medical history,medications,allergies,social history,family history, review of symptoms

Question 19

in step 4 whats the questions you ask for past medical history

Answer 19

diagnosed medical conditions
diagnosed mental health issue
learning disabilities
previous surgeries
recent illness/injury
last time going gp/hospital

Question 20

in step 4 whats the question you ask for medications

Answer 20

prescribed drugs
compliant with drugs
over the counter medicine
illegal drugs
recent injections/vaccinations

Question 21

in step 4 whats the question you ask for allergies

Answer 21

known allergies
any food/substance allergies
what happens when in contact

Question 22

in step 4 whats the question you ask for social history

Answer 22

occupation
smoker/how many a day
drink alcohol/how much a day
who do they live with
any carers/social workers
do they exercise
normal mobility/need assistance
daily activitys independently

Question 23

in step 4 whats the questions you ask for family history

Answer 23

any direct family medical issues (sibling, biological parents)

Question 24

in step 4 whats the questions you ask for review of systems

Answer 24

headaches
fits, faints
dizziness/blurred vision
coughs
shortness of breath
chest/abdo pain
changes to mobility
changes to menstrual cycle

Question 25

whats the 5th step of history taking

Answer 25

handover tools:
create a working diagnosis and a different diagnosis
once all info is collected etc transfer this info to other healthcare professionals

Question 26

(used for step 5) whats the acronym used for trauma patients handover

Answer 26

age
time
mechanism
injuries
signs and symtoms
treatment

Question 27

(used for step 5)whats the acronym used for medical patients handover

Answer 27

age
sex
history
injuries/intervention
condition
expected time of arrival