WEEK5- History taking & communication tools Flashcards
what is history taking
gathering information on what is making the patient unwell/ill. This will help with working out the working diagnosis
whats step 1 of the history taking
establish a presenting complaint:
presenting complaint= symptom the patient is presenting with
whats step 2 of the history taking
the history of the presenting complaint.
collect info using SOCRATES
what does socrates stand for
site
onset
character
Radiation
associated symptoms
timing
exacerbating factors
severity score
explain s in socrates
site:
wheres the pain/problem.
ask patient to point where pain is
explain o in socrates
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)
explain the c in socrates
character:
ask the patient to describe what symptoms/pain feels like
explain the r in socrates
radiation:
does the symptom/pain travel anywhere else around the body
explain the a in socrates
associated symptoms:
what other symptoms does the patient have that could associate the presenting complaint
explain the t in socrates
timing:
how does the symptom/pain present
is the pain continuous/come in waves
explain the e in socrates
exacerbating factors:
what makes the symptoms better/worse
does anything change the pain
explain the s in socrates
severity score:
ask patient to score pain out of 10, 1=little/no discomfort
10=worst pain imaginable
whats step 3 in history taking
focused patient questioning:
ask relevant questions relating to presenting complaint which can help distinguish between multiple different diagnosis’
what are some questions that may be asked for cardiovascular focused patient questioning
- pain relieved by moving forward (pericarditis)
- ever had this pain before (chronic chest pain-angina/ acid reflux)
- what was you doing when the pain came on (stable angina-movement unstable angina- rest
- any burping/vomiting/belching (acid reflux/mi)
any shortness of breath (mi)
what are some questions that may be asked for respiratory focused patient questioning
- is pain pinpoint (PE)
- is there a cough (breathing condition, chest infection)
- coughing up blood- haemopatsis (cancer or PE)
- shortness of breath worse lying flat (heart failure)
- recent calf pain,swelling,redness (PE)
what are some questions that may be asked for neurological/endocrine focused patient questioning
- headaches (migraine,meningitis,stroke)
- neck stiffness (meningitis)
- confusion (stroke)
- changes to mobility (had a stroke)
- recent history of head injury (intracranial bleed)
- changes to vision (stroke,aura migrane)
- all symptoms resolved (tia)
what are some questions that may be asked for gastrointestinal focused patient questioning
- changes to menstrual cycle (endometreosis,pregnancy,pelvic inflammatory disease)
- pregnancy (could be ectopic)
- vomited (gastroenteritis, acid reflux, appendicitis, bowel obstruction
- blood in vomit (red blood- peptic ulcers, dark brown blood- bleed lower down the gastrointestinal tract
- pain worse when you cough (indicative of appendicitis
whats step 4 of history taking
patients’ medical history:
past medical history,medications,allergies,social history,family history, review of symptoms
in step 4 whats the questions you ask for past medical history
diagnosed medical conditions
diagnosed mental health issue
learning disabilities
previous surgeries
recent illness/injury
last time going gp/hospital
in step 4 whats the question you ask for medications
prescribed drugs
compliant with drugs
over the counter medicine
illegal drugs
recent injections/vaccinations
in step 4 whats the question you ask for allergies
known allergies
any food/substance allergies
what happens when in contact
in step 4 whats the question you ask for social history
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
in step 4 whats the questions you ask for family history
any direct family medical issues (sibling, biological parents)
in step 4 whats the questions you ask for review of systems
headaches
fits, faints
dizziness/blurred vision
coughs
shortness of breath
chest/abdo pain
changes to mobility
changes to menstrual cycle
whats the 5th step of history taking
handover tools:
create a working diagnosis and a different diagnosis
once all info is collected etc transfer this info to other healthcare professionals
(used for step 5) whats the acronym used for trauma patients handover
age
time
mechanism
injuries
signs and symtoms
treatment
(used for step 5)whats the acronym used for medical patients handover
age
sex
history
injuries/intervention
condition
expected time of arrival
