Histories summary Flashcards
(10 cards)
Simplified history structure [5]
- IIIWUP
- Two open questions (what do you mean by that, and that?)
- Questions relevant to what they’ve said
- SOCRATES
- R/o differentials [e.g. diarrhoea caused hyperthyroidism] [PMH]
- PMH, DHx, FHx, SHx, ICE
- R/o differentials [e.g. diarrhoea caused by hyperthyroidism]
Excl. SOCRATES, rest of general medical history [10]
PMHx - conditions, under control? surgeries/scans/biopsies [2]
DHx - Rx, OTC, allergies (bad reaction?) [3]
FHx - run in family (age got e.g. MI), relevant condition (e.g. for DM, any AID?) [1]
SHx - occupation (stress)/relationships, sleep, smoking, alcohol, recreational drugs [3]
ICE - ideas, concerns, expectations [1]
General SOCRATES structure [16]
TRY GET ALL RELEVANT DETAILS FIRST [e.g. if vomited what does vomit look like?]
S - site, on both sides, where worst? [1]
O - onset and duration [2]
C - describe the pain/heart beating, constant/intermittent [2]
R - radiating? RFs for DVT/IHD [2]
A - systemic ass Sx (infection - contact, flight, fever, food and malignancy - night sweats, fever, weight loss), relevant ass Sx [2]
T - TOD, first time? triggers? [3]
E - AF/EF (exercise/food/alcohol/medication), the event (before/during/after-feel, witness, consciousness) [2]
S - 1 to 10, or affected sleep/walking/ADLs [2]
GI associated symptoms
- Abdo pain!
- Nausea & vomiting
- Blood: haematemesis, haemoptysis, stools, urinating
- Jaundice: PS, DU, YS
- Anaemia: tiredness, SOB
- Chest pain
- Dysphagia, dyspepsia
- Change bowels: consistency, colour, odour, frequency, voiding [tenesmus], blood, constipation,
- Blood stools:
- Infx: food, travel, contact
- Pregnancy: menstruation/distention
- IBD [UC, Crohn’s, Coeliac’s]: mouth ulcers, joint pain, diarrhoea
Neuro associated symptoms
- Pain: headache/face pain
- Meningismus: neck stiffness, photophobia, systemic Sx
- Senses: vision, hearing, smell problems
- Movement and sensation body affected?
- Movement mouth [speech] or swallowing?
- Dizziness or vertigo?
- ICP: N&V
- trauma: banged head
- Fits or faints [lots consciousness?]
- feel before/during/after collapse
- tonic-clonic: bit tongue, incontinence, alcohol/lights trigger, tiredness, tired out after [from tremor]
GU associated symptoms [6]
Blood: important :)
Urinating: FUNKY [freq, urgency, nocturia, Ket (poluria), Ye wee stoter (terminal dribbling, poor stream, hesitancy)]
Pain: burning penis/vag [UTI], stone pain: suprapubic [bladder], loin [renal], loin to groin [urethral]
Incontinence: urge/stress
Occupation: rubber/dyes then bladder Ca
Sex: menstruation, itch, discharge, intercourse, OCP, HIV screen
Endocrine [incl. thyroid] associated symptoms
- Appetite and weight changes
- Diarrhoea/constipation
- Visual/eye changes
- Neck mass
- Menstrual/obstetric changes
- Hair loss/gain
- Lethargy
- Mood: depressed/anxious/lowered cognition
- Headache
- Thirst/volume urine pass [polyuria/polydipsia]
- Skin changes
- DH: amiodarone, lithium, steroids
- impotence
- sweating, palpitations, SOB, tremor, warm/cold environ.
- muscle weakness, voice changes, pretibial myxoedema
CV associated symptoms
- Ankle/leg swelling
- N&V, sweating, cough, SOB, pale
- RFs DVT/IHD
- fatigue/mood/anxiety/work
- thyroid screen
- GTN spray/exercise trigger
- orthopnoea/PND
- night/rest pain
- sitting forwards AF pain
- tingling or numbness or weakness
- impotence
- skin/hair changes
Respiratory associated symptoms
- Cough, wheeze, chest pain, SOB
- Blood, sputum, odour, colour, consistency [B SOaCCked]
- orthopnoea/PND/leg swelling [LVHF/CHF]
- pain inspiration/coughing
- infx: abroad/food/contact w/ pneumonia
- BCG vaccine
- asthma: pollen/dust/cold air
- allergies/pets/work [allergic alveolitis/psittatosis/mesothelioma]
MSK associated symptoms
- Pain muscles/joints/back
- Ass swelling/stiffness [esp. TOD]
- Symmetrical?
- unilateral or bilateral?
- Numbness/tingling/weakness
- trauma
- TOD stiffness
- time to relieve morning stiffness [+pain]?
- bowel/eye/urinating problems
- ANALGESICS
- awake at night?
- mood
