History Taking Flashcards
1
Q
Introduce yourself
A
- open posture, good distance from patient
- hi I’m Ellie
2
Q
Initial questions
A
- why have we been called today
- assess ICE (Ideas, Concerns, Expectations)
3
Q
Detailed HPC
A
- SOCRATES
- when did this start
- how long has this been happening
- restate what the patient has told you
4
Q
Past medical history
A
Myocardial infarction Thromboembolism Jaundice TB Hypertension Rheumatic fever Epilepsy Asthma Diabetes Stroke
Childhood illnesses
Previous tests/ admissions
5
Q
Surgical history
A
Any surgery?
Childhood / adulthood
Complications
Scars
6
Q
Medications.
A
- prescribed / over the counter
- why do you take them?
- side effects
7
Q
Allergies
A
- drugs
- pets
- food
Type of reaction?
8
Q
Family history
A
- sudden cardiac death?
- current or long term?
9
Q
Social history
A
-smoking
Alcohol/ drugs
Food
Exercise
Hobbies
Activities
Travel
Housing
Employment
Living dependents/ parents
Pets
10
Q
Review of systems
A
General Cardiac Respiratory Gastro Neuro MSK Genitourinary Rheumatology Integumentary Endocrinology
11
Q
Revisit ICE
Anything else
Differentials
A
Explain this to the patient, explain each of the diagnoses and rule out any red flags
12
Q
Make a plan with patient
Any questions
A
Ensure this is agreed and informed
13
Q
Further investigations
Working diagnosis
Treatment / referral
A
14
Q
Safety netting
A
- mobility
- medication / food
- telephone
- family/ friends
- specific advice
15
Q
Close consultation
A
- reiterate advice
- what you have found
- ensure patient is happy
