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ACP > History Taking > Flashcards

History Taking Flashcards

(31 cards)

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1
Q

Why take a history

A

First contact
Gather information
Provisional diagnosis
Affect on pt and carers

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2
Q

ICEE

A

Pt Idea of what’s wrong
Pts Concerns about what’s wrong
Effect of problem on pt
Pts Expectations

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3
Q

Structured history
(What to do - overarching areas)

A

Intros and wash hands
Check name and dob
Consent
History of presenting complaint (SOCRATES)
Past medical history
Medication history, prescription and non prescription and ALLERGIES
Social history
Family history
Review of systems
Ideas/expectations/concerns
Plan
Safety netting

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4
Q

SOCRATES

A

Site
Onset
Character
Radiation
Associated factors
Time
Exacerbating/relieving
Severity

Cause

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5
Q

Socrates

A

Site

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6
Q

sOcrates

A

Onset

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7
Q

soCrates

A

Character (type of pain)

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8
Q

socRates

A

Radiates

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9
Q

socrAtes

A

Associated factors

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10
Q

socraTes

A

Time

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11
Q

socratEs

A

Exacerbating/relieving factors

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12
Q

socrateS

A

Severity
Plus pain score and cause

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13
Q

Past medical history
JAMTHREADS CA

A

Jaundice
Anaemia/haematological disorders
Myocardial infarction/heart disease
TB/thyroid
Hypertension
Rheumatoid disease
Epilepsy
Asthma/COPD
Diabetes
Stroke/surgery
Cancer
Anything else?

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14
Q

Jamthreads ca

A

Jaundice

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15
Q

jAmthreads ca

A

Anaemia and haematological disorders Myocardial infarction

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16
Q

jaMthreads ca

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A

Myocardial infarction/heart attack

17
Q

jamThreads ca

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A

TB and thyroid issues

18
Q

jamtHreads ca

19
Q

jamthReads ca

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A

Rheumatoid disease

20
Q

JamthrEads ca

21
Q

JamthreAds ca

22
Q

jamthreaDs ca

23
Q

jamthreadS ca

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A

Stroke and surgery

24
Q

jamthreads Ca

25
jamthreads cA
Anything else
26
Medication history
ALLERGIES + reaction prescription meds, are you compliant? Over the counter Internet meds Illegal Homeopathic
27
Social history
Smoking, be specific if yes Alcohol units Housing situation Social circumstances, where living with who Employment, present and past Functional abilities re ADL Travel Pets Hobbies Anything else
28
Family history
Do Jamthreads ca
29
Review of systems
Cardiac Respiratory Gastrointestinal Genitourinary Neurological Endocrine Musculoskeletal Mental state
30
ROS cardiac
Chest pain/tightness Wake up in night short of breath Stop you from exercising Worse after a meal
31
ROS respiratory
Short of breath Cough, cough anything up Colour of phlegm Blood in phlegm Wheeze Exercise tolerance

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