Flashcards in History Taking Deck (18):
What are the sections of the clerking process?
1. Presenting complaint
2. History of Complaint
3. Patients Perspective
4. Past Medical History
5. Drug and Allergy History
6. Family History
7. Social History
8. Systematic Enquiry
What is covered in the stage of the presenting complaint?
Identify the main problem or reason for attendance.
What pieces of information should be gathered for the History of Complaint?
Pattern, recurrence, progression
Also - any other relevant symptoms from the same area
How do you assess pain in the history of complaint?
What does SOCRATES stand for?
Exacerbating and relieving factors
What comes after History of presenting complaint?
What is discovered in the patients perspective?
Ideas, concerns and expectations
Ask appropriate questions and summarise what you think the patients perspective is.
What is discussed after the patients perspective?
Past medical History
What is discussed in the past medical history?
Past Medical and Surgical Problems
Take a list of operations and illnesses requiring hospitilisation as well as any chronic illness in CHRONOLOGICAL order.
Any problems associated with previous treatment
What is discussed after the past medical history?
Drug and Allergy History
What is discussed in the Drug and Allergy History?
Find out the prescribed medicines the patient is taking :
- Method of Delivery
Non-prescribed medicines - painkillers, herbal remedies
Contraceptive pills and hormone replacements!
Drug allergies - ask them what their adverse reaction was
What is discussed after the Drug and Allergy History?
What is discussed in the family history?
Illness which runs in the family
You are primarily interested in the first degree relatives
What is discussed after family history?
Social History or lifestyle
What is discussed in social history or lifestyle
Habits (duration and amount) - Includes, drinking, Alcohol and recreational drug use
What follows the social history or lifestyle?
What is the purpose of the systematic enquiry?
Highlight a list of important symptoms that may have been missed (any other concerns)