History Taking Flashcards Preview

FoCM > History Taking > Flashcards

Flashcards in History Taking Deck (18):
1

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

2

What is covered in the stage of the presenting complaint?

Identify the main problem or reason for attendance.

3

What pieces of information should be gathered for the History of Complaint?

Site
Severity
Radiation
Character
Onset
Duration
Pattern, recurrence, progression
Exacerbating factors
Associated symptoms
Functional Consequences

Also - any other relevant symptoms from the same area

4

How do you assess pain in the history of complaint?

Socrates

5

What does SOCRATES stand for?

Site
Onset
Character
Radiation
Associated symptoms
Timing
Exacerbating and relieving factors
Severity

6

What comes after History of presenting complaint?

Patients Perspective

7

What is discovered in the patients perspective?

Ideas, concerns and expectations

Ask appropriate questions and summarise what you think the patients perspective is.

8

What is discussed after the patients perspective?

Past medical History

9

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

10

What is discussed after the past medical history?

Drug and Allergy History

11

What is discussed in the Drug and Allergy History?

Find out the prescribed medicines the patient is taking :
- Name
- Dose
- Method of Delivery
- Frequency

Non-prescribed medicines - painkillers, herbal remedies

Contraceptive pills and hormone replacements!

Drug allergies - ask them what their adverse reaction was

12

What is discussed after the Drug and Allergy History?

Family History

13

What is discussed in the family history?

Illness which runs in the family

You are primarily interested in the first degree relatives

14

What is discussed after family history?

Social History or lifestyle

15

What is discussed in social history or lifestyle

Habits (duration and amount) - Includes, drinking, Alcohol and recreational drug use
Exercise
Social circumstances
Household members
Work circumstances
Hobbies
Pets
Overseas travel

16

What follows the social history or lifestyle?

Systematic enquiry

17

What is the purpose of the systematic enquiry?

Highlight a list of important symptoms that may have been missed (any other concerns)

18

What sections of the history taking do you perform when it is shortened?

History of presenting complaint
Family History
Social History
Patients perspective