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Clinical Methods > History Taking > Flashcards

History Taking Flashcards

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1
Q

What’s the full meaning of SOCRATES?

A 
Site
Onset
Character
Radiation
Association
Time Course
Exacerbating / Relieving Factors
Severity
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2
Q

What is the ultimate goal of a Medical History?

A

To reach a diagnosis or a differential diagnosis

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3
Q

What is the content of History taking ?

A 
Rapport 
Demographics 
Presenting complaint 
History of presenting complaint 
Past medical histories
Drug history 
Family history 
Social history 
Systemic enquiries 
Synthesis 
Summary
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4
Q

Have you created a flashcard today?

A

Let’s build together, create a flashcard

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5
Q

Aims of history taking

A
  1. To identify the relevant organ system(s) responsible for symptoms
  2. To clarify the nature of the pathological processes at play
  3. To characterize the social context of patients’ illness, their concerns, and interpretation of symptoms
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6
Q

Ways of showing the patient you’ve been listening to the content of their problem

A
  • Facilitating(e. g. Nodding, “uhuh”, “go on” etc.)
  • Rephrasing
  • Clarification and Elaboration
  • Further questioning
  • Summarizing periodically
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7
Q

most important and crucial part of history taking

A

History of Presenting Complaints(HPC)

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8
Q

Mention 5 characteristics of symptoms that are “fluid in nature” (bleeding, vomiting, loose bowel movements)

A
  • Frequency/# of episodes
  • Volume/amount
  • Color
  • Content
  • Consistency
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9
Q

“CAGE” questions for a patient who consumes alcohol

A
  • “Have you thought about Cutting down?”
  • “Have you ever gotten Annoyed when people talk to you about your drinking?”
  • “Have you ever felt Guilty about your drinking?”
    • “Do you ever have a drink first thing in the morning (Eye opener)?”

NB: An affirmative answer to 2 or more CAGE questions has a sensitivity and specificity of > 90% for alcohol dependence.

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10
Q

Doctors make diagnosis by

A
  1. History taking
  2. Physical examination
  3. Investigation
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11
Q

Mention 3 egs of symptoms that are fluid in nature

A

bleeding, vomiting, loose bowel movements

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12
Q

burning substernal chest pain is more likely to be due to

A

esophageal reflux

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13
Q

squeezing or crushing chest pain is more likely to be

A

angina or myocardial infarction

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14
Q

What does the patients ICEs mean?

A

ideas, concerns and expectations

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15
Q

An example of an expected side effect of morphine

A

Itching

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16
Q

Give one adverse reaction from taking aspirin

A

Gastric bleeding

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17
Q

What is pruritus

A

Itching

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18
Q

What is Malaise?

A

a feeling of weakness, overall discomfort, illness, or simply not feeling well

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19
Q

What is Odynophagia?

A

Painful Swallowing

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20
Q

What is Tinnitus?

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A

Ringing or buzzing noise in one or both ears that may be constant or come and go, often associated with hearing loss

21
Q

Immune thrombocytopenia (ITP)

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A

A disorder that can lead to easy or excessive bruising and bleeding. The bleeding results from unusually low levels of platelets, this usually happens when your immune system mistakenly attacks and destroys platelets.

22
Q

What is Colonoscopy?

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A

the endoscopic examination of the large bowel and the distal part of the small bowel with a CCD camera or a fiber optic camera on a flexible tube passed through the anus

23
Q

Doctors can not practice medicine without

Study These Flashcards
A

effective communication skills

24
Q

Poor communication causes

Study These Flashcards
A

a lot of medicolegal and ethical problems

25
A doctor’s primary goal is to
1. make a diagnosis 2. treat and cure where possible 3. bring relief in suffering 4. help the patient cope with illness, disability and death
26
Patients management include
1. Pharmacological | 2. Non-pharmacological
27
Past medical history to inquire of an adult?
``` hypertension stroke diabetes heart disease tuberculosis sexually transmitted infections cancer asthma hepatitis B/C ```
28
Drugs that can cause GI bleeding
NSAIDs
29
Is an alcoholic the same as a chronic alcohol abuser? | If yes, what is the difference?
They are not the same. An alcoholic is dependent on alcohol but a chronic alcohol abuser is not. An alcoholic will therefore have withdrawal symptoms when he tries to stop. A chronic alcohol abuser can stop drinking without any withdrawal symptoms.
30
What is Mallory Weiss Syndrome?
It refers to a tear or laceration of the mucous membrane of the stomach, commonly the gastroesophageal junction. This is mostly due to retching or violent coughing. In history taking its presentation is this: vomitus will initially be gastric contents , later it will contain blood.
31
When clerking patients with a symptom of pain....
``` If the patient is presenting with a disease of the GIT, for T (Socrates) - always ask for its relationship with food, ie, whether the pain is worsened or better with food. ```
32
2 tiny very important things to note in history taking
1. Give the patient an assurance of CONFIDENTIALITY. 2. Always show EMPATHY especially when the patient makes mention of bad news, extreme pain etc. Eg. oh I’m so sorry, so what happened next.
33
3 reasons for history/ 3 important questions to be answered in one’s history
1. To find a working diagnosis 2. To find the risk factors associated with the disease condition. 3. To find out whether the patient has developed complications or not.
34
What are the questions for the general review of system?
1. Usual state of health 2. Fever 3. Chills 4. Night sweats 5. Appetite 6. Sudden weight change 7. Fatigue 8. Malaise 9. Sleep pattern 10. Pruritus
35
What are the questions for the review of the cardiovascular system?
1. Chest pain 2. Palpitations 3. Shortness of breath (dyspnea) - on exertion,   orthopnea, paroxysmal nocturnal dyspnea 4. Pedal swelling 5. Intermittent claudication
36
What are the questions for the review of the respiratory system?
1. Cough 2. Sputum production 3. Hemoptysis 4. Chest pain 5. Dyspnea 6. Wheezing
37
What are the questions for the review of the of the gastrointestinal system?
1. Appetite 2. Nausea 3. Emesis 4. Hematemesis 5. Coffee ground emesis 6. Dysphagia 7. Odynophagia 8. Dyspepsia 9. Abdominal pain 10. Abdominal distension 11. Jaundice 12. Change in stool color/caliber 13. Constipation/Diarrhea 14. Melena stools 15. Hematochezia
38
What are the questions for the review of the of the Neurological system?
1. Limb weakness 2. Numbness or tingling of hands/feet 3. Tremors 4. Loss of memory 5. Confusion 6. Sleep changes 7. Nervousness 8. Speech disorders 9. Poor balance (ataxia) 10. Seizures 11. Blurred or loss of vision 12. Double vision (diplopia) 13. Light-headedness 14. Dizziness 15. Fainting 16. Loss of smell or taste 17. Headaches 18. Neck pain/stiffness 19. Tinnitus
39
Differential history of a "breast patient"
Traumatic fat necrosis Chronic breast abscess Tuberculosis of the breast Breast lymphoma
40
3 main symptoms a "breast patient" presents with
Pain Lump Nipple discharge
41
This is a current health concern that acts as the reason for the health care visit.
Presenting/Chief Complaint
42
This is additional information that is collected to understand the full picture of the chief complaint.
History of Present Illness
43
General State of Health per patient, Significant adult or childhood illnesses or injuries, Psychiatric illnesses, Past hospitalizations, surgeries or long-term treatments are elements of
Past Medical History
44
The chief complaint is best derived from: 1. The patient, either verbally or nonverbally 2. The initial radio dispatch 3. The scene size-up 4. Medical records
1. The patient, either verbally or nonverbally
45
MNEMONIC for causes of clubbing
``` C-Cyanotic heart disease, cystic fibrosis L-Lung cancer, lung abscess U- Ulcerative colitis B-Bronchiectasis B-Benign mesothelioma I-Infective endocarditis, Idiopathic pulmonary fibrosis N-Neurogenic tumour G-Gastrointestinal disease ```
46
Causes of splinter haemorrhage
``` Bacterial endocarditis Rheumatoid arthritis Vasculitis Trauma Sepsis (from any source) ```
47
Working Diagnosis
The leading contender in a list of 2 or more potential diagnosis
48
What is the most common cause of deep pulmonary embolism?
Deep Vein Thrombosis(DVT)

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