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Flashcards in history taking Deck (18)
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1
Q

what must you always do at the start of a consultation

A

introduction

2
Q

what happens in an introduction

A
greeting - good morning 
full name
status 
patient name 
patient DOB 
check this  
what they would like to be addressed by 
explain procedure - gain consent
3
Q

what does Socrates stand for

A
site 
onset
character 
radiation
associated symptoms
Timings 
exacerbations/ reliving (worse or better)
severity 
functional consequences
4
Q

what is the order of a history taking

A
PC 
history of PC along with systems enquiry - ICE 
ICE 
PMH
drugs and allergies 
family social 
any systems questions
5
Q

what does JAMTHREADS stand for

A
jaundice - yellow skin 
Asthma 
MI - heart conditions 
TB or thyroid 
hypertension - High Blood pressure 
rheumatic fever
epilepsy 
anaemia 
diabetes 
stroke
6
Q

what must you cover in past medical history

A

all hospital visits
allergy to anathstetic
GP and chronic conditions

7
Q

what must you cover in drugs and allergies

A

drugs - name, dose, frequency, route of administration, when did you start treatment

allergies - allerganes
effect

other sensitiviteise

other trwatments nit medical - ie physicotherapy

8
Q

what must you cover in family history

A

first degree relatives

age,current health, cause of death, age of death

9
Q

what areas must you cover in social history

A

social circumstances - seeing friends ect.
housing
work

smoking
alcohol
drugs

physical activity
diet

hobbies
pets
overseas travel

10
Q

what are they general systematic enquiry points

A

fatigue
fever

weight/appetite
thirst

sleep disturbance
nigh sweats

skin - rash, brusies, bleeding
puritus - want to scratch skin

neck swelling/ lumps

11
Q

what are the respiratory system systematic enquiry points

A

cough - coughing up anything

sputum - colour?, how much
heamoptaissi - how much

dysponea SOB
wheeze

chest pain - (pleuritic) sharp around the edges

sinusitis symptoms

ear ache
sore throat

12
Q

what are they symptoms of sinusitis

A

blocked nose
nasal discharge
face pain
reduced smell

13
Q

what colours can sputum be?

A

clear - normal
yellow green - infection
brown/ rust - blood

14
Q

what are they cardiovascular systems systematic points

A

chest pain
dyspnoea

palpitations - heart beating out your chest

ankle oedema

varicose veins

claudications

15
Q

what are claudications

A

lower extremity pain/ cramp (always after the same distance of walking)

16
Q

what are the types of dyspnoea

A

at rest
exercise
orthopnoea (lying flat)
paroxysmal nocturnal (attacks of severe SOB at night - waking person up )

17
Q

what must you always do in a history taking

A

ask about ICE
ideas
concerns
expectations

18
Q

what are some things that could be used in a consultation

A

signposting

summary