history taking Flashcards
what must you always do at the start of a consultation
introduction
what happens in an introduction
greeting - good morning full name status patient name patient DOB check this what they would like to be addressed by explain procedure - gain consent
what does Socrates stand for
site onset character radiation associated symptoms Timings exacerbations/ reliving (worse or better) severity functional consequences
what is the order of a history taking
PC history of PC along with systems enquiry - ICE ICE PMH drugs and allergies family social any systems questions
what does JAMTHREADS stand for
jaundice - yellow skin Asthma MI - heart conditions TB or thyroid hypertension - High Blood pressure rheumatic fever epilepsy anaemia diabetes stroke
what must you cover in past medical history
all hospital visits
allergy to anathstetic
GP and chronic conditions
what must you cover in drugs and allergies
drugs - name, dose, frequency, route of administration, when did you start treatment
allergies - allerganes
effect
other sensitiviteise
other trwatments nit medical - ie physicotherapy
what must you cover in family history
first degree relatives
age,current health, cause of death, age of death
what areas must you cover in social history
social circumstances - seeing friends ect.
housing
work
smoking
alcohol
drugs
physical activity
diet
hobbies
pets
overseas travel
what are they general systematic enquiry points
fatigue
fever
weight/appetite
thirst
sleep disturbance
nigh sweats
skin - rash, brusies, bleeding
puritus - want to scratch skin
neck swelling/ lumps
what are the respiratory system systematic enquiry points
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
what are they symptoms of sinusitis
blocked nose
nasal discharge
face pain
reduced smell
what colours can sputum be?
clear - normal
yellow green - infection
brown/ rust - blood
what are they cardiovascular systems systematic points
chest pain
dyspnoea
palpitations - heart beating out your chest
ankle oedema
varicose veins
claudications
what are claudications
lower extremity pain/ cramp (always after the same distance of walking)
what are the types of dyspnoea
at rest
exercise
orthopnoea (lying flat)
paroxysmal nocturnal (attacks of severe SOB at night - waking person up )
what must you always do in a history taking
ask about ICE
ideas
concerns
expectations
what are some things that could be used in a consultation
signposting
summary
