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SKILLS LAB > L1 HISTORY TAKING > Flashcards

L1 HISTORY TAKING Flashcards

(30 cards)

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1
Q

What are the initial 6 steps of patient interaction?

A
  1. Introduce Yourself
  2. Explain Process
  3. Gain Consent
  4. Demographics- name, age, occupation, address
  5. Presenting Complaint(PC)
  6. History of Presenting Complaint (HPC)
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2
Q

What does Presenting Complaint (PC) entail?

A

In patient’s own words.

Ask open ended question e.g. what brings you in today?

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3
Q

What does History of Presenting Complaint (HPC) entail?

A

Obtain body of History

Questions pertaining to
complaint and any associating symptoms.

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4
Q

What is the acronym for pain assessment?

A

SOCRATEs

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5
Q

What does the S in SOCRATEs represent?

A

Site

Where is the pain?

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6
Q

What does the O in SOCRATEs represent?

A

Onset

When did it start?

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7
Q

What does the C in SOCRATEs represent?

A

Character

What type/nature of the pain?

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8
Q

What does the R in SOCRATEs represent?

A

Radiation

Where else does it go?

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9
Q

What does the A in SOCRATEs represent?

A

Associating factors

Any accompanying symptoms

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10
Q

What does the T in SOCRATEs represent?

A

Time

What time of day does it occur?

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11
Q

What does the E in SOCRATEs represent?

A

Exacerbating
What makes it worse?

Alleviating factors
What makes it better?

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12
Q

What does the s in SOCRATEs represent?

A

Severity
Utilize a scale from 0 to 10.
0 is no pain & 10 is the worse pain ever experienced.

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13
Q

What are the 7 systems that need to be reviewed?

A
  1. CNS (central nervous system)
  2. CVS (cardiovascular)
  3. RESP (respiratory)
  4. GU (Genitourinary)
  5. GI (Gastrointestinal)
  6. MSS (musculoskeletal)
  7. General
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14
Q

What are common symptoms associated with CNS?

A

Headaches, dizziness, loss of consciousness, visual

problems

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15
Q

What are common symptoms associated with CVS?

A

chest pain, shortness of breath

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16
Q

What are common symptoms associated with RES?

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A

flu like symptoms, cough

17
Q

What are common symptoms associated with GI?

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A

Abdo pain, diarrhoea /constipation, blood in stools

18
Q

What are common symptoms associated with GU?

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A

Dysuria- burning or difficulty when passing urine Hematuria- blood in the urine
Increase frequency

19
Q

What are common symptoms associated with MSS?

Study These Flashcards
A

Rashes, Joint pain

20
Q

What are common symptoms associated with any body system?

Study These Flashcards
A

fever, weight loss, loss of appetite

21
Q

What does Past medical history (PMHx) entail?

Study These Flashcards
A

What existing conditions/ illnesses the patient has.

Does the patent attend a clinic?

Who diagnose?

Any follow up?

22
Q

What does the acronym HIDEABC stand for?

Study These Flashcards
A

Hypertension, Ischemic heart disease, Diabetes, Epilepsy, Asthma, Blood conditions (eg sickle cell disease),
Cancer

23
Q

What does Past Surgical History (PSHx) entail?

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A

Any surgeries, complications

24
Q

What does Drug History (Rx) entail?

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A

Any meds? : over the counter meds, herbal remedies

25
What does Family history (FHx) entail?
Any medical conditions of family members
26
What does Allergy history entail?
Food or drug. | What reaction after consumption/ use.
27
What does Hospitalization History entail?
when, why, how long stay, diagnosis, treatment
28
What does Social History entail?
Cigarette smoking – how many per day for how long Alcohol consumption – how often, what do they drink, how much Recreational drugs- marijuana, cocoaine, etc Occupation Exercise Diet Sleep History
29
What are the different categories that need to be considered when taking a patient's history?
1. History of Complaint 2. History of Body Systems 3. Past Medical History (PMHx) 4. Past Surgical History (PSHx) 5. Allergies 6. Hospitalization 7. Family History (FHx) 8. Social History 9. Travel History 10. Gynecological History and Obstetric History 11. Sexual History
30
What is done after a complete history is taken?
Thank Patient Summarize – positives and significant negatives

SKILLS LAB (2 decks)

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