taking a patient history Flashcards
(30 cards)
introduce yourself - key so they know who they are talking to so are freer to give details: what should we say?
Hello, I am heer, and I will be your pharmacist today
- smile + open body language
confirm the patients identity - how
- full name
- age: have to ask d.o.b
- confirm address
- ‘can i confirm…’ ‘could you please tell me your…’
just so I can make sure I have the correct details
discussing the purpose of the consultation
Today, I’d like to talk to you to get a better understanding of your health and any symptoms you might be experiencing. The purpose of this consultation is to take a detailed history so we can figure out what might be going on and help guide your care
Discussing the Structure (What we’ll do)
I’ll start by asking about your main concern or symptoms, then we’ll go through some questions about your general health, any medications you’re taking, allergies, and relevant lifestyle factors. I might also ask about your medical history and family history.
Ofc there will be time at the end for any questions or anything else you’d like to share, but honestly feel free to stop me and ask at any point.
how to seek consent of patient BEFORE starting the consultation
Is it alright if I go ahead and ask you a few questions to get started? I just want to make sure I have your consent to begin the consultation.
how to negotiate a shared agenda
We might each have different things we want to focus on, so I’d like to make sure we’re on the same page — is there anything you’d like to make sure we talk about today?
- so I can make a note of it and make sure we address your concerns
Thanks — I’ll make a note of that and do my best to make sure we cover it today
what should we start off by asking
maybe about social history to make it seem natural?
things to ask about when exploring social history: lifestyle may not support the meds
- occupation and home life:
- living situation - marriage? & any plans to travel etc?
- smoking, drinking?
what to ask for occupation and home life
whats a normal day for you at work and after?
what to ask about after social history
Thanks for sharing a bit about your daily life and habits—that really helps me understand your overall context. To make sure I have a full picture, can I ask what medications you’re currently taking?
when we ask what medications they are taking what info do we need to get
drug, strength, formulation and dose
what can we follow up on / ask about the medications
- whether they are experiencing any side effects
- also need to be able to mention some side effects they might be experiencing
- also mention allergies here
‘have u been having any issues taking your medications?’
- document a full medication history: what else does this include, not just prescribed stuff on the system
- family history
- ask if they know why they’re taking a certain medication (so we know which indication treatment is for)
- how are you taking your meds
- have your bought any OTC meds
- have you taken any herbal remedies or supplements or hard drugs
- any meds prescribed to you e.g. eye creams / eye drops etc
- ALLERGIES
- ask if they know why they’re taking a certain medication - why?
so we know which indication treatment is for
what else do we ask that might not be on the system
if they have any other medical illnesses
support them to ‘take power’ by understanding the rationale for their treatment (helps with adherence)
do you know why you are taking this medication
elicit patients understanding of their illness (we don’t wanna be the first person to talk about their diagnosis)
has anyone explained why you are taking these medications e.g. your doctor
elicit any concerns about treatments to be able to address them
e.g. look at non-verbal cues: do you have any issues taking your medications e.g. formulations etc, or with it e.g. if blood pressure remains high etc
assess patient adherence: how much do they miss?
- you’re on a lot of meds… how do you manage?
- in the last week how many doses do you think you might have missed? why?
establish reasons for missed doses
- how could we fit it into your lifestyle?
- what do you think works best?
identify and prioritise patients pharmaceutical problems
e.g. if you want to talk about [a less relevant issue e.g. smoking] feel free to arrange a follow up?
how do we summarise the key points
To summarise what we’ve covered today: we talked about your background and current situation, including your social environment and daily routines. We also discussed any medications you’re taking.
appropriate closing
“Thanks for sharing all of that with me—it really helps to build a clear picture of how things are going for you.
From here, I’ll [briefly explain next steps – e.g., pass this on to the doctor, arrange a follow-up, write it up in your notes, etc.].
Before we wrap up, is there anything you’d like to ask me or anything you feel we haven’t covered?”
Drug class: Statins
Examples: Atorvastatin, Simvastatin, Rosuvastatin
What they do: Lower cholesterol to reduce risk of cardiovascular disease by having less artery plaque build up
side effects?
Muscle pain or weakness (myalgia)
Gastrointestinal upset - nausea, diarrhea
