Taking a Clinical History in English Part 2 Flashcards

Flashcards covering the components of a medical clinical history including Family History, Social History, Review of Systems, and the ICE framework.

Presenting History

A comprehensive history including the introduction, presenting complaint, history of presenting problem, past medical history, drug history, family/social history, system reviews, ICE, and summary.

Family History (FH)

Focuses on conditions in immediate family members like parents and siblings that may be hereditary, such as heart disease or cancer.

Drug History

Information regarding the medications a patient currently takes and any known allergies.

Social History (SH)

An exploration of lifestyle factors including occupation, home circumstances, alcohol and tobacco use, and recent stress levels.

Alcohol History Calculation

Determining the patient's consumption by identifying the type of drink (wine, beer) and calculating the units per week.

Smoking History

Inquiry into whether the patient is a current or past smoker, the duration in years, and the quantity of cigarettes, roll-ups, or cigars per day.

Review of Systems (ROS)

A systematic 'head-to-toe' check involving a couple of questions for each body system to identify symptoms missed in the history of presenting complaint.

CNS (Central Nervous System) ROS

Checking for symptoms such as fits, faints, funny turns, headaches, and vision problems.

CVS (Cardiovascular System) ROS

Checking for symptoms such as chest pain, palpitations (heart fluttering), and ankle swelling.

RS (Respiratory System) ROS

Checking for symptoms including Shortness of Breath (SOB) and coughing blood.

GI (Gastrointestinal System) ROS

Checking for symptoms such as change in bowel habits, blood, nausea, vomiting, or weight loss.

GU (Genitourinary System) ROS

Checking for symptoms such as change in waterworks, blood in urine, and menstrual problems.

Red Flags

Critical symptoms identified during the Review of Systems, specifically coughing blood, blood in bowel habits, and weight loss.

ICE

An acronym used to understand the patient’s perspective: Ideas, Concerns, and Expectations.

Ideas (ICE)

Asking the patient if they have any thoughts as to what the problem may be.

Concerns (ICE)

Identifying what the patient is most worried about regarding their condition.

Expectations (ICE)

Determining what the patient hopes to get from the medical visit.

Illness Framework

The patient perspective focusing on ideas, concerns, expectations, feelings, thoughts, and life effects.

Disease Framework

The biomedical perspective focusing on symptoms, signs, investigations, and underlying pathology to reach a differential diagnosis.

Closing and Summary

Summarizing key points back to the patient to verify accuracy, allowing for corrections, thanking the patient, and explaining the next steps.