Structure: Opening & Paraphrase
History of Presenting Complaint HPC
SOTCRAS (Pain), OA (Non-Pain)
- Site
Can you please point with one finger where the pain is exactly? - Onset
- When did the pain (or non-pain symptom) start?
- How did it start? Gradually or Suddenly?
- What were you doing when the pain started?
- Has it been continuous or it has been coming and going?
- Continuous- Are you still in pain?
- Yes (Progression)- Is it getting worse?
- Intermittent-
- Frequency- How many episodes did you have?
- Duration- How long did each episode last?
- Progression- Do you have it more often?
- Time- Is there any particular time of the day when you feel this pain?
- Character- Could you please describe the pain for me?
- Radiation- Does the pain go anywhere?
Shifting- Where was the pain when it started? - Aggravating factors- Is there anything that makes your pain worse?
Relieving factors- Is there anything that makes your pain better? - Score- Can you please grade the pain for me, on a scale from 1 to 10 with 1 being the lowest and 10 being the highest pain you have experienced so far.
Suicide Hx
Before: Plan it? Tell anyone? note? Under influence? Forced?
During: Pills or cut? How many or depth? where? When? Anyone around?
After: Inform anyone? Symptoms?
Fall Hx
Before: LOC? Heart racing? meal as usual? dizziness? room spinning? balance problem? weakness?
Non-medical- slipping? Poor light? Alcohol? NAI?
During: shakiness? wet yourself? tongue biting?
After: Remember? vomiting? injury? how you got here?
Fits Hx
Before, During, After
Sleep Hx
Can you tell me more regarding your sleep?
Do you have trouble going to sleep or maintaining it?
Before:
- How is your sleeping environment? (Mattress-pillow-temp-light-noise-Device)
- Do you take any food or beverage before going to bed? (Caffine-heave meal-alcohol)
- Do you exercise before going to bed?
- What time do you go to the bed?
- What time do you fall asleep?
During:
- Do you wake up in middle of the sleep?
- How many times do you wake up?
- Do you have difficulty falling back to sleep?
After:
- What time do you wake up?
- Do you feel tired after you wake up?
- How is your concentration during the day?
Ruling out DDs
Discharge Symtoms
TRAC- Timing, Relation, Amount, Color/Content
T- Do u notice it at any particular time of the day? Since how long?
R- Any discharge from anywhere else? Nose? Ear? Cough?
A- How much is the discharge?
C- What’s the colour of the discharge? Any blood? Pus?
In Vaginal: How does it smell?
Cancer symptoms
FLAWS: Fever, Lethargy, Appetite, Wt Loss (intentional?), Sweating (night sweats)
Anemia symptoms
Do you feel SOB? heart racing? weight loss? constipation or diarrhea?
Cough & Hemoptysis
The Five Symptoms: SOB, Cough, Fever, Heart racing, Trauma
Confusion Symptoms:
Not able to think or speak clearly or quickly
Not knowing where they are, feeling disorientated.
Struggling to pay attention or remember things.
See or hear things that aren’t there (hallucinations).
Try asking the person their name, their age and today’s date.
Autism symptoms: (remember it via sense)
Ear: Not responding to their name.
Eye: Avoiding eye contact.
Face: Not smiling when you smile at them.
Nose & Tongue: Getting very upset if they do not like a certain taste, smell, or sound.
Limbs: Repetitive movements, such as flapping their hands, flicking their fingers or rocking their body
Mouth: Not talking as much as other children and repeating the same phrases.
BPH urine questions:
Frequency & Nocturia- Do you have increased frequency of urine at night?
Urgency- Do you have to rush to the loo?
Hesitancy- Do you have difficulty in starting urination?
Dribbling- Have you noticed any leak at the end of urination?
Incontinence- Are you able to hold your urine before going to toilet?
Poor stream- Do you have a weak urine stream? stops and starts?
Poor emptying- Do you feel like you are not able to completely empty your bladder?
Hematuria- Any blood in urine? Any pinkish colour urine?
ADHD
unable to sit still
unable to concentrate on one task
excessive talking
Chest Symptoms
P - Pneumonia, Pulmonary embolism
A - Asthma
S - Smokers cough
H - Heart failure
A - Anaphylaxis
These questions cover PASHA DDs:
D: Any bleeding that you have noticed recently? (Anti platelets-clopidoge)
D: Any Fever?
D: Any recent chest trauma?
D: Any change in your weight recently?
MAFTOSA
Medical condition
Do you have any medical condition?
Medication
Do you take any regular medication, including OTC or herbal?
Allergy
Do you have any allergies from food or medicines?
Family History
Has anyone in your family suffered from similar condition in the past?
Travel
Have you traveled out of the UK recently? Do you drive?
Occupation
What do you do for living?
Surgery & Hospitalisation
Any previous surgeries or hospitalisation?
Anything else
Additional History Questions
Psychiatric Hx
MCFAMISH- Mood, Cognition, Family-Friends-Finance-Forensics, Alcohol, Men
WHIL- Worthless, Hopeless, Irritability, Loss of interest
Do you have feelings of emptiness or worthlessness?
Do you feel sad, hopeless, or irritable most of the time?
Do you have loss of interest in everyday activities?
Do you have episodes of feeling very happy or overjoyed?
How is your concentration nowadays?
Female Hx: 4P
I’m going to ask you some questions related your periods.
Periods- When was your last period? Are they regular? Any spotting in between your periods?
Pregnancy- Is there any chance, you could be pregnant? Yes-Did you do a test to confirm? Is this your first pregnancy? Was it a planned pregnancy?
Pills Contraceptive- Do you use any type of Contraception?
Pap smear- Are you up to date with your pap smear? (If she is > 25 years old)
Sexual Hx:
I’m gonna ask you some private questions, they might sound unusual but they’re routine questions.
Are you currently sexually active?
Do you have a stable partner?Have you had any other partners in the past 6 months?-No, How many partners do you have?
How is your partner’s health in general?
Have you been tested for HIV or STIs?
Do you practice safe sex, by that I mean do you use condoms?
No
When did you had your last unprotected sex?
Have you been tested for HIV or STIs?
Sorry to ask you, have you ever had anal sex?
What’s your sexual orientation?
Do you have any abnormal discharge from your front passage?
Gay: Do you prefer receptive or insertive sex?
(If she is <16 years old) add 2 questions:
D: How old is your partner?
P: (If the same age group= do nothing)/ (If not the same age group= inform social services after telling her)
D: Have you ever been forced into having sex? (To exclude sexual abuse/rape/coercion)
Partner’s health
- How is your partner’s health in general?
- How are things at home?
- Do any medical conditions run in his family?
- Are you related to your partner in any way?
- Was it a planned pregnancy?
Antenatal Questions: 5+5
Could you please confirm the age of your pregnancy?
How has your pregnancy been so far?
Have you had any complications so far?
Have you attended your Antenatal Clinic(s)?
Have you been pregnant before? Yes
How may times have you been pregnant before?
When was it? / When was each pregnancy?
What was the outcome?
What was the mode of delivery?
Did you have any complications?
D: Could you confirm the age of your pregnancy?
D: Is this your first pregnancy?
D: Have you attended all your antenatal check-ups?
D: How has your pregnancy been so far?
D: Have you developed any complications?
D: Have you got any symptoms now?
D: Have you had any scans done?
D: Are you having twins in this pregnancy? (Risk factor)
D: Can you feel the movements of your baby?
BIRDDDD
B-Birth: How was his Birth?
I-Immunisation: Is he up to date with his jabs?
R-Red book: Are you happy with his red book?
D-Development: Are you happy with his development in comparison to others of his age?
D-Diet: Any changes to his diet recently?
D-Dehydration: Is your baby active and playful? No, Does he wet his nappies as usual?
D-Damage (NAI) Who do you and Adam live with? How are things at home?
Social History
DESA-
Diet, Exercise, Smoking, Alcohol
D- How is your Diet?
E- Do you Exercise?
S- Do you smoke?
A- Do you drink Alcohol?
Alcohol History:
What kind of alcohol do you drink?
How much do you drink?
How long have you been drinking?
Alcohol Units
- Wine: 1 glass = 3 units, 1 bottle 3 glasses, A bottle of wine = 9 units
- Beer: 1 pint = 2.5 units
- Spirit, Whisky, Brandy, Vodka, Rum, Gin, Tonic: 1 shot = 1 unit, 1 shot is 25 ml, 1 bottle = 30 units, Half a bottle = 15 units
- Recommended amount < 14 units per week.
Recreational Drug
Sorry, I need to ask you some questions that might sound a bit intrusive. Have you been taking any recreational drugs?
How you take it?
Do you share needles?
Psychosocial impact
How is it affecting your life?
How is it affecting your daily activities?
How is it affecting your job?
Has this affected your driving?
How is it affecting your mood? (must)
ICE
Ideas
- What do you think is causing your symptoms?
- What are your thoughts about what might be going on?
- Do you have any ideas about what could help you feel better?
- Do you have any idea what might be causing the problem?
- What do you believe is the best approach to manage your condition?
Concerns
- What are you most worried about regarding your symptoms or condition?
- Are there any aspects of the proposed treatments that concern you?
- Do you have any specific worries about the impact of your condition or its treatment on your life?
- Is there anything that you’re afraid we might find?
- Apart from this, do you have anything else that’s concerning you?
Expectations
- What are you hoping to achieve from this treatment?
- What do you expect to happen during and after your treatment?
- Are there specific results or improvements you are expecting from your care?
- How do you see this treatment fitting into your life?
- Are you expecting anything in particular from us today?
Examination
Vitals: I
General physical examination:
I would also like to examine your tummy, eye, ear, front or back passage,…
Managment
Diagnosis- Explain findings in terms of symptoms, risk factor and Ix and then disclose & explain diagnosis
Where the patient going next?
Send Home- Self limiting
Send to A&E (by themself or ambulance)
Admit
Indications for admission in pneumonia
→ CURB 65 (Confusion- Urea- RR- Bp low- age 65)
Urea: 7 or more
RR: 30 or more
BP: Systolic <90, Diastolic < 60.
Referral to a specialist
- Immediate: within few hours.
- Very urgent: within 48 hours.
- Urgent: within 2 weeks.
- Suspected cancer pathway: within 2 weeks.
- Non-urgent
Clinic- Sleep Clinic, TIA Clinic, Smoke cessation clinic, pain management clinic, sexual health clinic, migraine clinic, GUM clinic, enuresis clinic, Diabetic Clinic, Dementia Clinic, Travel Clinic, Menopause centre, rapid access chest pain clinic, Vestibular rehabilitation center, TB clinic
Support group- Epilepsy Action, Epilepsy Society, Ataxia UK, Adoption UK, Surrogacy UK, The Ectopic Pregnancy Trust
Program: Needle exchange program, Partner notification program
Organisation:
APNI- Association for Post Natal Illness
PANDAS- Pre and Postnatal Depression Advice and Support
RSPCA-
CAB- Citizens Advice Bureau
CAMHS- Bulimia
Senior- I’ll discuss and inform my senior about your condition.
Investigation
Full Blood Count, Blood Sugar, Liver Test, Kidney Test, Thyroid Test, Electrolytes, Infection Markers
Treatment
Symptomatic Rx: Pain, Fluids, Fever, Rest
Specific Rx
Lifestyle Management
General advice
Follow up & Safety netting