History Taking

University:
Stanford University
Course:
PEDS 282 | Pregnancy, Birth, and Infancy
Academic year:

2023
Views:

401

Pages:

2
Author:

Pierre BERNARD

History Taking Geriatric Giants Immobility Instability Incontinence Intellectual impairment Iatrogenesis Present Complaint Route of Admission – ambulance, relative, self refer, where from? Accompanied By – nil, friend, neighbour, relative, carer Common presentations: • Silent MI • Sepsis without fever • “quiet one” • “off legs” • dizzy (presyncope, vertigo, CVS, Neuro, MSK) • fatigue • confusion/talking nonsense PMH Previous admissions Any fractures, falls, continence problems MI, Angina, Asthma, COPD, PE, DVT, Stroke, RF, DM, Epilepsy Faints, Fits, Funny turns Drug history • Temazepam = benzo, sleeping tablet (causes dependence after 10 days & reduces reflexes • Captopril = for BP, HF, diabetic nephropathy • Glibenclamide = long acting diabetic drug • Aspirin = stroke/MI/pain • Atenolol = B blocker, BP, Angina, can à postural hypotension • St John’s Wort = herbal antidepressant & liver enzyme inducer (affects warfarin, simvastatin, weight) • Grapefriut/cranberry juice Family Whos at home Other family in the area Family medical history Social – Who live with? Where? Social support – Shopping, cleaning, cooking Drive? Hobbies & Outings Barthel ADL Scale (for all 0 = dependent) • Bowel 1 = accident 1/7 • Bladder 1 = accident 1/24 2= • Toilet 1 = independent • Bathing 1 = independent • Grooming 1 = independent • Dressing 1 = about ½ 2= • Transfer 1 = major help 2= • Mobility 1 = wheelchair 2= • Stairs 1 = some help • Feeding 1 = help with cutting/butter 2 = continent continent independent minor help 3 = independent walk with help 3 = independent 2 = independent 2 = independent Examination Obs – HR, BP (sat & stood), sO2, RR, BM Cognitive status – AMT4 (All boys pee yellow = age, birthday, place, year) or MMSE Nutritional status, muscle bulk, oedema, behaviour FULL – CVS, RS, ABDO, Joints, Neuro CHECK Under bandages Gait (transfer, walking aids)