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Summarising
Summarise what the patient has told you about their presenting complaint.
This allows you to check your understanding regarding everything the patient has
told you.
It also allows the patient to correct any inaccurate information & expand further
on certain aspects.
Once you have summarised, ask the patient if theres anything else that
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youve overlooked.
Continue to periodically summarise as you move through the rest of the history.
Signposting
Signposting involves explaining to the patient;
What you have covered Ok, so weve talked about your symptoms & your
concerns regarding them
What you plan to cover next - Now Id like to discuss your past medical history
and your medications
Menstrual History
Age of menarche the earlier the greater the exposure to oestrogen risk of
breast Ca
LMP (first day of LMP)
Duration & Regularity ( X / 28 days)
Flow heavy/light - number of sanitary towels / tampons can be useful to estimate
loss
Menstrual Pain use the SOCRATES method shown above to assess menstrual pain
Irregular bleeding
Post-coital ectropion / STDs/ vaginitis
Intermenstrual
Consider malignancy in older females - e.g. endometrial Ca
Younger females may have unexplained irregular periods
Poor compliance with oral contraceptives can result in intermenstrual bleeding
Associated Symptoms Bowel, Bladder dysfunction or pain
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Occupation?
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Systemic Enquiry
Systemic enquiry involves performing a brief screen for symptoms in other body
systems.
This may pick up on symptoms the patient failed to mention in the presenting
complaint.
Some of these symptoms may be relevant to the diagnosis e.g. reduced urine output in
fluid overload
Choosing which symptoms to ask about depends on the presenting complaint & your
level of experience
Cardiovascular Chest pain / Palpitations / Cyanosis / SOB / Syncope
/ Orthopnoea / Ankle swelling
Respiratory Cough / Sputum / Chest Pain / SOB / Wheezing / Stridor/
Haemoptysis
GI - Appetite / Nausea / Vomiting / Indigestion / Dysphagia / Weight loss /Pain /
Bowel habit
Urinary - Frequency / Dysuria / Polyurea / Urgency / Hesitancy / Nocturia /
Incontinence
Nervous System Vision / Headache / Weakness / Sensory disturbance / LOC /
Seizures / Incontinence
Musculoskeletal Bone & Joint pain / Muscle pain / Joint swelling / Difficulty
mobilising
Dermatology Rashes / Skin breaks / Ulcers
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Comments
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