08-11-21 - History Taking Flashcards
Learning Outcomes
- Demonstrate an understanding of the framework of a medical history
- Understand the role of a medical history in making a clinical diagnosis
- Understand the skills required in taking a detailed medical history
What are the 7 stages for the structure of history taking?
1) Presenting complaint (PC)
2) History of presenting complaint (HPC)
3) Past Medial History (PMH)
4) Drug History (DH)
5) Family History (FH)
6) Social history (SH)
7) Systems Inquiry (SE)
How do you start the presenting complaint section (PC) of history taking?
What do you then do?
What is it important to do when doing this?
• The presenting complaint section of history taking should start with an open-ended question
• Examples:
1) Can you tell me a little bit about why you have come in today?
2) Can you tell me what brought you here today?
3) What can I do to help you today?
- It is then important to get a description of symptoms from the patient
- It is important to use the patients’ own words, and get everything down in one sentence e.g cough, sore throat, tummy pain, sore chest
What is it important to establish during history of presenting complaint (HPC)?
What is it important to do during this section?
How can patient conversation be facilitated?
What is a useful 8-part mnemonic for when patients present with pain during the History of presenting complaint (HPC) section?
- During history of presenting complaint, it is important to establish a timeline of events from the first symptom to the time of the interview
- Is it important to allow the patient to speak, and not jump in during this section
- Also important to facilitate the patient giving their account by asking a mix of open and close questions
- S – Site – location of pain
- O – Onset – when the pain started
- C – Character – shooting, stabbing, dull ache, throbbing pain
- R – Radiation – see if pain radiates away from source
- A – Associated symptoms – give examples
- T – Timing – pain worse at a particular time? Is it constant or intermittent?
- E – exacerbators/relievers – What makes the pain better/worse
- S – severity – pain on a 1-10 rating
What are 6 questions that may be asked during the Past Medical History (PMH) section of interview?
What is the 10-part mnemonic for PMH?
• Information about previous illnesses:
1) Have they been to their doctor for anything before?
2) Have they ever been in hospital?
3) Have they had any operations?
4) Have they had any investigations/treatments for other health problems?
5) Establish if problems are on-going / resolves fully / managed by medication etc
6) Establish chronology and document in ordered fashion
• 10-part mnemonic for PMH
1) J - Jaundice
2) A - Anaemia and other haematological conditions
3) M - Myocardial infarct
4) T – Tuberculosis
5) H – Hypertension and heart disease
6) R – Rheumatic fever
7) E – Epilepsy
8) A – Asthma and COPD
9) D – Diabetes
10) S – Stroke
What 4 types of drugs are considered during Drug history (DH)?
What are the 5 things considered when documenting a drug in drug history?
What must be asked regarding allergies?
What is an important allergy to keep in mind?
What is the difference between allergies and adverse effects?
• 4 types of drugs considered during drug history:
1) Prescribed medication
2) Over the counter medication
3) Herbal medication
4) Consider illicit drug use (recreational)
• 5 things considered when document a drug in drug history:
1) Name of drug
2) Dose
3) Route (e.g oral, intramuscular, per rectum)
4) Frequency
5) Duration
- Regarding allergies, we must ask “are you allergic to anything/any medicines that you know of?
- Elastoplast/latex allergies are important to keep note of
- Adverse effects are expected known side effects of drugs, and are not the intended therapeutic purpose of the drug
- Allergies to medicine are adverse drug reactions mediated by an immune response
What is the purpose of asking about family history (FH)?
What are 4 questions that may be asked?
What may be useful during this section?
• Asking about family history may give clues about possible genetic pred-disposition to illness
• 4 questions that may be asked regarding family history:
1) Are your parents still alive?
• If yes – how old are they? Do they have any health problems?
• If no – When did they die? What age were they? What did they die from?
2) Do you have any brothers or sisters? How old are they? Are they well/any illnesses?
3) Do you have any children? How old are they? Are they well/any illnesses?
4) Are there any health problems that run in your family?
• It may be useful to draw a family tree during this section
What are the various aspects of social history (SH) asked about?
1) Employment
• Are you working at the moment?
• May I ask what you do?
• Wat does that involve?
• Have you had any other jobs in the past?
• Has your health impacted your work at all?
• Important to consider occupation exposure e.g asbestos, excessive noise
2) Smoking
• Do you smoke at all?
• Have you ever smoke?
• If stopped, when did you stop?
• Important to calculate pack years – Packs of cigarettes smoked a day x number of years the person has smoked (20 cigarettes per pack)
• E.g 1 pack year is equal to 1 pack of cigarettes a day for a year (1x1)
3) Alcohol
• Do you drink at all?
• If yes – How often do you drink and how much?
• Try convert these to units, and be aware of recommended limits of alcohol consumption
• Men and women advised to not have more than 14 units a week on a regular basis
• Drinking should be spread across 3 or more days if 14 units is consumed regularly in a week
4) Home circumstances
• Who do they live with, or do they live alone?
• Do they live in a house / flat / bungalow, are there stairs?
• DO they have any help at home? How many carers a day
• ADLs (activities of daily living) e.g getting dressed, making food, walking up and down stairs
5) Other questions to consider: • Exercise/diet • Do they have any hobbies or interests? Do they have any pets? • Do they drive?
What is system enquiry?
What is the purpose of the system enquiry portion of an interview?
What are 7 systems that may be asked about?
What are symptoms we may look for?
• System enquiry is a couple of questions for each remaining system, which acts as a quick screening tool
• Examples of systems and symptoms:
1) CVS – palpitations, syncope (fainting/passing out)
2) RS – cough, mucus
3) GI – change in bowels, abdominal pain
4) GU – urinary systems, LMP (last menstrual period)
5) Endocrine – lumps in neck, temperature intolerance
6) MS – aches / stiffness in joints / muscles / back
7) CNS – headache, fits
What are 3 questions we ask to address ideas, concerns, and expectations of the patient?
• Questions to address ideas, concerns, and expectations of patient
1) Do you have any thoughts as to what the problem may be?
2) Is there anything that you are particularly worried it may be?
3) What are you hoping I will be able to do for you today?
What is the purpose of summarising to complete a history taking?
What is important that needs to occur throughout the session?
- Summarising:
- Helps to clarify points
- May highlight questions you haven’t asked or misunderstanding
- Brings up main points of Presenting complaint (PC) and History of presenting complaint (HPC)
- Brings up relevant features in the remainder of history
- Brings up relevant positives/negatives from systems enquiry
• It is important to explain and gain consent for examination as appropriate
What are the 4 parts of a SBAR handover?
1) S – situation
2) B – Background
3) A – assessment
4) R - recommendation
