Comms Skills/History Taking

Question 1

What to do in the introduction of clerking?

Answer 1

wash hands + ensure correct PPE
introduce name, role, why you are there
confirm name and date of birth
seek consent to ask the patient questions
reassure the patient their information is kept confidential within the medical team

Question 2

components that make up a history

Answer 2

presenting complaint
history of presenting complaint
past medical history
family history
drug history
social history
systems review
ICE

Question 3

what to do when closing a history?

Answer 3

summarise + give the patient a chance to correct you
ask the patient if they have any questions for you
let the patient know you will relay to GP/doctor
thank the patient

Question 4

what is ICE?

Answer 4

ideas
concerns
expectations

Question 5

important questions to ask in presenting complaint?

Answer 5

describe current episode
use SOCRATES
risk factors

site
onset
character
radiation
associated symptoms
time
exacerbating/relieving factors
severity

Question 6

what questions to ask if worried about cancer?

Answer 6

fatigue
lethargy
appetite
weight loss
sweating (night)

Question 7

what questions to ask in PMHx?

Answer 7

any other conditions?
any surgeries in the past?
immunisations?
anything you see GP for regularly?

Question 8

what questions to ask in FHx?

Answer 8

any conditions run in the family?
age of onset?
age of death?

Question 9

what questions to ask in DHx?

Answer 9

any prescribed meds?
any over the counter meds?
any pain medication?
any herbal remedies?
any supplements?
any hormones?
any drug allergies?
dosage?
frequency?

Question 10

what questions to ask in SHx?

Answer 10

alcohol?
smoking?
recreational drugs?
diet?
exercise?
occupation?
travel?
family/living situation?
social support?
O+G/sexual?

Question 11

what questions to ask in ICE?

Answer 11

any ideas about what’s going on?
anything in particular that’s worrying you/you are concerned about?
what do you want/or expect from today? (test/diagnosis/discharge)

Question 12

break down systems review into the systems

Answer 12

general
cardiovascular
respiratory
gastrointestinal
neurology
genitourinary

Question 13

what questions to ask in history of presenting complaint?

Answer 13

previous episodes?
any admissions?
Ix or Rx (pending)?
related symptoms
establish baseline

Question 14

what to ask in general systems review?

Answer 14

fever
fatigue
weight loss
lumps

Question 15

what to ask in CVS systems review?

Answer 15

chest pain
palpitations
paroxysmal nocturnal dyspnoea/orthopnoea
ankle swelling

Question 16

what to ask in resp systems review?

Answer 16

cough +/- sputum
haemoptysis
SOB
exercise tolerance

Question 17

what to ask in GI systems review?

Answer 17

abdominal pain
appetite
vomiting
bowel habits
PR blood/mucus
dysphagia/dyspepsia

Question 18

what to ask in genitourinary systems review?

Answer 18

dysuria
frequency/urgency
nocturia
incontinence
abnormal discharge

Question 19

what to ask in neuro systems review?

Answer 19

headache
visual issues
speech issues
hearing issues
weakness/numbness
seizures
loss of consciousness