History Taking Flashcards
What is the general overview of taking a history?
WINDEC
SOCRATES
Open consultation
System symptoms
Systemic enquiry
Past medical history
Family history
Social history
ICE
Questions and further resources
What does WINDEC stand for?
W- wash your hands
I - introduce yourself - Good morning, first and second name, grade, just a couple of things before we get started
N - check patient’s name
D - check patient’s DOB
E - explain what you are going to do - I would like to ask you some questions about your health
C - consent - is that okay with you?
What does SOCRATES stand for?
S- site
O- onset (when it began)
C -Character
R - radiation
A - associated symptoms
T- timing (intermittent or constant, frequency)
E- exacerbating / relieving factors
S- severity (interfere with life)
System Questions: Cardiology
Cardiology : chest pain, palpitations, shortness of breath, syncope, ankle swelling
System Questions: Respiratory
Respiratory: cough, SOB, sputum, haemoptysis, chest pain
System Questions: Neurology
Neurology: headache, seizure, blackout, dizziness, faintness, vertigo, weakness, paraesthesia (numbness or tingling), dysarthria (speech disturbance), dysphagia (swallowing problems), visual changes, hearing problems . Assoc = nausea/vomiting
System Questions: Gastrointestinal
Gastrointestinal: abdominal pain, reflux, vomiting, constipation, diarrhoea, haematemesis, melena, urinary symptoms
System Questions: Musculoskeletal
Chronic or acute, infection, joint or soft tissue, pain, stiffness, swelling,which joints are affected
System Questions: Genitourinary
Colour of urine, UTI history, burning, frequency, hematuria (blood in urine), sediment, odour, kidney and renal history, STI history, nocturia
Questions to ask in: Systemic Enquiry
Head to toe:
Syncope/dizziness
Chest pain
Cough
Breathing difficulties
Abdominal pain
Bowel symptoms
Urinary symptoms
Leg pain or swelling
Weight loss
Night sweats
Fevers
Malaise
Sleeping habits
Questions to ask in: Past Medical History
Do you have any medical conditions that you see your GP for?
Have you had any surgeries previously
Do you take any regular medications? How are you with taking them?
Do you have any allergies to any medications? What happens when you take the medication?
Questions to ask in: Family History
Do you have any illnesses that run in the family?
Are your parents still with us?
Siblings
Children
Questions to ask in: Social History
Smoking history ( 1 pack year = 20 cigarettes per day for 1 year)
Alcohol history (units per week), how often do you drink a week? How many drinks do you typically have on any single occasion?
Recreational drug use
Diet - what sorts of foods are you eating in a general day?
Excercise - are you managing to keep active?
Occupation - prior occupation if retired, previous jobs too
Living circumstance - who’s at home with you, do you have a care package, how are you coping
Pets
Marital status
Hobbies
What does ICE stand for?
Ideas - what do you think is happening
Concerns - is there anything you’re worried about in relation to your symptoms
Expectations - is there anything you are specifically expecting to happen today
Closing a consultation
Do you have any questions? Signpost to leaflets, support groups, and websites available
Important things to remember during a consultation
Start with open questions. ‘The golden minute’. Reflect and recap. Work as a team. Chunk and check. Consent.
