History taking Flashcards
Steps in taking a history (7)
- Presenting complaint
- History of presenting complaint
- Previous medical/surgical history
- Drugs/allergies
- Immunisation history
- Family history
- Social history
Overview of a consultation (7)
- History (of current complaint)
- Patient perspective
- Background information (patient history)
- Physical examination
- Differential diagnosis and/or problems list
- Plan of management
- Explanation and planning
Presenting complaint
Cause for presenting complaint/most important symptom
Duration of symptom
(Whats brought you in today or how can I help you today?)
History of presenting complaint
SOCRATES
Site
Onset
Character
Radiation
Associated symptoms
Timing (duration, course, pattern)
Exacerbating/relieving factors
Severity
(Functional consequences)
Always consider patient perspective
Previous medica/surgical history
Notable illness/surgery/GP managed long term
Notable adverse events/problems during management of illness
Drugs and allergies
Drugs
* Name, dose, frequency, route, indication and concordance
- Prescription medicines
- Over the counter medicines
- Complementary/alternative medicines
- Recreational drugs
Allergies
- Allergens - medicine/other
- Effect
- Other sensitivities/significant adverse or sensitivities to medicines (i.e not allergies)
Immunisation history
Immunisation - name & date
- Allergies or side effects
Family history
First degree relatives (parents, siblings, children)
- Age and current health or cause of death & age of death
- Details of notable illness
Social history
Work circumstances
Social circumstances
Household members (if relevant)
Driving status
Physical activity (time spent active every week)
Diet (typical food eaten in a day)
Smoking (duration & amount)
Alcohol (amount & type)
Recreational drugs
Hobbies
Pets
Overseas travel
General systematic inquiry (9)
Fatigue
Malaise (weight loss)
Change in weight/appetite
Thirst
Fever or rigors
Night sweats
Sleep disturbances
Skin: rashes/bruising/bleeding/itching (pruritis)
Neck: sweeling/lumps
How to ensure patient perspective is taken into account
ICE
Ideas
Concerns
Expectations
Effects on life/activities of daily living
Feelings
How to open a consultation
Open questions
“How can I help you today?”
“What’s brought you in today?”
“What can I do for today?”
Golden minute - where patient speaks and you listen
How to close a consultation
Summarise and confirm with patient
Ask if there’s anything else the patient wants to tell you/ask
Do they have any concerns or questions
Review ICE
