History taking

Question 1

Standard history framework

Answer 1

Presenting complaint.
History of presenting complaint.
Past medical history.
Drug history.
Allergies/reactions.
Alcohol.
Smoking.
Family history.
Social history.
Systematic enquiry.

Question 2

Past medical history: ask specifically about…

Answer 2

Diabetes.
Rheumatic fever.
Jaundice. 
Hypercholesterolaemia.
Hypertension.
Angina.
Myocardial infarction.
Stroke or TIA.
Asthma.
TB.
Epilepsy.
Anaesthetic problems.
Blood transfusions.

Question 3

Past medical history: for each condition, specifically ask…

Answer 3

When was it diagnosed?
How was it diagnosed?
How has it been treated?

Question 4

Drug history: ask about…

Answer 4

Dose, duration and frequency of each prescription.
Significant side effects. 
Compliance/adherence.
Allergies and reactions.
Eye drops.
Inhalers.
Sleeping pills.
Oral contraception.
OTC drugs (bought at the pharmacy), vitamin supplements.
Herbal remedies.
Illicit or recreational drug use.

Question 5

Alcohol: CAGE questionnaire

Answer 5

A positive response to any of the 4 questions may indicate someone at risk of alcohol abuse.
A positive response to 2 or more questions makes the presence of alcohol dependency likely.
C: Have you ever felt that you should CUT DOWN your drinking?
A: Have you ever become ANGRY when someone suggests that you should cut down?
G: Do you ever feel GUILTY about your drinking?
E: Do you ever need an ‘EYE-OPENER’ in the morning to steady your nerves or get rid of a hangover?

Question 6

Smoking: cardiovascular health problems related to tobacco

Answer 6

Coronary heart disease.
Peripheral vascular disease.
Abdominal aortic aneurysm.

Question 7

Smoking: respiratory health problems related to tobacco

Answer 7

COPD.
Bronchitis.
Pneumonia.

Question 8

Smoking: neurological health problems related to tobacco

Answer 8

Cerebrovascular disease.

Question 9

Smoking: sexual health problems related to tobacco

Answer 9

Erectile and ejaculatory dysfunction.

Question 10

Smoking: neoplasia health problems related to tobacco

Answer 10

Oral cavity
Laryngeal
Pharyngeal
Bronchial/lung
Oesophageal
Gastric
Pancreatic
Renal
Cystic
Cervical
Acute myeloid leukaemia

Question 11

Smoking: conditions where smoking can worsen symptoms

Answer 11

Asthma.
Chest infections including TB.
Chronic rhinitis.
Diabetic retinopathy.
Optic neuritis.
Hyperthyroidism.
Multiple sclerosis.
Crohn's disease.