History Taking

Question 1

Consultation Overview

Answer 1

History
Patient Perspective
Background information - Context
Physical Examination
Differential Diagnosis and/or Problem List
Explanation and Planning

Question 2

Overview of History

Answer 2

Sequence of events
Symptom analysis
Relevant Systematic enquiry questions

Question 3

Overview of Patient Perspective

Answer 3

I - Ideas
C - Concerns
E - Expectations

Impact on daily life and activities
Feelings

Question 4

Overview of Background information - Context

Answer 4

Past medical history
Medication history and allergies
Immunisation history
Family history
Social history
Systematic enquiry

Question 5

Overview of Physical assessment

Answer 5

Including initial assessment

Question 6

Overview of Differential diagnosis and/or problem list

Answer 6

Including both disease and illness issues

Question 7

Overview of Explanation and planning

Answer 7

What is the patients understanding and perspective?
Provide structured explanation tailored to patient
Make explicit you clinical reasoning for investigations
Present options (BRAN)
Involve the patient and negotiate shared plans

Question 8

Introduction

Answer 8

Identify yourself and the patient fully
Explain reason for consultation and gain consent to proceed

Question 9

History

Answer 9

PRESENTING COMPLAINT
HISTORY OF PRESENTING COMPLAINT
PREVIOUS MEDICAL/SURGICAL HISTORY
MEDICATION HISTORY & ALLERGIES
IMMUNISATION HISTORY
FAMILY HISTORY
SOCIAL HISTORY

Question 10

PRESENTING COMPLAINT

Answer 10

Cause for presentation/most important symptom
Duration of symptom

Question 11

HISTORY OF PRESENTING COMPLAINT

Answer 11

Details of all current symptoms
This may include:
-Site
-Onset
-Character
-Radiation
-Associated symptoms
-Timing (duration, course, pattern)
-Exacerbating/relieving factors
-Severity
-Functional consequences
Ask relevant systematic enquiry questions

Question 12

PREVIOUS MEDICAL/SURGICAL HISTORY

Answer 12

Notable illnesses/surgery/GP managed long term
condition
Notable adverse events/problems during
management of illness (eg problems with
anaesthesia)
Could use ‘JAMTHREADS’ as an aide memoire for
common or important conditions

Question 13

MEDICATION HISTORY & ALLERGIES

Answer 13

Drugs – name, dose, frequency, route, indication and concordance:
- Prescription medicines – including OCP and HRT
- Over the counter (OTC) medicines
- Complementary or alternative medicines
- ’Recreational’ drugs

Allergies:
- Allergens – Medicine/Other
- Effect
- Other sensitivities/significant adverse or
sensitivities to medicines (i.e. not allergies)

Question 14

IMMUNISATION HISTORY

Answer 14

Immunisations – name and date
- Allergies or side effects

Question 15

FAMILY HISTORY

Answer 15

First degree relatives - parents, siblings and children:
- Age & current health or Age at & cause of death
- Details of notable illness

Question 16

SOCIAL HISTORY

Answer 16

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