History taking

Question 1

Sequence of events in patient assessment

Answer 1

-history
-examination
-problem list
-differential diagnosis- what could be wrong
-investigations- narrow down the diagnosis
-diagnosis confirmed
-treatment

Question 2

History sequence- the medical model

Answer 2

-presenting complaint (PC) and history of complaint (HPC)
-previous medical history (PMH), drugs history (DHx)
-family history (FHx), social history (SHx)
-sexual history (if relevant), review of systems (ROS)

Question 3

Presenting complaint- what to do

Answer 3

-ask open questions
-summarise in one sentence

Question 4

History of presenting complaint

Answer 4

OLDCARTS
-Onset- where, when, how, why
-Location
-Duration- constant, intermittent
-Characteristics
-Aggravating factors eg walking, sitting
-Relieving factors
-Treatment- taken medication?
-severity- pain score

Question 5

Drug history

Answer 5

DRUGS
-doctor- prescribed, compliance?
-recreational
-used for this current illness
-general- over the counter
-sensitivities- allergies

Question 6

Family history

Answer 6

-any family illness
-look for risk factors eg cardiac problems, diabetes, high cholesterol, hypertension(high BP)

Question 7

Social + personal history

Answer 7

-alcohol
-drugs
-smoking
-who’s at home
-home care, social services
-modifications to home eg ramps
-employment
-home enviro
-nutritional status
-travel exposures
-hobbies
-exercise tolerance

Question 8

Smoking history

Answer 8

pack years= packs smoked per day x years as a smoker
-over 30= high risk of COPD or lung cancer

Question 9

Review of systems / system enquiry

Answer 9

-irrespective of presenting complaint, ask other questions to help you reach diagnosis
-more closed questions
-eg. patient presenting with chest pain, ask about breathlessness, swollen ankles etc.