History taking

Question 1

Introduction:

Answer 1

AAA

Question 2

Presenting complaint: ?

Answer 2

• Why have you come in today

- How long has that being going on for

Question 3

History of presenting complaint:

Answer 3

AAA
SOCRATES
ICE?

Question 4

Systematic Enquiry: GI symptoms?

Answer 4

• Dysphagia (difficulty swallowing)
• Vomiting/ nausea
• Vomiting blood (haematemesis)
• Heartburn/dyspepsia
• Abdominal pain
• Abdominal bloating
• Yellowing of skin or eyes (jaundice)
• Changes in bowel habit (contiopation, diarrhoea, smelly?, melaena, rectal bleeding)
• Fat intolerance (intolerant to any food?)
• Itching, pain anywhere else?

Question 5

Past medical history:

Answer 5

• Do you have any chronic conditions that you see your GP for
• Have you ever been admitted to hospital (if so what was it for. If surgery, any complications, problems with anaesthesia)
  Do you or have you had any of the following conditions:
• Jaundice
• Anaemia
• Myocardial infection
• Tuberculosis
• Hypertension
• Rheumatic fever
• Epilepsy
• Asthma/ COPD
• Diabetes
• Stroke

Question 6

Drugs and allergies: ?

Answer 6

• Are you on any over the counter medication?
• Have you been prescribed any medication?
• Do you take any alternative medicines? (acupuncture)
• Do you take any recreational drugs?
• Do you have any allergies (if YES what’s the effect)
• Any side effects to medications?

Question 7

Family history: ?

Answer 7

• Any chronic conditions that run in the family

- Can ask about extended family