History Taking

Question 1

What are the different compartments to taking a general history?

Answer 1

• Name, age, occupation
• Background
• Presenting complaint - what brought them here? When did it start?
• Systems review (of other bodily systems) - RS, CVS, MS, Gen, GIT, etc
• PMH (previous medical history) - which doctors / when / any operations
• Drug history - what medications
• Family history
• Social history - impact of illness on the patient
• Risk factors

Question 2

What is included in a physical examination?

Answer 2

• extra-oral
• vitals - HR/BP/RR/temp
• System by system
• Neuro
• musculoskeletal
• Problem list

Question 3

What is important to do when finding out the presenting complaint?

Answer 3

Ask open questions

Go chronologically - go through history of presenting complaint for each symptom (e.g. cough started 3 weeks ago, fever started a week ago, etc)

Ask questions related to each symptom

Find out if they’ve spoken to their doctor

Question 4

What to ask with a past medical history?

Answer 4

Had any surgical procedures?

Any anaesthetic problems?

Any previous admissions? Who / what / why?

Ask more specifically - any diabetes / heart disease / etc

Question 5

What to ask during a drug history?

Answer 5

Have they brought their prescription?

Compliance (do they struggle taking their medications?)

Does the pt know what all the drugs do?

OTC meds / alternative meds or treatments?

Ask about responses to medications

Allergies? (drugs / latex / foods)

If yes, what sort of allergic rxns do they get?

Question 6

What to ask with a family history?

Answer 6

Ask about first degree relatives (parents, siblings, children)

Do any diseases run in the family?

Question 7

What to ask with a social history?

Answer 7

• smoking (if so how much), alcohol (how much), living circumstances
• do they have any dependents (kids / are they a carer)
• impact of illness on patient and family
• consider mood and outlook
• any modifications in lifestyle, activities of daily living
• occupation hazards / exposure
• change in occupation / hobbies

Question 8

How do you close the history?

Answer 8

Is there anything else you would like to add or tell me?

Is there anything else you think i should know?

Question 9

How do you present examination findings?

Answer 9

Present in the order you examined

Remember all positives

Not too many negatives

“I would complete my examination by…” - think logically about why you would do such a thing

Summarise at the end

Question 10

What are some examples of risks and problems?

Answer 10

• mobility issues, nutrition, complications of meds, patient education (smoking, alcohol, exercise)