History taking and examination

Question 1

Ask - intro

Answer 1

Name, Age, Occupation
Background/ serious medical conditions
Why are they in hospital?

Question 2

Presenting complaints

Answer 2

1, 2, 3
Identify px’s main problem in their own words
use open questions and clarify px’s responses

Question 3

History of presenting complaints

Answer 3

Go through HPC for each symptom
Ask questions related to each system
Maintain a chronological order
Investigations within the hospitals and treatments received
Try to find out who are their current doctor/ teams

Question 4

Past medical history

Answer 4

Complete the rest of the medical history with more info if necessary
Who/ when/ why/ what has happened
Plus any important negative e.g. DM, asthma, angina, MI
Ask about surgical procedures/ operations
Any anaesthetic problems?

Question 5

Drug history

Answer 5

Ask if they have brought their prescription
Compliance?
Does the px know what all the drugs do?
Over the counter/ alternative meds or treatments
Ask about responses to medications
Allergies (drugs, latex or foods)
If yes, what sort of allergic reactions do they get?

Question 6

Family history

Answer 6

Ask about first degree relatives (parents, siblings, children)
Do any diseases run in the family?

Question 7

Social history - impact of the illness on pt

Answer 7

Smoking, alcohol, living circumstances
Do they have any dependents? (kids, carer for spouse/ parent/ partner)
Impact of illness on px and family
Consider mood and outlook
Any modifications in lifestyle, activities of daily living
Occupation hazards/ exposure
Change in occupation/ hobbies

Question 8

Social history - if the px says they are an ex-smoker or have given up alcohol

Answer 8

Ask them when they gave up
How much did they smoke and how long for?
How many units do they drink or used to drink?
Ask about diet
Ask about recreational drugs (be aware that these are sensitive issues)

Question 9

Systems review

Answer 9

Series of screening questions
Adapt these qus according to px’s age and history
-most appropriate system first

Question 10

Closing the history

Answer 10

Ask px “is there anything else you would like to add or tell me/ is there anything else you think I should know?”

Question 11

Examination

Answer 11

General
Vital observations (HR/ BP/ RR/ T)
System by system (RS/ CVS/ GI/ Neuro/ MSK)
Go through main system first, that history is about
Then examine other relevant systems

Question 12

In the end

Answer 12

Thank you px
Cover px or let them dress themselves
Wash your hands
Document and report your findings

Question 13

Presenting examination findings

Answer 13

Present in the order you examined
Remember all positives
Not too many negatives
“I would like to complete my examination by..” - think laterally and logically and why you would do such a thing

Question 14

Summary

Answer 14

Do not repeat history of presenting complaint or your exam findings in great detail
Try to mention important and relevant features from px’s presenting complaint, HOPC and exam

Question 15

Risk factors - if relevant

Answer 15

Think of current ongoing problems
Social issues
Familial issues
Think laterally (outside the box)
Think about who or what dept can be involved to help you with problems
-->risk list becomes a problem list

Question 16

Investigating your px

Answer 16

Simple and logical first building up to more complex tests
Simple tests e.g. FBC, U&E, CRP
If needed add other test e.g. LFT’s, clotting profile and others if relevant to px’s history or diagnosis

Question 17

Mnemonic JAM THREADS

Answer 17

Jaundice
Anaemia and other haematological conditions
Myocardial infarction
Tuberculosis
Hypertension and heart disease
Rheumatic fever
Epilepsy
Asthma and COPD
Diabetes
Stroke