History Taking (M1)

Question 1

LO’s

Answer 1

Demonstrate the ability to take a focused history from a person presenting with symptoms suggestive of respiratory disease

Question 2

How to take respiratory history and summarise at the end.

Answer 2

1. Hello, my name is Rimshah, i’m a first year medical student.
2. Is it ok if I ask you some questions about why you are in today?
3. Please could I ask you your name and date of birth?
4. Ask about PC and all relevant questions about the complaint. Other symptoms, how long, what makes it worse/better, if pain ask where and intensity.
5. Have you taken medication for the PC?
6. Have you travelled abroad or have pets?
7. Ask about ICE.
8. Cardinal symptoms of respiratory disease: blood in phlegm, SOB and cough.
9. Specific ques: other conditions/medications, FH, working, married, stairs?
10. Drink, smoke, give up?

Summarise: mr/ms name, age, sex, past condition, patient’s PC, any positives and negative results.

EG) In summary, Mr Briggs is a 48 male with COPD, who presented with a three day history of shortness of breath, yellow phlegm and tighness in the chest. A chest examination showed normal chest sounds, apart from a mild wheeze.