History Taking Marking Scheme

Question 1

INTRODUCTION
& DEMOGRAPHICS

Answer 1

1.Introduction
Greet— good morning/Afternoon/evening

Introduce yourself— My name is Ama Ben Mocktal, A level 400 physician assistant student and as part of my clinical assessment, I have been asked by my supervisor to take a history of you.

explain purpose — this will involve me asking you some questions concerning why you’re here today

and seek consent—- please do I have your permission?

Demographics
2. NASMORAN for an adult
Name—what is your name?
Age — how old are you?
Sex— Male or female or other?
Marital status — are you married or single?
Occupation —what do you do for a living
Religion — are you a Christian, Muslim, or other?
Address — where do you live
NHIS— Do you have an NHIS if yes is it active?

Question 2

Presenting complaints

Answer 2

Should be in patients own words.

Symptom & Duration (1 mark for each complaint)

Eg.
So what brought you to the hospital today ?
Headache 🤕 , fever 🤒 and cough of 2 days duration

Question 3

HPC

Answer 3

Should be in a story form

4
Initial onset of polyuria (5 times daily)

5. Worsening of polyuria (10 times daily)
6. Onset of nocturia

7
Association with increased thirst (polydipsia)

8
Weight loss – assessment (self – through clothing; informed through friends)

Question 4

ODQ

Answer 4

Any four questions relevant to HPC (blurred vision, paresthesia, numbness, chest pains)

X
SYSTEMIC REVIEW (at least 2 each)

Question 5

SR

Answer 5

GI
Res
CVS
Musculoskeletal
Genitourinary
CNS

Question 6

PM&SH

Answer 6

History of current presentation

History of medical conditions (at least 4)

History of surgery
History of hospital admissions
History of blood transfusions

Question 7

DH

Answer 7

Prescribed medications e.g. paracetamol, etc.

X

22
Long term medications

X

23
Herbal medications

X

24
Food & Drug Allergies

Question 8

FH

Answer 8

Medical conditions (and person in the family affected)

Question 9

SH

Answer 9

number of childern, source of drinking water, occupation etc.

27
Smoking history / Alcohol intake / Recreational drug use

Question 10

Closing consultation

Answer 10

Thank patient

Question 11

SUMMARY (Each carries a mark of 0.25)

Answer 11

AGE/SEX/OCCUPATION/PRESENTING COMPLAINTS/DURATION & SEVERITY OF SYMPTOMS/MEDICAL HISTORY & FAMILY HISTORY

Question 12

FOLLOW UP QUESTIONS

Answer 12

FOLLOW UP QUESTIONS
30
State your provisional diagnosis

31
What system would you examine for this patient?

X
32
What are some investigations you would request for this patient?

33
Give any two possible complications of this condition