Medical History Taking

Question 1

What should be asked under Presenting Complaint?

Answer 1

Name
DOB
Purpose of Visit

Question 2

When can SOCRATES be used?

Answer 2

In History of Presenting Complaint if the patient has pain

Question 3

What does the first S in SOCRATES stand for?

Answer 3

Site - where is it

Question 4

What does the O in SOCRATES stand for?

Answer 4

Onset/duration - when did it start, how long does it go on for

Question 5

What does the C in SOCRATES stand for?

Answer 5

Character - ache, sharp, throbbing

Question 6

What does the R in SOCRATES stand for?

Answer 6

Relieving/exacerbating factors - anything you do that makes it better/worse eg - pain meds

Question 7

What does the A in SOCRATES stand for?

Answer 7

Associated - any other symptoms associated with it

Question 8

What does the T in SOCRATES stand for?

Answer 8

Timing - how often does it last, is it worse in the morning

Question 9

What does the E in SOCRATES stand for?

Answer 9

Effects - does it affect you in daily life, at work etc

Question 10

What does the second S in SOCRATES stand for?

Answer 10

Severity - 1-10

Question 11

What should be asked under Past Medical History?

Answer 11

Medical conditions
Any problems they feel may be relevant
Are they seeing a specialist for anything
Past hospital admissions

Question 12

What should be asked under Past Dental History?

Answer 12

Dental attitude
Anxiety
Experience of local anaesthetic
How often do they attend the dentist

Question 13

What should be asked under Past Drug History?

Answer 13

Medications they are on
Dosage
What for

Question 14

What should be asked for Social History?

Answer 14

What is their occupation?
Do they smoke (packets)
Do they drink (units)
Do they take recreational drugs
Do they exercise

Question 15

What kind of questions should be used in History of Presenting Complaint?

Answer 15

Open questions

Question 16

What are notable drugs that many patients are on?

Answer 16

Anticoagulants
Antiplatelets
Bisphosphonates - alendronic acid for osteoporosis
Steroids in the past 2 years - prednisolone for adrenal crisis

Question 17

What systems should Past Medical History be split into?

Answer 17

Cardiovascular
Respiratory
Gastrointestinal
Neurological
Endocrinology
Musculoskeletal
Blood Disorders

Question 18

What should be covered under Cardiovascular in Past Medical History?

Answer 18

Blood pressure
CVA
Angina
MI - Medical treatment - stents or CABG
Valvular disease

Question 19

What should be covered under Respiratory in Past Medical History?

Answer 19

Infections - pneumonia
Airflow obstruction - asthma, COPD - chronic bronchitis, emphysema
Gas exchange failure - fibrosis
Obstructive sleep apnoea
Tumours

Question 20

What should be covered under GI in Past Medical History?

Answer 20

Stomach reflux
Bowel - Crohn’s or ulcerative colitis
Liver - alcoholic liver disease, cirrhosis

Question 21

What should be covered under Neurological in Past Medical History?

Answer 21

Fits - seizure control, precipitating factors, change in meds
Faints
Headaches

Question 22

What should be covered under Endocrinology in Past Medical History?

Answer 22

Diabetes: type 1 - insulin deficiency, type 2 - insulin resistance
Thyroid dysfunction

Question 23

What should be covered under Musculoskeletal in Past Medical History?

Answer 23

Pain, swelling, stiff joints
Arthritis
Joint prosthesis
Osteoporosis

Question 24

What should be covered under Blood Disorders in Past Medical History?

Answer 24

Generic:
Do you bleed for a while after a cut, any issues with tooth extractions in the past, any blood disorders
Focused:
Hep B, Hep C, HIV
Haemophilia A and B
VW disease

Question 25

What should be asked for Family History?

Answer 25

Are parents still in good health

Is there history of cardiovascular disease at a young age