Medical History Taking

Question 1

C/O

Answer 1

What is the presenting issue
open question
what has occured at that time on that day to necesitate coning to hospital

Question 2

HPC

Answer 2

History of presenting complaint
If they fell: what were they doing, collapse, previous episodes??

Question 3

Pain History

Answer 3

SOCRATES
site
onset
character
radiation
associating factors
time
exacerbating factors
severity

Question 4

Past medical history: Cardiovascular?

Answer 4

blood pressure
CVA
Cardiac - angina, MI, Valvular Dx

Question 5

Respiratory

Answer 5

infections, airflow obstruction (asthma, COPD), gas exchange failure, OSA, Tumours

Question 6

Gastrointestinal

Answer 6

• stomach - reflux
• bowel - crohns, UC
• liver- ALD, Cirrhosis

Question 7

Neurological

Answer 7

Fits - seizure, change in meds
faints
headaches

Question 8

Endocrinology

Answer 8

• diabetes (type 1- insulin deficiency, type 2 - insulin resistance)
• thyroid dysfunction

Question 9

Musculoskeletal

Answer 9

• pain, swelling, stiff joints
• joint prosthesis
• osteoporosis

Question 10

blood disorders

Answer 10

• generic (bleed for a while? problem with tooth extraction?)
• Hep B C HIV
• haemophilia A & B
• vW

Question 11

What else can you ask?

Answer 11

medications
other medical conditions
previous surgery
prev. hospital admission
Allergies

Question 12

What drugs are notable?

Answer 12

= anticoagulants: warfarin, factor Xa inhibitors
= antiplatelets: aspirin, clopidogrel
= Bisphosphonates: alendronic acid
= steroids in last 2 years

Question 13

Past dental history?

Answer 13

Regular attender?
phobias
adverse effects to LA
Hx of bleeding to excess after XLA
Tx under sedation

Question 14

Social history?

Answer 14

= alcohol
= smoking
= occupation
= exercise
= recreational drug use
= living situation
= house or flat?
= who is at home
= mobility
= carers
= activities of daily living

Question 15

Family history?

Answer 15

= CV diagnosis at a young age?
= are parents still in good health