Taking a History Flashcards
Introduction!
Hello, my name is _____ and I am a _____ at the university of Aberdeen. Could I get your full name and date of birth, please?
Consent!
I am going to ask you a few questions, is that alright with you?
Presenting complaint!
What seems to be the problem?
How long has it been going on?
History of PC!
When were you last well?
Summarise to check understanding of PC.
Is there anything else I have overlooked?
SOCRATES!
Where is the pain?
What causes the pain?
What type of pain is it?
Does the pain radiate anywhere?
Do you notice anything else with the pain?
How long does the pain last? (PATTERNS)
What helps relieve the pain?
On a scale of 1-10…
How has the pain impacted your activities?
PMH!
Have you had any illnesses or surgeries recently?
Do you have any notable long-term conditions?
Do you have any problems managing illness (for example, any problems with anaesthesia)?
JAMTHREADS!
Jaundice, Anaemia, Myocardial infarction, Tuberculosis, Hypertension, Rheumatic fever, Epilepsy, Asthma, Diabetes, Stroke.
Drugs!
Do you take any medication?
What is the name of the medication?
Do you know the dosage?
How often are you meant to / do you take it?
(PRESCRIPTION / OTC / ALTERNATIVE / RECREATIONAL)
Allergies!
Do you have any allergies?
What symptoms do you get?
Are you sensitive to any medicines?
IH!
Have you had any immunisations?
What were they called?
When were they done?
Have you had any side effects to them?
FH!
How old are your family?
How healthy are your family?
How did your (member of the family) die? How old?
Do any of your family have notable illnesses?
SH!
Work?
Who do you live with?
Do you drive / exercise / smoke / drink?
What is your typical diet?
Do you have any hobbies / pets?
When was the last time you travelled overseas?
ICE!
What do you think is causing the problem?
What is your number one concern regarding this problem at the moment? (Probe further)
What were you hoping would happen today?
How can you show good communication?
Maintain appropriate eye contact.
Lean slightly forward; do not cross your arms or legs.
Do not interrupt the patient.
Establish a rapport - ask them how they are, and offer them a seat.
Summarise at regular intervals.
Care planning!
Have you expressed thoughts about medical treatments you do not want?
What is most important to you?
