Taking a history Flashcards
4 key points before you start taking a history?
- Wash your hands
- Introduce yourself- name and status
- Identify the patient- verbally and wristband
- Informed consent- make sure they know you’re doing it for educational purposes
Outline the 8 steps of a standard history framework
- Presenting complaint (PC)
- History of presenting complaint (HPC)
- Past medical history (PMH)
- Drug history (DHx)
- Allergies
- Family history (FHx)
- Social history- includes alcohol and smoking (SHx)
- Systems review
Define ‘collateral history’
Patient history obtained from sources other than the patient themselves e.g. relatives, friends, carers, GP, initial referrer, witnesses to an accident
In what clinical situations might taking a collateral history be necessary?
Whenever a patient is unable to give a full history themselves e.g. unconscious, delirious, demented, dysphasic
It is important to remember to … if you have taken a collateral history
Document clearly in the patient’s notes who the collateral history was given by, and why the patient was unable to speak for themselves
Define ‘presenting complaint’
- The patient’s main problem in their own words
2. Should be no more than a sentence
How do you identify a patient’s presenting complaint?
- Open question e.g. “I understand you’ve been suffering from X, could you tell me what the problem is?”
- Another open question e.g. “Can you tell me anything else about this problem?”
- Summarise back to patient
Define ‘history of presenting complaint’
Detailed chronological description of the presenting complaint
Outline the SOCRATES mnemonic for pain
Site Onset Character Radiation Associated symptoms Timing Exacerbating and relieving factors Severity
‘S’ in SOCRATES
Site- Where is the pain worse? Point to the pain with 1 finger?
E.g. Somatic pain often well localised e.g. broken ankle vs. visceral pain more diffuse e.g. angina
‘O’ in SOCRATES
Onset- When did it start? Circumstances? How quickly did it start?
‘C’ in SOCRATES
Character- Sharp/dull/burning/crushing/aching
Get the patient to find their own adjectives where possible
‘R’ in SOCRATES
Radiation- Does the pain spread anywhere else?
By local extension or referred by shared neuronal pathway to a distant unaffected site?
E.g. diaphragmatic pain at the shoulder tip via the phrenic nerve (C3,4)
‘A’ in SOCRATES
Associated symptoms- Any symptoms other than the pain itself?
E.g. N+V, dyspepsia, SOB, paraesthesia
Be aware that any severe pain can produce N+V, sweating, and faintness from the vagal and sympathetic response but MAY suggest underlying cause
‘T’ in SOCRATES
Timing- Duration, course and pattern since onset? Episodic or continuous?
‘E’ in SOCRATES
Exacerbating and relieving factors- Does anything make the pain better or worse?
E.g. Food, specific activities, postures (including avoidance measures, effects of medications and alternative therapeutic approaches)
‘S’ in SOCRATES
Severity- scored out of 10, where 10 is the worst pain imaginable, including any variation
Difficult to assess as is highly subjective
May be helpful to compare to other pains e.g. toothache, broken bones
Describe the typical onset and progression of symptoms with an infectious type of pathology
e.g. IE-COPD, UTI
Onset usually hours
Progressive fairly rapid over hours/days
Describe the typical onset and progression of symptoms with an inflammatory type of pathology
e.g. IBD, RA
Onset often quite sudden
Progression over weeks/months
Describe the typical onset and progression of symptoms with a metabolic type of pathology
e.g. DM, CF, haemochromatosis, PKU
Onset very variable
Progression can be hours to months
Basically there is no typical onset and progression, but suspect if steadily progressive in severity with no remission
Describe the typical onset and progression of symptoms with a malignant type of pathology
Onset gradual
Progression over weeks/months
Describe the typical onset and progression of symptoms with a toxic type of pathology
e.g. drug OD
Onset abrupt (dramatic due to exposure) Progression is rapid
Describe the typical onset and progression of symptoms with a traumatic pathology
e.g. broken bone
Onset abrupt (usually clear from the history) Usually little change from onset
Describe the typical onset and progression of symptoms with vascular type of pathology
e.g. MI, PE, ischaemic limb
Onset sudden
Progression over hours (with rapid development of physical signs)
Describe the typical onset and progression of symptoms with degenerative type of pathology
e.g. osteoarthritis, MS
Onset gradual
Progression over months/years
What information do you need to illicit in the HPC?
Full descriptions of main problem, and any other symptoms the patient has, including SOCRATES if reporting pain
List the 7 key features to determine for each symptom in the HPC
- Exact nature of the symptom- clarify any pseudo-medical terms e.g. flu, vertigo, pleurisy
- Onset- date it began and sudden vs gradual over how long vs long standing
- Periodicity and frequency- constant vs intermittent, how long does it last each time and the exact manner in which it comes and goes
- Change over time- improving or deteriorating
- Exacerbating factors- what makes it worse
- Relieving factors- what makes it better
- Associated symptoms
At the end of the PC and HPC you should …
- Summarise what the patient has told you to check you have everything about the problem and it is all correct
- “I don’t have any further questions at this stage about your main problem, so now I’m going to ask you about your general health and family history. This can help us work out what is causing the problem.”
It is important to work out … if a patient presents with a long-standing symptom
Why the patient is seeking help NOW
- Has there been a change?
- May be helpful to ask the patient when they were last well to bring them back to the start of the problem
4 factors that would increase a patient’s pain threshold
- Exercise
- Analgesia
- Positive mental attitude
- Personality factors
4 factors that would reduce a patient’s pain threshold
- Sleep deprivation
- Depression
- Financial/personal worries
- Anxiety about the cause
- Past experiences (personal and family)
Outline the MJ THREADS mnemonic for important PMH
Myocardial infarction
Jaundice
Tuberculosis Hypertension and Heart disease Rheumatic fever Epilepsy Asthma and COPD Diabetes Stroke and TIA
What should you ask about when taking PMH?
- Open question first- Any significant illnesses?
- Any previous admission to hospital/surgery/procedures? (If so, problems with anaesthetic)
- Check MJ THREADS
For each condition identified in PMH, you should ask …
- When it was diagnosed
- Where it was diagnosed
- Who it was diagnosed by
- How it has been treated since diagnosis
Give 6 details that should be recorded about each drug in a drug history
- Name of drug
- Dose of drug
- Indication for use
- Duration of use
- Response to drug, including significant side effects
- Likely compliance/concordance/adherence (plus any aids used e.g. pre-packaged weekly supply)
List examples of types of drugs which should be included in a drug history
Basically anything a patient is taking:
- Prescribed, including inhalers/eye drops/nasal spray
- OTC
- Vitamins/supplements
- Homeopathic/alternative medicine
- Illicit/recreational(include info on exact type, route of administration, site, frequency of use, shared needles)
If the patient is unsure what drugs they take, you should …
Confirm with the GP or pharmacy
You should take special note of any drugs that …
Have been started or stopped recently!
Discontinuation can cause symptoms and patient may not think to mention this as they are no longer taking the drug
Give the 2 important features of an allergies history
- “Have you ever had an allergic reaction to anything?” e.g. drugs, vaccines, food, latex, plasters
- “Can you describe to me the reaction you have with X?
e. g. itch, rash, swelling, anaphylaxis vs. just unpleasant side effect
In which 3 places should you record a true allergy reported by a patient?
- Patient’s file/notes
- Patient’s drug chart
- Patient’s computer records
Give the 3 important features of a family history
- Any diseases run in the family?
- Specific disease relevant to PC?
E.g. T1DM/coeliac/pernicious anaemia if suspecting AI, eczema/asthma/hayfever if suspecting atopic - 1st degree relatives- Age and state of health/cause of death
If you suspect an inherited single gene disorder, what sort of detail should you get from the family history?
Pedigree chart going back 3 generations, including racial origins and any consanguinity
List key facts to identify within the social history
- Domestic circumstances- Marital/relationship status? Dependents? Financial situation?
- Accommodation- Where? Rented or owned? House, bungalow, flat? Aids/adaptations? Pets?
- Occupation- and any previous occupations! If you’re unsure, get them to describe the job so you can identify any occupational hazards
- Getting out and about- Do they drive? Friends? Hobbies?
- Overseas travel- time abroad, countries visited, vaccinations, malaria prophylaxis (if relevant)
- Any help needed for ADL’s- e.g. informal care from family/friends, involvement of social services, district nursing
- Alcohol- Do you drink? What/when/where/with whom?
- Smoking- Do you smoke? If previous, when did you stop? Calculate pack years. Passive smoking? Anything other than tobacco?
What is the maximum weekly recommended limit of alcohol?
14 units
2 examples of questionnaires that can be used to screen for possible alcohol abuse
CAGE questionnaire
FAST questionnaire
How do you calculate pack years of smoking?
20 cigarettes = 1 pack
1 pack per day for 1 year = 1 pack year
What is the purpose for a review of systems in history taking?
- Identify symptoms the patient has forgotten about
2. Identify secondary, unrelated problems to address
Review of systems: general health? (5)
- Fever
- Lethargy
- Malaise
- Weight change
- Appetite
Review of systems: respiratory? (5)
- Cough +/- sputum (amount and colour)
- Haemoptysis
- Dyspnoea (exercise tolerance)
- Wheeze
- Chest pain (on inspiration or coughing)
Review of systems: cardiovascular? (7)
- Exertional dyspnoea
- Paroxysmal nocturnal dyspnoea
- Orthopnoea
- Palpitations
- Ankle swelling
- Claudication (pain in legs on walking)
- Chest pain (on exertion)
Review of systems: gastrointestinal? (8)
- Mouth (oral ulcers, dental problems)
- Difficulty swallowing (dysphasia vs odynophagia)
- N+V
- Haematemesis
- Heartburn+indigestion
- Abdominal pain
- Change in bowel habit (D+C)
- Change in stool colour (pale, dark, tarry black, fresh blood)
Review of systems: genitourinary? (7)
- Dysuria
- Frequency
- Nocturia
- Haematuria
- Libido
- Incontinence (stress and urge)
- Sexual partners (unprotected intercourse)
Review of systems: men only (3)
- Prostatic symptoms (hesitancy, intermittency, terminal dribbling)
- Urethral discharge
- Erectile dysfunction
Review of systems: women only (7)
- Date of last menstrual period (consider pregnancy)
- Timing and regularity of periods
- Length of periods
- Abnormal bleeding
- Vaginal discharge
- Contraception
- Dyspareunia
Review of systems: neurological? (8)
- Headaches
- Dizziness (vertigo vs. lightheadedness)
- Loss of consciousness (fits, faints, funny turns)
- Altered sensation
- Weakness
- Visual disturbance
- Hearing problems (deafness, tinnitus)
- Memory/concentration changes
Review of systems: musculoskeletal? (3)
- Joint pain, stiffness or swelling
- Mobility
- Falls
Review of systems: endocrine? (4)
Note- excludes anything covered in the men/women sections
- Heat/cold intolerance
- Change in sweating
- Polydipsia
- Neck swelling (thyroid)
Review of systems: skin? (3)
- Rashes
- Bleeding/bruising
- Lumps/bumps
What question would you ask to assess a patient’s ideas?
“What do you think might be happening?” / “Do you have any ideas about what might be happening?”
What question would you ask to assess a patient’s concerns?
“What are you concerned that it might be?” / “What was the worst thing you were thinking it might be?”
What question would you ask to assess a patient’s expectations?
“What were you hoping we might be able to do for this?”
Outline a mnemonic for a surgical sieve tool for constructing a differential diagnosis
Congenital: …
Acquired: VITAMIN DEF
Vascular Infective and Inflammatory Traumatic Autoimmune Metabolic and endocrine Idiopathic and Iatrogenic Neoplastic
Degenerative
Environmental
Functional
Describe a systems-based differential diagnosis
Constructing a differential diagnosis based on the affected organs or organ systems
e.g. abdominal pain could be divided into upper GI, lower GI, liver, pancreas and biliary tract, KUB, reproductive organs, cardiovascular, respiratory…etc…then identify possible diagnoses within each organ group to confirm/refute based on examination/investigation
