W4 Consultation skills Flashcards
Taking a Full History:
What are the 9 stages?
- Introduction
- Presenting complaint
- History of presenting complaint
- Past medical (and surgical) history
- Family history
- Social history
- Drug history (including allergies)
- System review
- Summarise
Full History-
What is done in regard to the Introduction?
(WIIPP)
- W – Wash hands / don correct PPE
- I – Introduce yourself (name, job role)
- I – Identify you are speaking to the correct individual (name, address/ DOB)
- P – Purpose of consultation and gain permission
- P – Position yourself to be at eye level with the patient and 1m away
What is asked in regard to the Presenting Complaint (PC)?
What are some open questions you can ask?
-Why has the patient come to see you? Why are they in hospital?
Open questions:
* “What has brought you into hospital today?”
* “What can I help you with today?”
* “What seems to be the problem?”
Points to remember from Year 1
* Active listening
* Open body language
* Building rapport
* Letting the patient speak
What is asked in regards to History of Presenting Complaint? (HxPC)
- Details relating to the presenting complaint
- Nature of your questions will depend on PC and the body system affected
- Common acronym used: SOCRATES
- S – Site
- O – Onset
- C – Character
- R – Radiation
- A – Associated Features
- T – Time Course
- E – Exacerbating/Alleviating Factors
- S – Severity
Explain how you would ask SOCRATES in practice e.g. Pain
- S – “Where exactly is the pain?”
- O – “When did the pain start? Did it start suddenly?”
- C – “Can you describe the pain to me?”
- R – “Does the pain move anywhere?”
- A – “Apart from the pain, do you have any other symptoms?”
- T – “Has the pain got better, worse or stayed the same?”
- E – “Does anything make the pain better or worse?”
- S – “On a scale of 1 to 10, how bad is the pain, with 10 being the worst pain
imaginable?”
What is asked in regards to the Past Medical/Surgical History (PMHx)
- Identifying what underlying conditions and surgical procedures the patient has had
- Some might be linked to the PC
- E.g. type II diabetes can increase risk of MI
- Use open questions to let the patient speak
- Useful to cross-match PMHx and DHx
- Can use acronym MJ THREADS Ca to help
- Way of checking most body systems and ensure none missed
MJ THREADS Ca acronym
- M – Myocardial infarction
- J – Jaundice
- T – Tuberculosis
- H – Hypertension
- R – Rheumatoid arthritis
- E – Epilepsy
- A – Asthma
- D – Diabetes
- S – Stroke
- Ca – Cancer
What is asked in regards to Family History? (FHx)
- Type of questions asked will relate to PC
- Some conditions will have genetic element
- Not always relevant, e.g. OTC sales
- E.g. Cardiovascular PC
- 1st degree relative having history of heart attacks?
- Parents or sibling passing away before 65 years of age, ?cause
- E.g. hay fever / asthma / eczema
- Any immediate relative with “atopic” condition
What is asked in regards to Social History (SHx)?
- Alcohol intake
- Weekly intake in units
- Tobacco use
- Quantify number of pack years (number of packs of 20 ciggs smoked per day x number of years smoking)
- Recreational drug use
- Don’t stereotype- ask everyone this question
- Employment history
- E.g. to ascertain if exposed to pathogens such as asbestos or dust
- Home situation
- Where are they living, with whom, any carers/support for ADL, mobility, or family support, do they feel like they’re coping at home?
- Travel history
- E.g. if PC is diarrhoea, need to check if recently been abroad
- Other
- E.g. any pets, exposure to farms, hobbies, exposure to food, relationship status
What is asked in regards to Drug History (DHx)?
Confirming the name and dose of all patient’s medication
* Those prescribed by GP
* Those prescribed by hospital
* Those bought OTC
* Also includes vitamins, supplements and herbal medicines
- Need to ascertain compliance – how?
- Does anyone help the patient with their medication?
- Allergies!
- Nature of the allergy
What is asked in regards to Systems Review?
- Specific questions relating to all body systems
- Check for any major symptoms
- Cardiovascular: chest pain, palpitations, oedema
- Respiratory: cough, SOB, sputum production, blood
- Gastrointestinal: abdominal pain, dysphagia, diarrhoea, blood
- Genitourinary: dysuria, discharge, erectile dysfunction, blood
- Neurological: numbness, weakness, tingling, visual changes
- Psychiatric: depression, anxiety, hallucinations
- General review: weight loss, appetite changes, rashes
What do you ask during the Summarise stage of a full history taking?
- Repeat the key information shared back to the patient
- This is to ensure you’ve understood fully what they’ve told you
- “Is there anything else you would like to add or you think is important for me to know?”
- Chance for patient to fill in any gaps
- Good for rapport – shows you have been listening and understand the
patient’s problem
Placement Focus: Drug History Taking
(for info)
Intro
* Who are you and why are you asking the questions?
Info Gathering
* Regular medication
* OTC, herbal, vitamins, supplements
* Any medication recently started or stopped?
* Any recent changes to doses?
Allergies
* To what and the nature of the allergy
Compliance questions
* Do you take the medication as prescribed?
* Do you have any difficulties taking your medication?
* Have you noticed any side effects?
* Does anyone help you to take your medication?
* Do you have the medication in boxes or in a tray?
Placement Focus: Drug History Taking
Sources of information
- Patient themselves
- GP records
- Relative or carer
- Community pharmacy patient medication records (PMR)
- Hospital discharge summary
- Clinic letters
- Patient’s own medication
- Medication administration record (MAR) chart
- Repeat prescription slip
Remember to use at least 2 sources where
possible
Other considerations – RPS Cheat Sheet
What questions could i ask?
