Introduction to History Taking Flashcards
80% of diagnosis is made from the history
General Advice
When on wardsm look smart and remember PPE, wash your hands and alcohol gel after you have seen your patient
ID badge should be visible, ensure patients know you are medical students, introduce yourslef
Listen to your patient, use active listening skills
Don’t be afraid to get them to repeat or clarify
If they are giving you a lot of information, ask them to slow down and break it into smaller parts, ask them to stop or pause
Summarise/repeat it back to clarify
Write down key notes, but tell patient if you are
Treat all information as confidential
Try to follow a structure, it will also help you remember all parts that need to be covered
Communicating with patients
Be aware of any sight, hearing or communication difficulties with your patients
Never shout at a patuent with hearing impairments; try to be clear, stand closer to them so you can talk closer to their ear or other patients may prefer you to stand directly in front of them. Ask what is best for them
Give a patient with a visual impairment more information
Someone with a communication difficulty may struggle to understand or express to you, slow your communication down, break setences up, gesture, write things down, use pictures. Get them to write down. If you don’t know, don’t assume.
Communicating with patients
Main aim in history is to elicit; the patients main problems, the patient’s perceptions of these and the physical, emotional, and social impact of the patient’s problems on the patient and family
Tailor information to what they want to know; check their understanding
Hollistic thinking - how is this issue affecting this patient?
Talk to your patient - give them the information, answer the specific question if you feel you’re able
No equipment needed
Question style - (open/closed)
Active listening
Facilitative responding
Cues
Clarification
Time-framing
Appropriate language¬
Patient encounter
History –> Examination –> Investigation –> Management
Introduction to history taking
Introduce yourself
Gain consent
Confirm patient’s name, age, DOB
Occupation
Main presenting complaint
History of presenting complaint - sequence of events, symptom detail and any associated symptoms
Systems review - how have they been in other aspects of their health?
Past medical/surgical history
Drug History - Prescribed/OTC, illicit use? Smoking, Alcohol?
Introduction to history taking slide 2
Allergies
Family history Travel History Social History - where do they live? Can they care for themselves? Are they mobile? Do they have any mobility aids? Do they have carers? Do they have children Effects on patient - Physical, psychogical, social Patient's perspective/ICE Summarise back to patient
Presenting complaint
The key is asking this as an open ended question, you’re asking your patient to tell you in their own words. Record and feedback how the patient has described things in their own words. Be aware there maybe more than one complaint, e.g. Ankle swelling and a fall
“What has brought you to hospital?”
“What has been the trouble/problem recently?”
“How can we help you today?”
SOCRATES
Site Onset Character Radiation Associated symptoms Time course Exacerbating/Relieving factors Severity
History of Presenting Complaint
Chronological and more detailed account of the presenting complaint
Open question initially
Let the patient talk (active listening - show them, ‘right’, ‘mm’, nod your head)
Closed questions to clarify points - (So can I just confirm as you have told me lots of important questions)
Specific questions related to the relevant system
Past medical history
Medical Illness: A - Asthma B - Blood pressure C - CVD/CVA D - Diabetes E - Epilepsy TB, Jaundice, Rheumatic fever
Drug history can be telling
Surgical procedures
Childood illnesses
When and where
Systems review
CVS - Chest pain / SOB / Orthopnoea / PND / Oedema / Palpitations
Respiratory - SOB / Cough / Haemoptysis / ET / Chest pain
GIT - Weight loss / N&V / Dysphagia / Bowe lhabit / Passing blood
GU - Dysuria / Hestitancy / Poor stream / Nocturia / Blood
CNS - Headaches / Fits/ Faints / Blackouts / Weakness / Clumsiness / Memory problems
MSK - Painful joints / Stiffness / Rashes / Swelling
The last few parts
Summarise the issues
Anything missed?
Any questions?
ICE
Ideas - Do you have any idea what this could be
Concerns - What are your main worries?
Expectations - What are you hoping we can help you with
