history taking

Question 1

What is the first part of taking a patient history?

Answer 1

• Identify yourself
• Identify patient
• Ask what patient would like to be called
• Explain
• Get consent

Question 2

What are the 5 sections of a history

Answer 2

PC + HPC
PMH
DH
FH
SH

Question 3

Describe the presenting complaint section of a history

Answer 3

Ask ‘what brought you in’ or ‘what brought you to see us today’ and then just go from there pal. Ask relevant questions and hope for the best

Question 4

Describe the history of presenting complaint

Answer 4

Get details of all current symptoms (use SOCRATES(F))

Question 5

What does the S in socrates stand for?

Answer 5

S - Site
Where is the pain?/maximal site of pain?

Question 6

What does the O in SOCRATES stand for?

Answer 6

O - Onset
When did the pain start? Was it sudden or gradual? Was it progressive or regressive?

Question 7

What does the C in SOCRATES stand for?

Answer 7

C - Character
What is the pain like? Ache or stabbing?

Question 8

What does the R in SOCRATES stand for?

Answer 8

R - Radiation
Does the pain radiate anywhere?

Question 9

What does the A in SOCRATES stand for?

Answer 9

A- Associations
Is there other signs or symptoms associated with the pain?

Question 10

What does the T in SOCRATES stand for?

Answer 10

T - Time course
Does the pain follow any pattern?

Question 11

What does the E in SOCRATES stand for?

Answer 11

E - Exacerbating/relieving factors
Does anything change the pain?

Question 12

What does the last S in SOCRATES stand for?

Answer 12

S- Severity
How bad is the pain?

Question 13

Describe the PMH section

Answer 13

• Noteable illnesses/Surgery/GP managed long term condition
• Noteable adverse events/Problems during management of illness (eg problems with anaesthesia)
  [have you had any surgeries? Do you generally keep well?Gave any long term conditions?Any recent hospital admissions?Have any illnesses recently]

Question 14

Describe the drugs and allergies section of a history

Answer 14

Drugs – name/dose/frequency/route/indication concordance:
- Prescription medicines – including oral contraceptive pill
- Over the counter (OTC) medicines
- Complementary/alternative medicines
- ’recreational’ drugs
[Have you ever been prescribed medications you dont take?]
• Allergies:
- Allergens – Medicine/Other
- Effect
- Other sensitivities/significant ad

Question 15

Describe the different sections of a FH

Answer 15

First degree relatives:
- Age and current health/cause of death/age at death
- Details of notable illlness
- Extended FH is strong disease corrolation

Question 16

Describe the different sections of a social history (12)

Answer 16

Activity
Diet
Smoking
Alcohol
drugs
Hobbies
Pets
travel
circumstances
Household
Work
Driving

Question 17

Describe the systematic enquiry of a heart issue?
(6)

Answer 17

• Chest pain?
• Dyspnoea
• Palpitations
• Anke oedema
• Varicose veins
• Claudication

Question 18

Describe the systematic enquiry of a respiratory issue

Answer 18

• Cough
• Sputum
• Haemoptysis
• Dyspnoea (SOB)
• Wheeze
• Chest pain (type)
  -Symptoms of sinitus (blocked nose, nasal discharge, facial pain, reduced smell)
• Earache
• Sore throat