History Taking

Question 1

Example Q do start consultation

Answer 1

“could you tell me little bit about what brought you in today”

Question 2

How do you start every history?

Answer 2

• Wash Hands
• “Hello my name is Olivia and I am a third yr medical student. Can I confirm your name and date of birth”

Question 3

What does SOCRATES stand for

Answer 3

Site, onset, character, radiation, associated symptoms, timing, exacerbating and relieving factors, severity

Question 4

PMH: what questions should you ask? (5)

Answer 4

• Do you have any other medical conditions that I should know about?
• Have you had any significant illness?
• Have you had any operations or durations in hospital?
• How is your mental health?
• Specific conditions

Question 5

What specific conditions should you ask about in PMH? (7+1)

Answer 5

• Heart attack (MI)
• Hypertension/ high BP or heart disease
• Asthma/ COPD
• Diabetes
• High cholesterol
• Stroke
• Epilepsy
• TB

Question 6

Drug History: what Qs (5)

Answer 6

• Do you take any medications?
• Do you taken OTC medications?
• If said yes to condition: is condition well controlled? compliance? side effects?
• Herbal medicine
• Allergies

Question 7

Family history Qs? (2)

Answer 7

• Any disease that run in the family?
• ask about specific relevant conditions?

Question 8

Social history Qs?

Answer 8

• Living conditions: live with anyone? any dependents? What accommodation?
• ADL? keeping up?
• Occupation
• Hobbies
• Pets
• Alcohol
• Smoking
• Recreational drugs
• Diet
• Sleeping

Question 9

What ideas Q (ICE)

Answer 9

do you have any ideas about what this might be yourself?

Question 10

What Concerns Q (ICE)

Answer 10

what are you concerned that it might be?

Question 11

what Expectations Q (ICE)

Answer 11

what were you hoping to get out of this consultation?

Question 12

What systems review questions?

Answer 12

• Headaches
• Numbness or tingling
• B symptoms (night sweats or weight loss)
• Fatigue
• Lumps
• Chest pain
• Breathlessness/sob
• palpitations
• Cough
• Abdo pain
• Nausea and Dominic
• change in bowel habit
• incontinence
• Periods
• paint, stiffness and swelling

Question 13

Cardiovascular systems review (8)

Answer 13

• Chest pain
• Palpitations
• SOB at rest or on exertion
• Breathlessness on lying flat and how many pillows
• Breathlessness at night
• Ankle swelling
• Poor circulation
• Pain in calves when walking

Question 14

Respiratory systems review (6)

Answer 14

• Cough
• Sputum
• SOB
• Wheeze
• Recent illness
• Fever

Question 15

Gastrointestinal systems review (11)

Answer 15

• Nausea/ vomiting
• Appetite + diet or weight changes
• Swallowing difficulties
• Indigestion/ acid reflux
• Abdominal pain
• Jaundice
• Change in bowel habits
• Pain on defection
• Constipation, diarrhoea
• Blood/mucus/slime
• Incontinence

Question 16

Neurological systems review (10)

Answer 16

• Headaches
• visual/ hearing/ speech disturbances
• dizziness/ vertigo
• faints/ fits/ blackouts
• Numbness
• Weakness
• Tingling
• Sleep disturbances
• Tremors
• concentration/ memory

Question 17

Genitourinary systems review (9)

Answer 17

• Incontinence
• Frequency/ urgency
• Hesitancy/ dribbling
• Dysuria
• Nocturia
• Haematuria
• Genital rashes/ lumps
• Sexual history
• Periods, possibility of pregnancy

Question 18

Endocrine systems review (10)

Answer 18

• Heat or cold intolerance
• Hair, nails + skin
• Fatigue/ energy levels
• Tremor
• Neck swelling
• Weight change
• polydipsia and polyuria
• Sleep + diet
• Periods
• Possibility of pregnancy

Question 19

Skin systems review (7)

Answer 19

• Itch
• Rash
• Bruising
• Swelling
• Lumps
• Ulcers
• pigmentation changes

Question 20

Haematological systems review (5)

Answer 20

• Night sweats
• Weight loss
• Bleed excessively
• Bruise easily
• Lumps (axially, neck + groin)

Question 21

Musculoskeletal systems review (3)

Answer 21

• Joint pain, stiffness or swelling
• Recent trauma
• Skin rash

Question 22

Mental health systems review (7)

Answer 22

• Mood
• Self harm + suicide
• Sleep and diet
• Energy levels
• Unusual beliefs/ delusions
• Memory problems/ cognitive impairments
• Learning difficulties

Question 23

What are different causes of LOC (categories)?

Answer 23

• Neuro
• Cardiac
• Vasovagal

Question 24

Questions to ask for falls history? What do you ask about before the fall?

Answer 24

• Was it witnessed
• Pre-syncopal symptoms; dizzy, light headed, palpitates
• What were you doing: getting up from lying down, toilet, walking
• How do you normally walk (walking aid)

Question 25

Questions to ask for falls history? What do you ask about during the fall?

Answer 25

• Do you remember falling?
• Was it witnessed?
• Was there any LOC?
• Did you put out your hands to break your fall?

Question 26

Questions to ask for falls history? What do you ask about after the fall?

Answer 26

• Any limb jerking?
• Urinary/faecal incontinence?
• How well orientated following the fall?
• Able to mobilise independently following fall?
• How long on the floor for?

Question 27

What Qs to ask in Urinary history relating to sexual history? (5)

Answer 27

• Any new sexual partners
• Difficulty achieving or maintaining an erection
• (F: abnormal dryness)
• Any itching, redness or rash in genital region
• Any history of STIs (recently checked)