History taking

Question 1

Sections of a history?

Answer 1

Introduction
PC
HPC including ICE
PMH
DH including allergies
FH
SH/lifestyle history
System review
Summary

Question 2

What should be included in your introduction?

Answer 2

Wash hands etc.
Name
Position
Task
Purpose
Reassurance of care
Confirmation of consent
Confirm identity

Question 3

Give an example of a good introduction

Answer 3

Hi, my name is Lakshya and I’m a 2nd year medical student. I’ve been asked by the GP to ask you some questions to improve my communication and make me a better doctor. You will still get the chance to have your appointment with the GP. Is it okay if I ask you a few questions about why you’re having this appointment today?

Question 4

How can you ask about the presenting complaint?

Answer 4

Why are seeing/talking to the GP today?

Tell me about why you’ve come in today?

Question 5

Questions to include in history of presenting complaint?

Answer 5

When did this problem start?
What did you notice first? Has it progressed?
Have you ever had this before?
What do you think is causing it?
How has this impacted your day to day life?
You seem worried - is there anything that is particularly concerning to you?
Have you had this investigated yet? Have you had any treatment yet?
What do you want from your appointment today?

Question 6

What acronyms to use to characterise pain and other symptoms?

Answer 6

Use SOCRATES and TED to characterise pain and symptoms

Question 7

SOCRATES - what does the first S stand for?

Answer 7

Site - where is the pain/symptom you’re feeling? Can you point to where the pain is?

Question 8

SOCRATES - what does the O stand for?

Answer 8

Onset - how did the pain/symptom start? Was it gradual or sudden? Has it been intermittent?

Question 9

SOCRATES - what does the C stand for?

Answer 9

Character - is the pain sharp? dull? stabbing? tingling? abnormal sensation?

Question 10

SOCRATES - what does the R stand for?

Answer 10

Radiation - does the pain spread? where does it spread?

Question 11

SOCRATES - what does the A stand for?

Answer 11

Associated symptoms - Have you noticed any other symptoms alongside these? e.g. nausea, vomiting, neurological weakness, shortness of breath

Question 12

SOCRATES - what does the T stand for?

Answer 12

Time - How long have you had this for? When did it start?

Question 13

SOCRATES - what does the E stand for?

Answer 13

Exacerbating/relieving factors - What makes it worse? What makes it better? What have you tried to help?

Question 14

SOCRATES - what does the second S stand for?

Answer 14

Severity - can you rate your pain from 0 to 10 with 0 being no pain at all and 10 being the worst pain imaginable.
Can you still do exercise or walk?

Question 15

What are TED questions

Answer 15

Tell, explain, describe

Question 16

What questions to ask for past medical history?

Answer 16

Is there anything you see your GP for regularly?
Have you had previous surgery, previous major illnesses?
Have you ever been admitted to hospital? What for?
Is there anything you see a specialist about?
Do you have any mental health problems?
Have you had any childhood illnesses that were serious?
Have you had all your immunisations?
Have you taken part in regular screening?

Question 17

What questions to ask in drug history?

Answer 17

What medication do you currently take? Do you know the drug name, dose, what it is for, the effect?
Have you ever had any side effects for medication?
Do you ever forget to take your medicine/s?
Do you have any allergies?
Have you ever had an allergic reaction? What was the reaction?
Do you take any non-prescribed drugs e.g. over the counter, recreational, herbal?
Do you take any non-oral drugs? - use creams etc.

Question 18

How could you use assess severity of illness in drug history?

Answer 18

how often medications are being used e.g. asthma - how often do you use your inhaler? When do you have to use it?
e.g. steroids - how often do you need them? do you take them long term?

Question 19

What questions to ask in family history?

Answer 19

NOTE: important to signpost to not worry patients
Is it okay if I ask some questions about your family’s health? Sometimes it’s useful to have a broader sense of wellbeing within your family.
Do you know of any illnesses or health conditions that run in the family?
Any relatives with or had heart problems? Diabetes? Cancer?
Try to determine age of diagnosis etc.

Question 20

What questions to ask in social/lifestyle history?

Answer 20

Do you drink alcohol? How much do you drink in a week?
Do you smoke? What do you smoke? How many in a day?
Talk me through a typical day of your diet or what you eat?
How is your sleep?
How is your physical activity? Do you exercise?
What is your marital status? Do you have a partner?
Do you work? What do you do?
Are you a carer for anyone? Do you have a carer at home?
Have you travelled anywhere recently?
Have there been any significant events or challenges in your life recently?
Who’s at home? Do you have any support?
ADLs, accessibility, stairs etc.

Question 21

Questions to ask in cardiorespiratory system review?

Answer 21

Do you have a cough? Is it productive/is there sputum?
Have you noticed any blood in your cough?
Have you had shortness of breath?
Have you had any palpitations?
Are you able to lie flat?
Have you had any ankle swelling?
Have you had any chest pain?
Do you have a wheeze?

Question 22

Questions to ask in GI system review?

Answer 22

How has your appetite been? Has it changed?
Have you had indigestion? Can you describe it for me.
Have you felt nauseous at all?
Have you experienced any vomiting?
Have you had any difficulties in swallowing? Is it with foods or liquids?
Have you had any changes in your bowel habit? Have you been constipated or had loose stools?
Have you had any abdominal pain?
Have you noticed any blood?

Question 23

Questions to ask in neurological review?

Answer 23

Have you experienced any dizziness? Any blackouts?
Have you had any headaches?
Have you had any visual changes?
Have you had any hearing changes?
Have you had any focal weakness?
Have you had any change in sensation?
Have you experienced any tremors?
Have you had any memory problems?

Question 24

Questions to ask in urogenital review?

Answer 24

Do you experience pain during urination?
Have you noticed blood in your urine?
Have you noticed any discharge?
Have you noticed any abnormal vaginal bleeding?
When was your last menstrual period?
Are you possibly pregnant?

Question 25

Other questions to ask in a systems review?

Answer 25

Have you noticed any rashes on your skin?
Have you noticed a change in weight? Was this intentional?
Have you had any joint pain? 
Have you noticed any swelling?
Have you had night sweats?
Have you had any sleeping problems?
Have you had any mood changes?
Have you had an itch?
Have you had any recent trauma?