Taking a history Flashcards
4 key points before you start taking a history?
- Wash your hands
- Introduce yourself- name and status
- Identify the patient- verbally and wristband
- Informed consent- make sure they know you’re doing it for educational purposes
Outline the 8 steps of a standard history framework
- Presenting complaint (PC)
- History of presenting complaint (HPC)
- Past medical history (PMH)
- Drug history (DHx)
- Allergies
- Family history (FHx)
- Social history- includes alcohol and smoking (SHx)
- Systems review
Define ‘collateral history’
Patient history obtained from sources other than the patient themselves e.g. relatives, friends, carers, GP, initial referrer, witnesses to an accident
In what clinical situations might taking a collateral history be necessary?
Whenever a patient is unable to give a full history themselves e.g. unconscious, delirious, demented, dysphasic
It is important to remember to … if you have taken a collateral history
Document clearly in the patient’s notes who the collateral history was given by, and why the patient was unable to speak for themselves
Define ‘presenting complaint’
- The patient’s main problem in their own words
2. Should be no more than a sentence
How do you identify a patient’s presenting complaint?
- Open question e.g. “I understand you’ve been suffering from X, could you tell me what the problem is?”
- Another open question e.g. “Can you tell me anything else about this problem?”
- Summarise back to patient
Define ‘history of presenting complaint’
Detailed chronological description of the presenting complaint
Outline the SOCRATES mnemonic for pain
Site Onset Character Radiation Associated symptoms Timing Exacerbating and relieving factors Severity
‘S’ in SOCRATES
Site- Where is the pain worse? Point to the pain with 1 finger?
E.g. Somatic pain often well localised e.g. broken ankle vs. visceral pain more diffuse e.g. angina
‘O’ in SOCRATES
Onset- When did it start? Circumstances? How quickly did it start?
‘C’ in SOCRATES
Character- Sharp/dull/burning/crushing/aching
Get the patient to find their own adjectives where possible
‘R’ in SOCRATES
Radiation- Does the pain spread anywhere else?
By local extension or referred by shared neuronal pathway to a distant unaffected site?
E.g. diaphragmatic pain at the shoulder tip via the phrenic nerve (C3,4)
‘A’ in SOCRATES
Associated symptoms- Any symptoms other than the pain itself?
E.g. N+V, dyspepsia, SOB, paraesthesia
Be aware that any severe pain can produce N+V, sweating, and faintness from the vagal and sympathetic response but MAY suggest underlying cause
‘T’ in SOCRATES
Timing- Duration, course and pattern since onset? Episodic or continuous?
‘E’ in SOCRATES
Exacerbating and relieving factors- Does anything make the pain better or worse?
E.g. Food, specific activities, postures (including avoidance measures, effects of medications and alternative therapeutic approaches)
‘S’ in SOCRATES
Severity- scored out of 10, where 10 is the worst pain imaginable, including any variation
Difficult to assess as is highly subjective
May be helpful to compare to other pains e.g. toothache, broken bones
Describe the typical onset and progression of symptoms with an infectious type of pathology
e.g. IE-COPD, UTI
Onset usually hours
Progressive fairly rapid over hours/days
Describe the typical onset and progression of symptoms with an inflammatory type of pathology
e.g. IBD, RA
Onset often quite sudden
Progression over weeks/months
Describe the typical onset and progression of symptoms with a metabolic type of pathology
e.g. DM, CF, haemochromatosis, PKU
Onset very variable
Progression can be hours to months
Basically there is no typical onset and progression, but suspect if steadily progressive in severity with no remission
Describe the typical onset and progression of symptoms with a malignant type of pathology
Onset gradual
Progression over weeks/months
Describe the typical onset and progression of symptoms with a toxic type of pathology
e.g. drug OD
Onset abrupt (dramatic due to exposure) Progression is rapid
Describe the typical onset and progression of symptoms with a traumatic pathology
e.g. broken bone
Onset abrupt (usually clear from the history) Usually little change from onset
Describe the typical onset and progression of symptoms with vascular type of pathology
e.g. MI, PE, ischaemic limb
Onset sudden
Progression over hours (with rapid development of physical signs)
Describe the typical onset and progression of symptoms with degenerative type of pathology
e.g. osteoarthritis, MS
Onset gradual
Progression over months/years
