HISTORY-TAKING

24 year-old female presents to GP with abdominal pain

HISTORY TAKING

HISTORY TAKING

Presenting Complaint

History of presenting complaint

Past Medical History

Drug History

Family History

Social History

Systems Review

Ideas, concerns, expectations

ash HandsWIPER

ntroduce self, check patient details

ermission

xpose patient (examination only)

ight-hand side of bed (examination only)

HISTORY TAKING

HISTORY TAKING

Presenting Complaint (PC)OPEN QUESTIONS:

“Why have you come in today?”

“Could you tell me more about the……….?”

History of Presenting Complaint (HPC)For PAIN, use a mneumonic:

SQITASite

uality

ntensity

iming

ggrevating and relieving factors

ymptoms associated

HISTORY TAKING

HISTORY TAKING

SUMMARISE the presenting complaint

HISTORY TAKING

Past Medical History (HPC)

HISTORY TAKING

Medical conditions

Hospitalisations

Serious illnesses / injuries

Operations

Drug History (DH)

HISTORY TAKING

ALLERGIESCurrent medications:• Prescribed• Over-the-counter

• Name• Dose• Frequency

Recreational drugs

Family History (FH)

HISTORY TAKING

Anyone in family had similar problem?

Any serious illnesses in the family?

Social History (SH)

HISTORY TAKING

Work

Home circumstances

• Current smoker?• Past smoker?• How many years?• Cigarettes/ roll-ups / cigars?• How many per day?

Smoking

• Who lives at home – partner? Children?• Stairs at home?• Need help with housework, shopping, cooking?

• Do you drink alcohol?• What? Wine? Beer?• How much? • Calculate units/week

Alcohol

Systems ReviewCouple of questions for each body system e.g:

• Fits, faints, funny turns• Headaches• Vision problems

CNS (central nervous system)

• Shortness of Breath (SOB)• Cough – blood (red flag)

RS (respiratory system)

• Chest pain• “Heart fluttering” (palpitations)• Ankle swelling

CVS (cardiovascular system)

• Change in bowel habits – blood (red flag)• Nausea or vomiting• Weight loss – red flag

GI (gastrointestinal system)

• Change in waterworks• Blood in urine• Menstrual problems

GU (genitourinary system)

• Joint or muscle pain• Skin rashes• Lumps or bumps

Other

HISTORY TAKING

ICE

Ideas

Concerns

Expectations

HISTORY TAKING

Closing“Is there anything you’d like to add or think I’ve missed?”

“Do you have any questions?”

THANK the patient!!!!!

HISTORY TAKING

HISTORY TAKING

SQITASite

uality

ntensity

iming

ggrevating/relieving factors

ymptoms associated

Pain SOCRATESite

nset

haracter

adiation

ssociated symptoms

iming

xacerbating/relieving

everity

RED FLAGS

HISTORY TAKING

Symptoms that may indicate serious underlying condition

Different for each body system

e.g. coughing-up blood (haemoptysis) and lung cancer

HISTORY TAKING

Signposting“I’d like to ask you about ….”

• Your general health• Your previous health• Your background• etc

WHY?

Patient and examiner know you have a structure

HISTORY TAKING

THANK YOU