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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
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
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