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history talking but medical records
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HISTORY-TAKING
24 year-old female presents to GP with abdominal pain
HISTORY TAKING
HISTORY TAKINGPresenting Complaint
History of presenting complaint
Past Medical History
Drug History
Family History
Social History
Systems Review
Ideas, concerns, expectations
ash HandsWIPERntroduce self, check patient detailsermissionxpose patient (examination only)ight-hand side of bed (examination only)
HISTORY TAKING
HISTORY TAKINGPresenting 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:SQITASiteualityntensityimingggrevating and relieving factorsymptoms associated
HISTORY TAKING
HISTORY TAKINGSUMMARISE the presenting complaintHISTORY TAKINGPast Medical History (HPC)
HISTORY TAKINGMedical conditionsHospitalisationsSerious illnesses / injuriesOperations
Drug History (DH)
HISTORY TAKINGALLERGIESCurrent medications:PrescribedOver-the-counter
NameDoseFrequency
Recreational drugsFamily History (FH)
HISTORY TAKINGAnyone in family had similar problem?
Any serious illnesses in the family?Social History (SH)
HISTORY TAKINGWorkHome circumstancesCurrent smoker?Past smoker?How many years?Cigarettes/ roll-ups / cigars?How many per day?SmokingWho 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/weekAlcohol
Systems ReviewCouple of questions for each body system e.g: Fits, faints, funny turnsHeadachesVision problemsCNS (central nervous system)Shortness of Breath (SOB)Cough blood (red flag)
RS (respiratory system)Chest painHeart fluttering (palpitations)Ankle swellingCVS (cardiovascular system)Change in bowel habits blood (red flag)Nausea or vomitingWeight loss red flagGI (gastrointestinal system)Change in waterworksBlood in urineMenstrual problemsGU (genitourinary system)Joint or muscle painSkin rashesLumps or bumpsOther
HISTORY TAKINGICEIdeasConcernsExpectations
HISTORY TAKINGClosingIs there anything youd like to add or think Ive missed?
Do you have any questions?
THANK the patient!!!!!
HISTORY TAKING
HISTORY TAKINGSQITASiteualityntensityimingggrevating/relieving factorsymptoms associatedPainSOCRATESitensetharacteradiationssociated symptomsimingxacerbating/relievingeverityRED FLAGS
HISTORY TAKINGSymptoms that may indicate serious underlying condition
Different for each body system
e.g. coughing-up blood (haemoptysis) and lung cancer
HISTORY TAKINGSignpostingId like to ask you about .
Your general healthYour previous healthYour backgroundetcWHY? Patient and examiner know you have a structure
HISTORY TAKINGTHANK YOU
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