1. HISTORY-TAKING

2. 24 year-old female presents to GP with abdominal pain
HISTORY TAKING

3. History of presenting complaint Ideas, concerns, expectations
Past Medical History
Drug History
Family History
Social History
Systems Review
Ideas, concerns, expectations
HISTORY TAKING

4. WIPER ash Hands ntroduce self, check patient details ermission
xpose patient (examination only)
ight-hand side of bed (examination only)
HISTORY TAKING

5. Presenting Complaint (PC)
OPEN QUESTIONS:
“Why have you come in today?”
“Could you tell me more about the……….?”
HISTORY TAKING

6. History of Presenting Complaint (HPC)
For PAIN, use a mneumonic:
SQITAS
ite
uality
ntensity
iming
ggrevating and relieving factors
ymptoms associated
HISTORY TAKING

7. SUMMARISE the presenting complaint
HISTORY TAKING

8. Past Medical History (HPC)
Medical conditions
Hospitalisations
Serious illnesses / injuries
Operations
HISTORY TAKING
HISTORY TAKING

9. Drug History (DH) ALLERGIES
Current medications:
Prescribed
Over-the-counter
Name
Dose
Frequency
ALLERGIES
Recreational drugs
HISTORY TAKING

10. Family History (FH) Anyone in family had similar problem?
Any serious illnesses in the family?
HISTORY TAKING

11. Social History (SH) HISTORY TAKING Work Home circumstances Alcohol
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
Current smoker?
Past smoker?
How many years?
Cigarettes/ roll-ups / cigars?
How many per day?
Smoking
HISTORY TAKING

12. Systems Review HISTORY TAKING CNS (central nervous system)
Couple of questions for each body system e.g:
Fits, faints, funny turns
Headaches
Vision problems
CNS (central nervous system)
Change in bowel habits – blood (red flag)
Nausea or vomiting
Weight loss – red flag
GI (gastrointestinal system)
Chest pain
“Heart fluttering” (palpitations)
Ankle swelling
CVS (cardiovascular system)
Change in waterworks
Blood in urine
Menstrual problems
GU (genitourinary system)
Shortness of Breath (SOB)
Cough – blood (red flag)
RS (respiratory system)
Joint or muscle pain
Skin rashes
Lumps or bumps
Other
HISTORY TAKING

13. ICE Ideas Concerns Expectations
HISTORY TAKING

14. Closing “Is there anything you’d like to add or think I’ve missed?”
“Do you have any questions?”
THANK the patient!!!!!
HISTORY TAKING

15. Pain SOCRATES SQITAS HISTORY TAKING ite nset ite haracter uality
adiation
ntensity
ssociated symptoms
iming
iming
ggrevating/relieving factors
xacerbating/relieving
ymptoms associated
everity
HISTORY TAKING

16. 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

17. Signposting WHY? Patient and examiner know you have a structure
“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

18. THANK YOU
HISTORY TAKING