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

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Presentation on theme: "24 year-old female presents to GP with abdominal pain HISTORY TAKING."— Presentation transcript:


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


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

5 OPEN QUESTIONS: “Why have you come in today?” “Could you tell me more about the……….?”

6 For PAIN, use a mneumonic: ite uality ntensity iming ggrevating and relieving factors ymptoms associated HISTORY TAKING

7 SUMMARISE the presenting complaint

8 HISTORY TAKING Medical conditions Hospitalisations Serious illnesses / injuries Operations

9 HISTORY TAKING Current medications: Prescribed Over-the-counter Name Dose Frequency Recreational drugs

10 HISTORY TAKING Anyone in family had similar problem? Any serious illnesses in the family?

11 HISTORY TAKING Current smoker? Past smoker? How many years? Cigarettes/ roll-ups / cigars? How many per day? 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

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


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

15 ite uality ntensity iming ggrevating/relieving factors ymptoms associated ite nset haracter adiation ssociated symptoms iming xacerbating/relieving everity

16 HISTORY TAKING Symptoms that may indicate serious underlying condition Different for each body system e.g. coughing-up blood (haemoptysis) and lung cancer

17 HISTORY TAKING “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


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