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Presentation on theme: "HISTORY-TAKING."— Presentation transcript:


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

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

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

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

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


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