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Taking a History

From Mediwikis

For more guides to clinical skills, communication with patients, and procedures, check out the huge OSCE category!

Taking a history is the most basic component of medical examination. Building a rapport early on and asking questions effectively can avoid the need for invasive or unneccessary tests down the line.

Introduction

  1. Wash hands, good afternoon, introduction.
  2. May I confirm your name and date of birth please?
History Taking, courtesy of the demonstrators.

Structure of the interview

  1. Introductions
  2. Presenting Complaint
  3. History of Presenting Complaint
  4. Past Medical History
  5. Social History
  6. Family History
  7. Systemic Review

And throughout:

  • Ideas, Concerns and Expectations
  • Summarise information and signpost your next questions

SOCRATES

This acronym is especially useful for pain, but can be used for a wide range of symptoms e.g. nausea, tremor, weakness.

  • Site
  • Onset
  • Character
  • Radiation
  • Associated Symptoms
  • Time Course (ie worse in morning/evening)
  • Exacerbating/Relieving factors
  • Severity-1 to 10, 1 being a pinch, 10 being the worst pain imaginable

Presenting Complaint

Open the consultation with an open question such as "How can I help you?" "How are you today?". Alternatively, ask an open question within a specific remit, e.g. "How is your cough today?"

Past Medical History

If you're stuck, check whether the patient is at risk of DEATH:

Medications

  1. Can you tell me what medication you're on please? Any over the counter drugs? Herbal remedies?

Family History

  1. Any medical conditions that run in the family?
  2. Parents still alive? Cause of death?
  3. Health of brothers/sisters?

Social History

  1. Smoke? For how long? How many a day?
  2. Drink? How many pints per day? How long does a bottle last?
  3. What do you work as? Does your job affect the symptoms/ vice-versa.

Systemic Investigation

Check the systems:

  • Cardiovascular
  • Respiratory
  • Gastrointestinal
  • Neurological
  • Psychiatric
  • Musculoskeletal

ICE

These are the Ideas, Concerns and Expectations of the patient regarding the symptoms, and are really useful for finding out the more emotional aspect of a diagnosis- ‘this pain started when my mother died’. Remember to respond to ICE in the correct way- there’s a mark for this- just be compassionate and empathetic- “I can see that would be upsetting for you”.

  1. So tell me, what are your ideas about what might be causing this pain?
  2. Is there anything you’re worried about with this?
  3. And what are you hoping to get from today's consultation?’’ (be careful with your voice here, can seem confrontational/defeatist)

Summarise at the end

Glossary of useful questions

  • Can you tell me about the pain?
  • Can you remember when the pain started?
  • And how long did it last?
  • Can you tell me where the pain is?
  • Does it spread to anywhere else?
  • Can you describe the nature of the pain?
    • Burning, Stabbing, Electric, Dull
  • Ever had it before?
  • Anything that gives you relief?
  • Anything that makes the pain worse
  • Any other symptoms associated with the pain?