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General Approach

A look at any history taking mark sheet will reveal three areas of high yield marks: your introduction; background, and closure. Irrespective of what type of history you are being asked to take, a solid approach to these three areas will net you a significant amount of marks.

Introduction

Background

Closure

Because the background section is such a high yield area, some will cover this before the main problem. Try to ensure a smooth transition, with a lead in phrase such as

“Before we explore the problem that has brought you here today, is it ok I find out a little bit more about you first?”.

There is no right or wrong approach, but background first may be useful if you are someone who runs close to time, also sometimes the marks for the actual problem are quite specific and may be less easy to achieve. 

Lastly, there is usually always a ‘hidden agenda’ which is why phrases such as do you have any specific concerns or “ is there anything in particular you are worried about are helpful.

Hidden agenda examples

History

Swollen testicle

Non – toxic paediatric paracetamol ingestion

Benign sounding headache

Traumatic ankle pain: not meeting x-ray criteria

Examples of hidden agenda

Malignancy

Mother’s friend died of an overdose

Relative died of a SAH

Previous missed fracture


Generic approach history example

Introduction

Background

Problem

Exploration

Summary

Planning and  closure


Pain Assessment: SOCRATES

SiteGeneralised vs specific
OnsetSudden vs gradual. When did it come on?
CharacterSharp; ache; constant
RadiationGo elsewhere?
AssociationsNausea and vomiting; systemic features
TimingIs there a pattern as to when it comes on?
ExacerbatingWhat makes it worse?
SeverityHow bad is it? Is it worse pain ever?

System Questions

GenericGastroenterologyObstetricSexual
CardiovascularGenitourinaryOpthalmologyTravel
DermatologyGynaecologyRespiratoryPaediatric
Ear, Nose and ThroatMusculoskeletal

Generic

Cardiovascular

Dermatology

Ear, Nose and Throat

Gastroenterology

Genitourinary

Gynaecology

Musculoskeletal

Obstetric

Opthalmology

Respiratory

Sexual

Travel

Paediatric