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
- Who you are and your level
- Confirm patient I.D and date of birth
- State you will:
- wash hands,
- apply PPE,
- ensure privacy,
- offer a chaperone,
- Ascertain comfort and offer analgesia if needed
Background
- PMHx: medical; surgical; obgyn; psychiatric; forensic
- Allergies
- Regular medications (include contraception and over the counter)
- Family history
- Social: smoking; drinking; recreational drugs; employment; foreign travel; whose is at home (including children, social services and domestic violence)
Closure
- Summary of:
- Likely problem or differential
- Investigations proposed
- If discharging:
- any follow up needed
- legal advice eg DVLA
- safety net + written advice
- Other concerns/unanswered questions from the patient
- Thank the patient
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
“Hello, my name is Victoria. I am a final yeal medical student.”
“Please can you confirm your name and date of birth, while I wash my hands, put on my PPE and ensure we are somewhere private.“
“Are you comfortable currently; do you need any pain relief or a drink?“
“How can I help you today?”
Background
“Before we explore the problem that has brought you here today, is it ok with I find out a little bit more about you first?”
- Past medical history: medical; surgical; obgyn; psychiatric.
- Allergies
- Regular medications (including contraception and over the counter)
- Family history
- Social
- Smoking
- Drinking
- Recreational drugs
- Employment
- Foreign travel,
- Who do you live with?
- Children at home (any Social Services involvement?),
- Safe at home (HITS – Hurts, Insults, Threats, Shouts)?
Problem
“Thank you for that, please can you tell me what has brought you here today?”
“Can you tell me a little more about that?”
(SOCRATES if pain / Systems questions system)
Exploration
“What are your concerns?”
“Is there anything you are specifically worried about?”
Summary
“Let me just summarise what you have told me; please correct me if you need to.”
Planning and closure
“In summary, I think the problem could be x, y, z…”
“I would like to examine… and perform the following tests…”
“Are there any other concerns or questions you had?”
“Thank you for your time”
Pain Assessment: SOCRATES
| Site | Generalised vs specific |
| Onset | Sudden vs gradual. When did it come on? |
| Character | Sharp; ache; constant |
| Radiation | Go elsewhere? |
| Associations | Nausea and vomiting; systemic features |
| Timing | Is there a pattern as to when it comes on? |
| Exacerbating | What makes it worse? |
| Severity | How bad is it? Is it worse pain ever? |
System Questions
| Generic | Gastroenterology | Obstetric | Sexual |
| Cardiovascular | Genitourinary | Opthalmology | Travel |
| Dermatology | Gynaecology | Respiratory | Paediatric |
| Ear, Nose and Throat | Musculoskeletal |
Generic
- Weight loss
- Fevers; sweats
- Tiredness
- Lethargy
- Swellings
- Sleep
Cardiovascular
- Chest pain
- Palpitations
- SOB on exertion
- Waking up SOB
- Number of pillows
- Ankle swelling
- Exercise tolerance
- Claudication
- Blackouts
Dermatology
- Rash = SOCRATES
- PMHx: systemic illness; allergy; atopy
- Previous dermatology history
- Social: occupation; exposures; travel
- Family history: infectious; sexual contacts
- S – site: of rash
- O -onset: how long; comes and goes
- C -characteristics: itchy; red; hot; weepy; blisters
- R – radiation: spread
- A – associations
- T– timing: had before
- E – exacerbating: sunlight; after exposure
- S – severity: same; worse; better
Ear, Nose and Throat
Ear
- Uni/bilateral
- Hearing loss (sudden; gradual)
- Vertigo
- Tinnitus
- Pain
- Swelling
- Discharge
- Trauma
- Foreign body
Nose
- Trauma
- Foreign body
- Discharge (uni/bilateral)
- Bleeding
Throat
- Dysphagia (acute; progressive)
- Odynophagia
- Voice changes
- Neck lump
- Cough
- Previous HPV infection; malignancy
Gastroenterology
ALARMS
- A – Anaemia
- L – Loss of weight
- A – Anorexia
- R – Recent/progressive
- M – Masses/melaena/haematemesis
- S – Swallowing
PLUS
- Heartburn
- Nausea/vomiting
- Bowel habit
- Pain
- Jaundice
- Pruritis
Genitourinary
- Frequency
- Urgency
- Pain on voiding
- Poor flow
- Incomplete emptying
- Incontinence
- Blood in urine
- Pelvic pain
- Changes in sexual function
Gynaecology
ABCD IFS
- Abdo pain (including dysparenuria)
- Bleeding: period history; intermenstrual; coital
- Contraception
- Discharge: colour; smell; volume; consistency
- Itch; skin; incontinence
- Fertility: menarche; menopause; gravidity; parity
- Screening (smears)
Musculoskeletal
- Pain
- Swelling
- Stiffness
- Deformity
- Function
Obstetric
Current pregnancy
- Gestation; EDD; single/twins
- Scan results; screening
- Folic acid
- Immunisations
Previous pregnancy
- Gravidity; parity; stillbirths
- Complications
- Birth weight
Specific questions
- Bleeding; discharge; fluid
- Abdominal pain
- Nausea or vomiting
- Foetal movements
- Headache, vision, oedema
- SOB; chest pain; leg swelling
- Pruritus
Opthalmology
- Glasses or contact lens wearer
- Eye surgery
- Trauma
- Acuity change: rapid; gradual; intermittent
- Flashes; floaters; field loss
- Painful eye
- Red eye
- Tearing or discharge
- Headache
- Scalp temple tenderness or pain on chewing
- Weight loss; joint pains; fever
Respiratory
- Chest pain
- SOB
- Cough
- Wheeze
- Sputum
- Haemoptysis
Sexual
Who
- Who act was with? One vs many
- Consensual
- Known sex worker
- Where were they from?
- Any knowledge of PMHx of person
- Other sexual partners
- STIs
What
- Nature of contact: penetrative; vaginal; anal; oral
- Condom use
- Drug use (chemsex)
When
- When did it happen?
Symptoms
- See gynaecology section
Travel
Travel onset
- Time symptoms started from return
- Pattern of symptoms
Room and Board
- Urban vs rural
- Local food; unpasteurised dairy; drinking water
- Mosquito nets; screens
Activities
- Freshwater
- Saltwater
- Caves
- Barefoot
- Animal contacts
- Bush meat
Vaccination/pre travel preparation
- Vaccines?
- Malaria prophylaxis and compliance
Exposure
- Medical care oversea; infections or transfusions
- Sick contacts within three months
- Tattoos
Location
- Exact itinerary
- Duration in each
- Stopovers
Paediatric
BFG EXTRA
Birth
- Gestation and weight
- Delivery mode and complications
- Neonatal problems
Feeding and elimination
- <12 months: breast/formula (type and amount)
- 6-12 months: weaning
- >12 months: solids and cow’s milk
- Number of wet/dirrty nappies
Growth and Development
- Red Book and Milestones
Extras
- Medications
- Allergies
- Immunisations
Social history
- Family Unit
- Smoking
- Social Services
- Safe at home (HITS)
- Education level
- Hobbies
Family
- Congenital problems
- Neonatal/infant deaths
- Sudden cardiac death <40 years old