HISTORY-TAKING

24 year-old female
presents to GP with
abdominal pain

HISTORY TAKING

Presenting Complaint
History of presenting complaint
Past Medical History
Drug History
Family History
Social History
Systems Review
Ideas, concerns, expectations
HISTORY TAKING

ash Hands
WIPER
ntroduce self, check patient details

ermission
xpose patient (examination only)
ight-hand side of bed (examination only)

HISTORY TAKING

resenting Complaint (PC

OPEN QUESTIONS:

Why have you come in today?

Could you tell me more about
the.?
HISTORY TAKING

History of Presenting
For PAIN, use a mneumonic:
Complaint (HPC)
SQITAS
ite
uality
ntensity
iming
ggrevating and relieving
factors
ymptoms associated

HISTORY TAKING

SUMMARISE the
presenting
complaint

HISTORY TAKING

ast Medical History (HPC

Medical conditions
Hospitalisations
Serious illnesses /
injuries
Operations
HISTORY
HISTORY TAKING
TAKING

Drug History (DH)

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

ALLERGIES
Recreational drugs

Family History (FH)

Anyone in family had similar

problem?

Any serious illnesses in the

family?
HISTORY TAKING

Social History (SH)

Work

Home circumstances

Who lives at home partner? Children?

Stairs at home?
Need help with housework, shopping,
cooking?

Smoking

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

HISTORY TAKING

Alcohol

Do you drink alcohol?

What? Wine? Beer?
How much?
Calculate units/week

Systems Review
Couple of questions for each body system e.g:

NS (central nervous system)

GI (gastrointestinal system)
Fits, faints, funny turns
Headaches
Vision problems

Change in bowel habits blood

(red flag)
Nausea or vomiting
Weight loss red flag

VS (cardiovascular system)
GU (genitourinary system)
Chest pain
Heart fluttering (palpitations)
Ankle swelling

RS (respiratory system)

Change in waterworks
Blood in urine
Menstrual problems

Other

Shortness of Breath (SOB)

Cough blood (red flag)

HISTORY TAKING

Joint or muscle pain

Skin rashes
Lumps or bumps

ICE
Ideas
Concerns
Expectations
HISTORY TAKING

Closing
Is there anything youd like to
add or think Ive missed?
Do you have any questions?
THANK the patient!!!!!
HISTORY TAKING

QITAS
ite

SOCRATE
ite
Pain
Snset

uality
ntensity

haracter
adiation

ssociated
iming
symptoms
iming
ggrevating/relieving factors
xacerbating/reliev
ymptoms associated
ing
everity

HISTORY TAKING

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

HISTORY TAKING

Signposting
Id 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

THANK YOU

HISTORY TAKING