History Taking:
Hand washing
Bare below elbow
Introduce Yourself
Don’t forget Chaperone
Provide privacy/Dignity- Pull curtains, screens, close the door
Information Governance- confidentiality, Duty of condor
Name and Age: (confirm with patient or Carer) Interpreter /language Line
Present complaints:
History of present complaints: (Take a separate history for each problem eg.
chest pain, rash, fever etc.) (OLDCARTS, SOCRATES or OPQRST)
OLDCARTS
Onset
Location
Duration
Character
Alleviating/Aggravating
Radiation
Time
Severity
SOCRATES
Site
Onset
Character
Radiation
Associated symptoms
Time& duration
Exacerbating/relievin
g
Severity
OPQRST
Onset
Provoking
Quality
Region
Radiation
Severity
Time
(Timing questions, since when, Sudden/gradual, All the time/come and go,
Getting worse).
Previous episodes- If yes, how often? When does it happen? Ever investigated
before? Any treatments?
If bleeding: quantity, colour, consistency, mixed with anything, smell
In your history taking ensure to cover differential diagnoses (eg. chest pain)- ask
the CVS Q, Resp Q, GI Q, MSK Q.
Is there a scoring system relevant to the PC eg.haematemesis and Rockall scoreif so make sure you have asked all the questions you need to complete the score.
Are there risk factors relevant to the history? Eg. MI, osteoporosis
Assess severity of condition eg. COPD- home nebs, NIV, ITU admissions
Make sure you have covered Red Flags if relevant
Think around the subject eg. If COPD ask about vaccinations, pulmonary rehab,
mood, seen in COPD clinic?
Past medical/ surgical History (including surgery abroad)
Admissions, operations, anything they see the GP for?
Ask relevant PMH eg. haematemesis ask re. previous stomach ulcers
When and how were relevant diagnoses made? (X rays, Scans, Biopsy, OGD,
colonoscopy)
Family History: (eg. Cancer)
Social History:
Smoking (pack years), drinking (units), drugs (IVDU),
Employment (FT/PT)
Number of family members
Known to social services – Adult/ Children safeguarding issues
Living in Foster care/ under protection order/ Known to Red Thread
Recent Travel- High risk countries (Asia, South America)
Homeless/Living in Hostel/HMP/Type of house (sheltered, residential/Nursing
home)
Pets/ Hobbies/QOL/Mood
Driving/Hearing aid/Glasses/check for implants/piercings
ADL
Sexual History: (single/Multiple sexual partners, safe sex)
Drug History:
Medications- have they got a list with them?
Compliance
Any side effects of medications?
OTCs, herbal meds, meds bought from internet
Vaccines
Allergies (Drugs/Food/Pets)
Ask about any relevant medications eg. Cough- ACEI, bleeding- NSAIDs etc.
Are any medications new?
What treatment have they had for the condition in the past?
ICE (ideas, concerns and expectations) do-not forget to address concerns!
Systems Review:
General check:
Fatigue/malaise
Fever/rigors/night sweats/swollen glands
Weight/appetite
Skin rashes/bruising
Sleep disturbance
CVS:
Chest pain, SOB (and on exertion) Orthopnoea, PND, Palpitations, Ankle swelling,
Syncope, presyncope
Resp:
Chest pain, SOB, Wheeze/stridor/stertor, Cough (and sputum colour, amount,
consistency, blood, smell) Haemoptysis, Exercise tolerance
GI:
Appetite/weight, Dysphagia/odynophagia, Nausea, vomiting, haematemesis,
Indigestion/heartburn, Jaundice, Abdominal pain
Bowels: change/constipation/diarrhoea/stool/blood/mucus/flatus
Bloating, tenesmus, urgency
MSK:
Pain/swelling/stiffness in muscles/joints/back, Reduced range of
motion/function, Power, Difficulty with ADLS, Raynauds, photosensitivity rash,
hair loss, ulcers, dry eyes/mouth
GU:
Frequency/dysuria/nocturia/polyuria/oliguria, Haematuria,
Incontinence/urgency, Prostatic symptoms, Impotence, Menstruation (if
appropriate), Vaginal/urethral discharge, Catheter/SPC/leg bag, Penile implant
CNS:
Headaches, Fits/faints/blackouts, Dizziness, Vision- blurring/double/bits
missing, Hearing, Weakness, Numbness/tingling, Loss of memory/personality
change, Anxiety/depression
Endocrine:
Menstruation, Hirsutism/alopecia, Polyuria/polydipsia, Amount of sweating,
Hair
Skin:
Rash, Itch
Ask the patient if they have any questions? (they will have a prompt sheet with
questions to ask you!)
Close the consultation:
Any further questions?
Summarise
Propose solutions to problems
Explain possible diagnoses, investigations and management and followup to the
patient
Summarise to the examiner:
Tell the examiner your differential diagnoses, problem list and plan.
Explain what investigations you would like to do: structure this answer: bedside
tests, blood tests, radiological tests, histological tests for example.
Suggest treatment options:
Points to Remember:
Body language
Communication skills
Addressing concerns
Formulating a differential diagnosis
Suggesting investigations and management
Maintaining patient welfare