PowerPoint Presentation

HISTORY-TAKING

24 year-old female presents to GP with abdominal pain

HISTORY TAKING

HISTORY TAKINGPresenting Complaint

History of presenting complaint

Past Medical History

Drug History

Family History

Social History

Systems Review

Ideas, concerns, expectations

ash HandsWIPERntroduce self, check patient detailsermissionxpose patient (examination only)ight-hand side of bed (examination only)

HISTORY TAKING

HISTORY TAKINGPresenting Complaint (PC)OPEN QUESTIONS:Why have you come in today?

Could you tell me more about the.?History of Presenting Complaint (HPC)For PAIN, use a mneumonic:SQITASiteualityntensityimingggrevating and relieving factorsymptoms associated

HISTORY TAKING

HISTORY TAKINGSUMMARISE the presenting complaintHISTORY TAKINGPast Medical History (HPC)

HISTORY TAKINGMedical conditionsHospitalisationsSerious illnesses / injuriesOperations

Drug History (DH)

HISTORY TAKINGALLERGIESCurrent medications:PrescribedOver-the-counter

NameDoseFrequency

Recreational drugsFamily History (FH)

HISTORY TAKINGAnyone in family had similar problem?

Any serious illnesses in the family?Social History (SH)

HISTORY TAKINGWorkHome circumstancesCurrent smoker?Past smoker?How many years?Cigarettes/ roll-ups / cigars?How many per day?SmokingWho lives at home partner? Children?Stairs at home?Need help with housework, shopping, cooking?Do you drink alcohol?What? Wine? Beer?How much? Calculate units/weekAlcohol

Systems ReviewCouple of questions for each body system e.g: Fits, faints, funny turnsHeadachesVision problemsCNS (central nervous system)Shortness of Breath (SOB)Cough blood (red flag)

RS (respiratory system)Chest painHeart fluttering (palpitations)Ankle swellingCVS (cardiovascular system)Change in bowel habits blood (red flag)Nausea or vomitingWeight loss red flagGI (gastrointestinal system)Change in waterworksBlood in urineMenstrual problemsGU (genitourinary system)Joint or muscle painSkin rashesLumps or bumpsOther

HISTORY TAKINGICEIdeasConcernsExpectations

HISTORY TAKINGClosingIs there anything youd like to add or think Ive missed?

Do you have any questions?

THANK the patient!!!!!

HISTORY TAKING

HISTORY TAKINGSQITASiteualityntensityimingggrevating/relieving factorsymptoms associatedPainSOCRATESitensetharacteradiationssociated symptomsimingxacerbating/relievingeverityRED FLAGS

HISTORY TAKINGSymptoms that may indicate serious underlying condition

Different for each body system

e.g. coughing-up blood (haemoptysis) and lung cancer

HISTORY TAKINGSignpostingId like to ask you about .

Your general healthYour previous healthYour backgroundetcWHY? Patient and examiner know you have a structure

HISTORY TAKINGTHANK YOU