How to take a history
Start by putting the patient at ease:
• Greet the patient by name: "Good morning, Mrs Jones"
• Introduce yourself and
... [Show More] explain that you are a medical student.
• Shake the patient's hand, or if they are unwell rest your hand on theirs.
• Ensure that the patient is comfortable.
Standard history taking
• Name
• Address
• Date of birth
• Date of admission
• Presenting complaint
• History of presenting complaint
• Previous medical history
• Systems enquiry
• Drug history and allergy
• Family history
• Social history
• Conclusion/summary
General questions to ask the patient:
• Tell me what seems to be the problem.
• How long have you been unwell?
• When did the symtoms start?
• Not What brought you here?
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History of presenting complaint
If the history of the presenting complaint includes pain, ask about it using the
mnemonic SOCRATES
• Site - where exactly is this pain?
• Onset - when did the pain start, did it start suddenly or gradually?
• Character - describe the pain - sharp? knife-like? gripping? vice-like?
burning? crushing?
• Radiation - does the pain spread anywhere? To the arm, jaw, groin
etc?
• Associations - is the pain accompanied by any other features?
• Timing - does the pain vary in intensity during the day?
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• Exacerbating and relieving factors - does anything make the pain better
or worse?
• Severity - does the pain interfere with daily activities or with sleep?
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Questions to ask about previous medical
history
General question:
• Have you suffered from any previous illness?
Medical
• Ask about childhood illness and immunization
• Have you had TB or whooping cough?
• Have you ever been found to have high blood pressure?
• Have you had rheumatic fever?
• Have you ever suffered from epileptic seizures?
• Do you get asthma (episodic breathlessness, usually with wheeze)?
• Have you suffered from anxiety or depression?
• Do you have diabetes? [Show Less]