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HISTORY-TAKING

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. WIPER.

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HISTORY-TAKING

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  1. HISTORY-TAKING

  2. 24 year-old female presents to GP with abdominal pain HISTORY TAKING

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

  4. WIPER ntroduce self, check patient details ermission xpose patient (examination only) ash Hands ight-hand side of bed (examination only) HISTORY TAKING

  5. Presenting Complaint (PC) OPEN QUESTIONS: “Why have you come in today?” “Could you tell me more about the……….?” HISTORY TAKING

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

  7. SUMMARISE the presenting complaint HISTORY TAKING

  8. Past Medical History (HPC) • Medical conditions • Hospitalisations • Serious illnesses / injuries • Operations HISTORY TAKING HISTORY TAKING

  9. Drug History (DH) • Current medications: • Prescribed • Over-the-counter • Name • Dose • Frequency ALLERGIES Recreational drugs HISTORY TAKING

  10. Family History (FH) Anyone in family had similar problem? Any serious illnesses in the family? HISTORY TAKING

  11. Social History (SH) Work • Who lives at home – partner? Children? • Stairs at home? • Need help with housework, shopping, cooking? Home circumstances Alcohol • Current smoker? • Past smoker? • How many years? • Cigarettes/ roll-ups / cigars? • How many per day? • Do you drink alcohol? • What? Wine? Beer? • How much? • Calculate units/week Smoking HISTORY TAKING

  12. Systems Review Couple of questions for each body system e.g: Other • Fits, faints, funny turns • Headaches • Vision problems • Shortness of Breath (SOB) • Cough – blood (red flag) • Joint or muscle pain • Skin rashes • Lumps or bumps • Change in waterworks • Blood in urine • Menstrual problems CNS (central nervous system) RS (respiratory system) GU (genitourinary system) GI (gastrointestinal system) • Change in bowel habits – blood (red flag) • Nausea or vomiting • Weight loss – red flag • Chest pain • “Heart fluttering” (palpitations) • Ankle swelling CVS (cardiovascular system) HISTORY TAKING

  13. ICE Ideas Concerns Expectations HISTORY TAKING

  14. Closing “Is there anything you’d like to add or think I’ve missed?” “Do you have any questions?” THANK the patient!!!!! HISTORY TAKING

  15. SOCRATES Pain ite SQITAS nset ite haracter uality adiation ntensity ssociated symptoms iming iming ggrevating/relieving factors xacerbating/relieving ymptoms associated everity HISTORY TAKING

  16. 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

  17. Signposting • “I’d 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

  18. THANK YOU HISTORY TAKING

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