Introduction 1. Your name, role and why you are there.
2. Patient name and DOB.
3. How would you like to be addressed?
4. CONSENT!
Presenting Open question . Pain
complaint / (‘How are you today’, ‘How can I S - site
Problem list (PC) help you today’?) O - onset
History of Include: C - character
presenting 1. Sequence of events R - radiation
complaint (HxPC) 2. Symptom analysis (e.g. SOCRATES if pain) A - association
3. Systems review (Dependant on body system involved) T - time (time of day/ how long?)
E - exacerbating / relieving
S - severity
Patient Include:
perspective (Ideas, What ideas the patient has of what may
concerns, be causing the symptoms?
expectations) What is concerning the patient about
their symptoms and how are the
symptoms affecting their life?
What is the patient expecting from the
consultation?
How does the patient feel about their
symptoms?
MEDICAL HISTORY TAKING
Past medical ‘Have you any other ongoing medical problems?’ Ask about conditions that may be
history (PMHx) related to what your differential
is.
Past surgical ‘Have you ever had any surgery?’ Relative surgeries to your
history (PSHx) differential.
Drug history (DHx) ‘Do you take any regular medications?’ When do they take the medicine?
‘Have you got any allergies?’ What form is the medication in?
Are they easy for patient to take?
(DO NOT FORGET TO ASK ABOUT ALLERGIES) OTC medication.
Ask what happened when they last had the allergic reaction
and to what. In some cases, if the allergy is mild, the benefit
of the medication may outweigh the allergic reactions effect.
What treatment was needed to counter the allergic
reaction?
Family history ‘Are there any diseases that run through your With some patients who are
(FHx) family?’ dependant, or someone is
Be more specific about diseases that are dependent on them, it is good to
relevant to presenting complaint. find out about the family
dynamic.
2. Patient name and DOB.
3. How would you like to be addressed?
4. CONSENT!
Presenting Open question . Pain
complaint / (‘How are you today’, ‘How can I S - site
Problem list (PC) help you today’?) O - onset
History of Include: C - character
presenting 1. Sequence of events R - radiation
complaint (HxPC) 2. Symptom analysis (e.g. SOCRATES if pain) A - association
3. Systems review (Dependant on body system involved) T - time (time of day/ how long?)
E - exacerbating / relieving
S - severity
Patient Include:
perspective (Ideas, What ideas the patient has of what may
concerns, be causing the symptoms?
expectations) What is concerning the patient about
their symptoms and how are the
symptoms affecting their life?
What is the patient expecting from the
consultation?
How does the patient feel about their
symptoms?
MEDICAL HISTORY TAKING
Past medical ‘Have you any other ongoing medical problems?’ Ask about conditions that may be
history (PMHx) related to what your differential
is.
Past surgical ‘Have you ever had any surgery?’ Relative surgeries to your
history (PSHx) differential.
Drug history (DHx) ‘Do you take any regular medications?’ When do they take the medicine?
‘Have you got any allergies?’ What form is the medication in?
Are they easy for patient to take?
(DO NOT FORGET TO ASK ABOUT ALLERGIES) OTC medication.
Ask what happened when they last had the allergic reaction
and to what. In some cases, if the allergy is mild, the benefit
of the medication may outweigh the allergic reactions effect.
What treatment was needed to counter the allergic
reaction?
Family history ‘Are there any diseases that run through your With some patients who are
(FHx) family?’ dependant, or someone is
Be more specific about diseases that are dependent on them, it is good to
relevant to presenting complaint. find out about the family
dynamic.
