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H O W T O T A K E A H I S T O R Y INEZ MURRAYWhat is a history? • Taking a history allows healthcare professionals to have a record of the patient's presenting, past and family medical history • This is a key diagnostic tool which can help to guide investigations and shape patient management • It is incredibly important to take a thorough history, but it is also important to show your active listening and your patience.First Y ear History T aking CARDIOVASCULAR RESPIRATORY ANAEMIA (TIREDNESS) MUSCULOSKELETALIntroductions Greet the patient Greet •Good morning, it is lovely to meet you today Introduce yourself – name and role Introduce •My name is Inez Murray, and I am a second-year medical student at Queen's Check their name and DOB Check •Do you mind if I just check your name and date of birth? •*Also consult with name bracelet if available Ask what they would like to referred to Ask •What name would you like me to call you today? Is Ms Smith ok? Explain the procedure and ask for consent Explain •Today, I have been asked to take a history. •This will involve me asking you a few questions about what brings you in today, as well as some questions about your past and family medical history. •Would that be ok with you?The Golden Minute • In an OSCE, you will not be told which type of history station it is (i.e. respiratory history, anaemia history etc.) • You will have to deduce from the patient's presenting complaint which type of history you are supposed to take. • This is why the golden minute (not that long in an OSCE!) is so important! • Patients are keen to be listened to, and from the start of your OSCE this gives you an opportunity to show your listening skills and your patient-centred manner. • Ask them: So, what brings you in here today?T H E P R E S E N T I N G C O M P L A I N TOPERA General Presentation ONSET • "So, when did this start?" PROGRESSION • "Have your symptoms changed or progressed over time?" • Worse? More frequent? More intense? EXACERBATING • "Is there anything that makes this worse?" • Movement? Rest? Heat? Stress? Eating? RELIEVING • "Is there anything that makes this better?" • Paracetamol? Ibuprofen? Rest? Movement? ASSOCIATED SYMPTOMS • "Have you noticed any other symptoms or any changes recently?" • Shortness of breath? Weight changes? Fatigue? Pain anywhere? • Complete short OPERA for theseSOCRATES Pain Presentation SITE • "Whereaboutsis the pain?" ONSET • "When did the pain start?" CHARACTER • "Can you characterise this pain?" • Sharp? Stabbing? Blunt? Aching? RADIATION • "Does the pain move anywhere?" ASSOCIATEDSYMPTOMS • "Do you have any associated symptoms?" • Nausea? Fatigue? Bleeding? TIMING • "Does the pain come at any particular time?" • "Is it worse in the mornings/evenings? Does it wake you up at night? Does it change throughout the day" EXACERBATING AND RELIEVING FACTORS • "Does anything make it better?" - Ibuprofen, Paracetamol, Movement, Rest • "Does anything make it worse?" - Movement, Rest, Stress, Emotions, Lotions SEVERITY • "On a scaleof 1-10, with 10 being the worst pain you have ever felt in your life, how painful would you rate this pain?"What else do you need to ask...? If you think it is CARDIOVASCULAR.... DOPAPSI! • Dyspnoea? • Orthopnoea? • Paroxysmal Nocturnal Dyspnoea? • Ankle Swelling? • Palpitations? • Syncope? • Intermittent Claudication? If you think RESPIRATORY … Can She Have Delicious Chicken Wings? • Cough? • Sputum? • Haemoptysis? • Dyspnoea? • Chest Pain? • Wheeze? • PLUS Systemic Q's (weight changes, energy levels) + Cardiac Q'sWhat else do you need to ask...? If you think it is ANAEMIA …WAMS and Helping People Boost Confidence Levels • Weight • Appetite • Mood • Sleep • Headache? • Palpitations? • Breathlessness? • Chest pain? • Light heads or faints? It is also important to consider causes • Ask about dietary restrictions (V, VG, GF) • Ask about bleeding or injuriesWhat else do you need to ask...? • If you think it is MUSCULOSKELETAL … ask about stiffness and swelling, as well as: 2F's, 2W's, 2P's and R E D • Fatigue? • Fever? • Weakness? • Weight changes? • Penile discharge? • Preceding illness? • Eye problems – Red? Conjunctivitis? • Dysuria? • Rash?Past Medical History General Questions • "Do you have any medical conditions?" • "Have you ever had any operations" Targeted Questions • CV: Angina, MI, Stroke,TIA, Diabetes, Hypertension (High BP), Hyperlipidaemia (High Cholesterol) • Resp: Asthma,Allergies, Hayfever, Bronchitis,TB, Pneumonia, Chest Surgery • Anaemia: Previous Anaemia (type?), Thyroid Disease, Recent Injuries, Blood Transfusions, Recent Pregnancies • MSK: Joint Problems, Arthritis (Rheum or Osteo), IBD, Psoriasis, IritisFamily Medical History • Similar to PMH – general and targeted questions (same as before). • If patient reveals family member had condition,show empathy.Ask what age they were diagnosed? How is this condition managed? How is the family member? • If they reveal a family member to be suffering with this condition or deceased, show patience and empathy, such as "I'm very sorry to hear that, that must be difficult for you, are you feeling/coping ok?" TOP TIPS FOR PMH and FH • Enquire more! What do you need to know? • Beware of the patient's age and sex! Obvious point but easily missed. • If you were the doctor, what PMH and FH would you like to know? Think about related conditions and connections.Drugs History P - Prescriptions O - Often D - Demand H - High I – Intelligence • Prescribed • Compliance? Dose? Frequency? • Over the Counter • Ibuprofen? Paracetamol? • Dose? Frequency? • Drug Allergies • Herbal Remedies • Illicit Drugs • Be sensitive - "Apologies, but we have to ask all of our patients this question – have you ever taken any illicit drugs?"Social History • Smoking • Have you ever smoked? • How many per day? • What age did you start? • Alcohol • On average, how much would you drink in a week? • Occupation • Do you work? • RESP - Any triggers in your workplace? Is your breathlessness worse at work? • Lifestyle • Would you say you're active? • What type of diet would you have? • RESP – Any new triggers? Pets? Holidays? B R I N G I T B A C K T O T H E P A T I E N T !Lifestyle and ICE How has this been affecting your Ideas lifestyle? Concerns ExpectationsTips from Y ear 2 Students • "You are not going to get the title of the station in the exam" • "Be empathetic" • "Listen – you may be asked for a simple diagnosis" • "It's ok to have a script but remember it’s a real conversation" • "Take the time to listen" • "Be quiet when they're speaking" • "If they bring something up, go into more detail about it" • "Read the page before the exam – sometimes it can ask you to leave stuff out" • "Make sure to ask targeted questions" • "Be genuinely curious – if you're stuck for questions, think of what else would be related to the diagnosis" • "Ask at the end is there anything else you would like to tell me" • "Don't use jargon"