PLAB2 Revision Dr Adrienn Gyori
Summary
This on-demand teaching session will cover history taking for medical professionals who are preparing for the Platte to exam. Participants will learn about components of a general history, recommended resources, and tools and acronyms to help with history taking. They will also learn structure for more focused histories to hone in on relevant details and communication skills. The session will provide comprehensive training to give attendees the best chance of success in their upcoming Platte to exam.
Learning objectives
Learning Objectives:
- Identify and practice the components of a general history.
- Understand and implement the SOKRATI acronym for pain history.
- Identify red flags in a patient’s history and comprehend their implications.
- Utilize the head-to-toe systems approach for reviewing the patient’s past medical history.
- Employ pneumonic devices and acronyms to assist with focusing a history.
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Perfect. All right, lovely. Hello and welcome to the plat two series too, Platte to preparation series. We'll be kicking off today with history taking. I'm not sure if any of you attended uh my previous session on Platt to well the prime in general sort of a business for an overview. And at that session, we put plans in place to deliver Platt to. So this is sort of the practical exam did the or ski side of things to deliver lectures ahead of the in person day. So again, some of you may be attending that on the 28th of March is sort of places allocated on a first confessor basis. But definitely if you're thinking of attending that day and please by all means, um stick with these lectures as we will be going through a lot of content. Um Let me sorry, just trying to, trying to slide. It's perfect. So quick, very quick, disclaimer plat two letters delivered by the crisis Rescue Foundation Metris team purpose of the room of the lecturers not to provide guidance on matters relating to GM see registration. So please if you have any questions relating to these matters please save them will the G M C representatives? Because unfortunately, we're not in a position really to answer questions about that side of things that further a do. I'm going to kick off the contents of the lecture. So recommended resources. I would definitely say Samson Hunt book for plat to really, really good, really comprehensive takes you through essentially all the most relevant stations including Marks Games as well. That my club in the exam, I cannot recommend geeky medics enough. So they're completely free online or ski platform. Pretty much. I would say every medical student and even sort of f one doctors preparing for uh specialty exams do use geeky medics. They also have a bunch of my youtube videos and I would highly recommend you look at their history taking section terms of books, don't feel too pressured into buying another one. But if you do have a cop, a lying around a library that gives you access to my clothes, clinical diagnosis, I would really recommend it. It's a good book because it sort of works backwards. It kind of gives you the decide the symptom that you're working within a sort of works backwards, which is quite helpful in terms of the contents for today. We'll go over bits of general. So components of a general history and then we'll give you, I'll also try and give you structures for more focus histories and plaid to sort of get your general history taking uh stations and then you get more focused history, taking uh stations. So we'll try and cover both of those. And I'll also be touching a bit more communication skills as well. So to introduce you to the concept of a general history, these are essentially the component and they typically follow a certain former Falessa and pattern that I would recommend sticking with. So the the introduction to the station, I'll go over this inferred detail in a moment. You'll want to go through with your patient presenting complaint, the history of that presenting complaint, the patient's past medical history, drug, drug history, and medications history, uh family history, and then any relevant social occupational travel history. And then at the end of the station, you'll typically be asked to present a summary, uh the most salient findings and give differential diagnoses. So the introduction, so wash hands, even if you're not going to do it for real, that there is a sort of a moment of like something that you would indicating that you would do that introduce yourself. Um So that's full name and position, confirm the patient's identity. So always make sure you know who is that you're dealing with? You typically have a brief in the exam which tells you the patient's name. Explain that you would like to take a history and make sure that you gain consensus really will important always to follow that sort of set up in terms of introducing yourself and gaining that consent as well. So is that initial report building with the patient? Now, the you may have come across various different acronyms. I'm going to be giving you a few today in the Monarchs acronyms. I've got terrible memories. So I always found these really quite useful when I was preparing for exams, still do. So when we look at history of presenting complaint, particularly when it comes to pain, which is very often presenting complaint. Uh I would quite like to use sokrati. So this is again, something that's widely taught in UK medical schools, Socrates really goes through site. So, whereas the pain onset, when did start pain start gradually or suddenly the character services sort of door, sharp, aching, stabbing, etcetera, radiation. Is it going anywhere, is it sort of felt anywhere else, any associated symptoms? Obviously at the discretion of what sort of pain talking about? So think about your differentials, whether it's a headache and abdo pain, chest pain. And and also ask at this point about again, depending where that pain is about any red flags. So for example, with abdo pain, you might want to ask about his life. Weight was because that would be a red flag center in terms of timing. So is the pain constant or periodic or is it associated with activity time of day? So the time of day, if you think about your rheumatoid or osteo arthritic type pain, so one is worse in the morning and they're on the other is worse in the evening. There, anything that exacerbates the pain? So it makes it worse equally. Is there anything that makes it better when you're covering that question? And finally, severity? So we didn't intend to ask that on a scale of 1 to 10, one being no pain and 10 being sort of the worst ever pain felt by the patient. And obviously that's quite a subjective scale, but pain is, is going to be subjected to the patient. Another new morning that I came across one, preparing the slice. Personally, I didn't really use. This one is uh would power. I always took with Socrates and seemed to work well for me, I just adapted to the station. So even if it was a non pain presenting complaint, but similar idea you want to ask about on sit duration of the symptom progression though, is it getting worse aggravating and relieving practice essentially work exacerbation and again, any associated symptoms so feel free to use these as and when. But as long as you know, you have that structure and you, you're making sure that you're not missing anything. That's kind of the main point here. The past medical history, I tend to advocate for sort of toe to toe systems approach. Again, as long as nothing gets missed, uh do whatever structure feels best to you. But I tend to go through in term of in terms of sort of starting from the head. So starting with a few, you know, uh past medical issue of headaches, loss of consciousness fits greater stroke. It's all the sermons here and balance problems. So quick, quick overview of the head, chest, cardiac problems, previous semi potential rest problems, I can Parton heart and lungs really abdomen, obviously all the various bits and bobs. So bowel urine, liver, kidneys, diabetes, et cetera and then joins them just again, any arthritic problems uh in past medical history. So surgical history is also relevant and typically also admission's history as an admission to hospital or even to intensive care. So like for example, if you were taking a history of an asthmatic patient, you would definitely want to know whether or not their asthma has ever landed them in the ICU medication or drug history. So remember to include allergies at this point as well. You want to ask about regulate regular medications and contraceptives typically separately because it's so easy to forget. But obviously, you can have impact on things like remember prophylaxis and what not. So it's definitely important to know about it and also about any over the counter alternative medications that patient's might be taking, that wouldn't come up under the prescriptions, family history. So again, particularly if you think about uh Children often pediatric histories or heritable diseases, uh you want to ask about other conditions or if you think about uh my cardio in facts, one of these sort of heart school criterias whether or not they had an immediate so relatives. So like a sibling or a parent who had an M I or even died young or an MRI, you would want to know. Um So definitely important in terms of your cardiovascular history is often social history will include smoking, alcohol, any illicit drugs and often for elderly patient or patient's with disabilities, you would want to know about their living situation. Do they have carers? Do they manage to live independently? And again, in the elderly, definitely ask about their mobility as well. So if you think about an elderly patient prone to falls at risk falls, if they've got sort of two flights of stairs in their home to get up and down, then that's not necessarily a safe environment is always important to know um in some histories, the travel history may well be relevant. So if you think about hepatitis diarrhea, vomiting fever of in the traveler type scenarios, and then again, some, sometimes it's important to know about occupation as well. So your dermatological histories and often sort of long histories as well. So, and think about things like asbestos exposure, for example. So that's kind of our general history taking in an optional. So what I'm going to try and do now is break it down to your more specific history. So if you follow that format with most, anything in the general sense that you get given in in a plaque to station or when you're seeing, seeing a patient in real life, you can't really go wrong. If you follow that format, you'll probably be taking through those most, you know, Saline boxes, you'll be getting those more, the most important information out of it. Or it can get a little bit tricky is where, then you have to sort of hone in on a focus history and that's why I've paid out the ones I felt like would be the most tricky to get around without having those additional bits and Bobs. And this was that the list that I arrived at it, it's not exhaustive. So I'm sure if you went out, you had a look, especially in places like Kiki Medics, you would find sort of further histories. But I would, I would definitely say that these are the main ones if you have your general histories and you have these focus histories to add on it, I think you've covered your bases quite well. But like I say, it is not exhausted. So do you try and go through as much from, say the Samson Hamburg or sort of past paper practice with the club as possible. So, starting off from pediatrics. So again, like I said, I'll be giving, giving you guys a lot of Pneumonic some acronyms just because these are literally the ones that I use in my exam as well. They're quite commonly used in the UK. Definitely at medical schools and I just found them really, really helpful just to have something to hang the structure of when I'm going in. So remember with the focus history, the idea is that you do sort of a quick whisk through the general history. Really, the really where you want to spend most time is the focused. So with younger Children big if these is where that we, we sort of got taught, we remember So you wouldn't know about any complications during birth. So beef birth immunizations, whether on all these today growth. So are they in then or more percentile or are they drop, dropping or gaining through percentiles, especially dropping through percentiles could be quite dangerous, obviously for small Children or babies uh feeding. So again, bears bottle intolerances, allergies, appetite, that sort of thing. Developments are particularly of developmental milestones. I would suggest having a quick read through various of domains of um of pediatric milestones and just having a bit of an idea because it's not the wildest thing. Um And we definitely have this exams where you get shown like a clip, like a two minute clip of like a child playing and doing a bit. And then essentially you have to comment on milestones and say what developmental stage there at um and their social environments at home nursery school, who they're with, who they're seeing. Um sort of do they live with parents or, or para separated or their siblings? So any sort of additional strain strains potentially in their environment that could be relevant for all the kids. So we start thinking more about adolescence. These have sort of been more sort of independent kids. You, we, we tend to talk about heads as the acronym. So heads for page for home. So again, sort of the idea of siblings, parents, family, um you know, who's, who's at home with e tends to, we tend to put education, exercise and employment in here a activity. So hobbies pastime, if they have any care responsibilities, often all the kids will unfortunately have care responsibilities. That's really important to know, map for safeguarding purposes. The with cover drinking and drugs and as with covered sex safety and, and suicide. So bit of safety net in general. So again, if, if you do use sort of a general general history room through and then you adults, the pediatric focus bids, then you've covered your bases really quite well there of central history. So essentially take a history here of the current pregnancy, like how it's been going, what scans they've had, what blood's, they've had, what investigations hate they've had and also uh include a gynecological history as well. So again, etcetera history. This is literally how I would approach in exams. I I used that cream bash, fun. So any bleeding, any abdominal pain, any systemic symptoms, obsess fresh feet where pure itis, headaches, fatigue, urinary symptoms, nausea, vomiting. So again, just quick run through gynecological history is a bit a little bit longer. So again, acronym here being Moscow, pneumonic being Moscow. Um So start off with menstrual history. So length of cycle, last menstrual period, regular, irregular bleeds, any associated symptoms, menorrhagia, amenorrhea, dysmenorrhea, as well as the normal bleeding in between etcetera history. So, gravitate and paris and how many live births, how many Children, how many terminations miscarriages. So you want to know about that side of things. Sexual history partners, unprotected, sexual intercourse, any stds at any point, um can be quite important if you think about your risk of future miscarriages and association with this TV, for example, smear tests in the UK, this is one of the, so this is cervical cancer screen. So it's one of the cancers that gets screened for and that's done from ages 25 to 64. And typically, it depends on the region, it should be done every three years. But unfortunately, some, some areas can only fund it for every five years, but it should be done every three years, painting windows ages, contraception, uh definitely important and then any additional, you know, you're in a reasonable rare bowel symptoms. And again, that's sort of friends like your gynecological history, taking neurological history. So essentially, this focuses on your lower urinary tract symptoms. So, um uh we we, it's, I think it's easy, easier to think about this in terms of dividing it between the red flag symptoms uh voiding lower urinary tract symptoms and the storage related lower urinary retracting symptoms. So, read flies when you think about a urological history and would be this furious of any pain, uh incontinence, incontinence or impotence, blood hematuria. So especially if, if there is actually no pain. So if it's a painless hematuria's to and also systemic symptoms. So again, ask about those be type symptoms of weight, lost night sweats. If you're examining them, think about lymph nails and that sort of thing. So those, those would be your red flag symptoms. Um in terms of avoiding symptoms, you probably want to ask about weakness, intermittent straining, hesitancy, incomplete, emptying of the bladder and dribbling as well. And then your storage symptoms would probably best be um summarized by any frequency urinary frequency, urgency and nocturia as well. So having to get up at night to, to urinate as well. So again, just having a bit of a structure in terms of, you know, what set of symptoms or put you in which direction in terms of uh low urinary tract symptoms. Um damage, economic medical history is probably it's great because it spells out psoriasis and that makes me happy. Um The, so again, damn history, it's pre pre self explanatory pets. So, irritation allergies, sort of mites from pairs of cats, dogs, that sort of thing can bring about irritation. Sun exposure is really important, especially in your elderly patient when you're sort of trying to sort of, you know, when you're looking at a skin lesion trying to decide whether or not they've, they've had a cumulative throughout their lives, some exposure that might then predis composing them to throw fewer Melanomas and, and S CCS. It's quite important when, especially in someone comes in and shows you sort of skin lesion two to ask whether or not they're at risk occupation. Again, very important. Are they working with sort of chemicals in the day? Couldn't, could they be accidently giving themselves chemical bands? Um or again, any, any sort of cancerous agents that might be, they might be dealing with. So yeah, definitely ask about occupation uh reflect against systemic symptoms, immuno suppression. So if you think about the predisposition to sec and like renal transplant, patient patient, so there immuno suppressed, then they might have predisposing factors to sec um infections. So again, um sometimes there is a dermatological manifestation of, of infections. So if you think about your, you know, chicken pox, for example, but always worth asking. Um and also don't forget you're not no infection necessarily. But again, thinking about systemic symptoms or think your gastro, for example, IBD type illness can manifest with a dermatological symptom as well. Um You want to take to think about eight to pay. So that's sort of the the class trough of diagnosis or um I suppose that um would include hay fever as morality's X. And so that sort of ear, it irritable, irritable um immune response essentially is what you want to be asking about here. Uh Skin care routines actually changes the skin care routine because um sometimes people sort of start using a new product and that causes irritation. Um and quite important, especially with the impact and the activities, social work. So if them, them is one of those things that is very, very visible to people. So actually a lot of dermatological problems and complaints present to GP almost as proportionately. So for how typically benign they are, but because it is very visible is it can be quite distressing for patient's and then finally, social history. So again, always you asked about alcohol, smoking drugs when you are doing an assessment of just quickly included here, the 80 assessment of skin lesions. So I appreciate it's more of an examination but say you were working in a GP practice and you can see the patient, you were doing a telephone consultation, then it would be quite handy to just very quickly run them through um these features of potential skin lesion than they're calling you about. So, asymmetry. So um does it have sort of uh a shape in size that's not really particularly symmetrical? That's so that's always a worrying um sign. How is the border? Is it sort of nice and even or is it kind of like patchy and not very discriminative as a color? Is it quite dark, quite light or infinitive? Puree that sort of thing diameter. So again, anything above six millimeters is, is not not ideal, especially if it's then also evolving. So it stands for revolution. That's really growth slash is it's starting to itch is just starting to bleed, particularly when the patient like catches on something like on their clothes, something like that. So that would be quite handy, quick run through. Again, if, if you don't have the patient necessarily in front of you can ask them, but definitely incorporate it into any dermatological exam of a lesion that you might do. We now get onto the psychiatry history bit. So I've divided this into the mental state examination, which is a bit of a bit of a long one, but it has come up in the past, in past years in the plaque to exam. And I'm also going to talk to you a little bit about miscellaneous of a bit of psychiatry history that you might want to um might want to ask your patient about. So I'll start with the MSC with sense for mental state examination. And again, these are the components that automatically form part of this assessment and again, try and sort of run through it in this order because that's typically the order you would see it using. So it's definitely this was the order I used when I was doing my psychiatry job. Um So starting off with a appearance, they're just making out of the patient's clothes, the skin hair, way, personal hygiene, don't make note of any scars that they might have, especially like self harm type scars, behavior is quite a big one. So it's quite a lot here. So, engagement and report, how are they with you? Are you able to sort of build that report with them, engage with them or do they appear distracted? Are they perhaps engaging with imperceptible stimuli? Are they talking to someone that's not in the room? Do they seem to be seeing things that are not actually there? So how is the, how is their engagement? Are they distracted? Are they engaged? Eye contact? Is it reduced excessive facial expression? What can you see, are they angry, relaxed, that etcetera, what your language again? Are they very withdrawal, sort of everything quite tucked in or are they sort of a bit more open and make potentially built even sort of threatening and with muscles tensing that kind of thing? Um Psychomotor activity. So this really is about assessing how quickly someone responds to say like a question that you put to them. So if is this speech extremely like slow and their engagement extremely slow or is it actually on the other end? And they're sort of a bit jumpy and a bit agitated and a bit restless? And that, that's kind of what you're asking there and then anything a normal that you notice in terms of pushes and movements. So your tremors take slips fucking rocking any sort of almost like automation, Zoe's of movement. But something that would be a bit abnormal next day is speech. So you want to comment on rape, wanted to tell in volume fluency rhythms. So generally, how is their speech? Um the next thing, mood in effect. So these are easily confused. They are quite different in that mood is the, is what the patient tells you as to how they feel. So the mood is subjective internal say as described by the patient. So if they say I feel sad, that would be their mood. The effect is what you observe in terms of how and what they are expressing in terms of motion externally. Okay. So someone's underlying moon might be sad, but actually they're effect might be irritated or jittery or just something else that layers on top of on top of that mood in terms of what they're expressing outwards. Okay. So I I appreciate they they can be very, they can seem like quite similar things, but they are quite different. So think about it, one is kind of a subjective assessment and one is kind of the objective assessment thought. So again, quite, quite a bit to cover in this one. So again, speed of thought. So again, are they very slow and and and this is often expressed through the volume of speech and the volume, the sort of level of engagement as well. So that's how you can sort of, in, for um speed of thought from that flowing coherence. So you want to think about associational thought? Uh Do they have this patient have circumstantial tangent or thought? So, they do, they sort of just completely got on a subject that is not related to what was being told about or their flight of ideas as in just sort of flicking from one thing to another or thought blocking, which is kind of the opposite. Like they get to a point where they seem, it seems like they're a bit stunted and they can't, can't sort of get on to the next thing. Um Are they repetitive? So that do they have a degree of perspiration or do their units? Neologism as well? So, neologism are newly made up words and you, do you see it sometimes with patient suffering with mania or schizophrenia where they literally just come up with words on the spot that don't have any meaning, but making up quite sort of persistent and repetitive with them. Uh content of thoughts, delusions, obsessions, commotions, valued ideas, suicidal or homicidal or pilon thoughts as well. So, ideations and thoughts um I thought possession. So this is in session with withdrawal and broadcasting. So this is quite often what you do um experience what you do notice with patient's who, who are experiencing delusions. So thought insertion is them telling you that someone is putting thought into their mind, like sort of someone on the radio is, is sort of channeling thoughts into their head withdrawals, is, is the opposite, right? As someone on TV, on, on radio, think taking thoughts out of their head or them again, broad casting, like, feeling like whatever is coming through like the TV, or the radio is kind of directed at them and they're sort of part of that narrative. So who, who, who is actually in possession of the thoughts? Is it, is it the person themselves or is it someone some where is it perceived to be someone external um perception is to do with the interpretation of stimulus? So this is where you would have your hallucinations, studio, hallucinations, illusions, the personalization and the realization. So this is all about there is an external stimulus which may or may not actually be there. But how does the patient then interpreters? So this is like when the patient seems destructed by hearing another voice that may well be indicative that they have a disturbance in the perception because they're experiencing an auditory hallucination. For example, cognition again, that might sound similar, but cognition is quite different in that it assesses more sort of the logical thinking, the knowledge and the awareness of the patient. So if you think about the way that you would assess like a delirious patient's similar sort of idea is your patient orientated to space in time, do they have the ability to concentrate on a task concentrating? Questions? Do they have an attention span. Do they have sort of an intellectual term memory? And often times again, you will find that mental health illness can impair someone's cognition. So if you set them down and have a chat to them and say, oh, we spoke about this yesterday on Ward round, they won't remember it. And that, that indicates an impaired cognition when it comes to natural term memory. And inside is the patiently to understand and recognize their mental health problems. So you will see patient's have no insight whatsoever. They sort of think that things are happening to them. They completely believe that the hallucinations, for example, are real. So they don't have awareness of the fact that they have an underlying mental health problem which might impair their ability to interact with their external environment and perceive the external environment, so to speak correctly. Um But then some, some patient's do so some patient's you'll talk to and then they'll say, oh his, you know, I know that this person is into the room. I know that there is no one else here, but I can still hear them, talk to me. So that indicates that they, they have inside, they know that what they're experiencing might not be real, but they have recognition on that. So they do have insight and finally, we come into judgment. So basically, this is a patient's ability to put all of that information and all the stimuli in perceptions, put it together and be able to weigh up and made decisions appropriately. So, judgment would be typically you kind of need insight to be able to make. Uh well, let's say a sensible quote, unquote judgment about something. But judgment would be then to say, okay, well, I've got insight about the fact that I'm experiencing in order to re hallucination. So my judgment of that situation will be to then keep taking my medication because that is kind of the conclusion that I've come to. If I take my medication, then the hallucinations will get better. So that would be kind of the judgment is the Axion that they can sort of go forward with. So the conclusion in the Axion, so that concludes uh the MSC side of things. And like I said, I just wanted to give you a few more miscellaneous psychiatry history bits because they sometimes come up and it's a little bit bitter at this point. And the certain things that you really do want to ask about specifically in terms of mood assessment, uh safety assessment. And then I'll also give you a quick OCD checklist at this point. But I would say that whenever you do take a psych history, and my assessment is quite important in that it can give you an insight into a patient who, who has or is at risk of depression, for example, of anxiety um of sort of um mood swings in general. So mood assessment, I I always use scales again as pneumonic. So sleep concentration anhedonia. So those top three would be very much indicative of depressive symptoms if patient reported them low mood eating. So again, disordered eating, it can be over eating and greeting and suicidal ideation, self harm. So whenever there is a patient in front of you with any sort of mood disturbance, mood assessment, including of a safety risk assessment about suicidal ideation, stuff on this really important. Um When, if you want to add on a full sort of suicide risk assessment, um the best way of approaching that is sort of having before during and after. So if they've already had a suicide attempt, then having a look at the before, during and after events is really really important. And part of that is looking at regret to, would they, you know, do they feel regret about trying to kill themselves? Uh Do they have the intention of trying again? Uh Were they making any plans? So typically any planned premeditated suicide attempts are always, um that's much more of a red flag that they might try again um as opposed to something that was done sort of impulsively in the heat of the moment, not really thought it through. So planning is always a bit of a red flag and whether or not then finally, if they sought help, so firstly, if they've already, you had an attempt, did they seek help? And secondly, if they felt like they got to a point where they might attempt suicide again. Would they seek help? And this tool I used many again, many times in my psychiatry rotation where it was essentially um someone with suicidal ideation who'd come in, for example, presented to accident emergency, very low, most suicidal ideation. Um in terms of whether or not to admit the patient's when I would go away and discuss it with the consultant, these would be the sort of things that we would discuss whether or not the patient had regret about their thoughts, had intentions, further planning and whether or not they knew how to, where to or would have inclination to seek help. So those would be very important in deciding whether or not the patient needed urgent admission and just very quickly to run you through an OCD checklist, which again makes me happy because it spells tour. Uh So checking, counting handwashing, cording, obsessing ritualistic behaviours and excessive behaviors as well. So if you did come, come across sort of an OCD type patient in a scenario or in or in real life, this would be definitely things to ask about and particularly the one that we did come across a lot again, on my elder elderly psychiatry placement was holding and that that can be potentially very, very dangerous because it's sort of massive fire risk hazard. You sometimes see pictures of people's homes and flats and houses. I think it was definitely a very risk environment for them to be in, which is why it's so important to ask about. So, um I think I've got one more for you, which is the ophthalmic history. So this is um um if, if someone comes in again, very common presentation to JP to emergency departments coming in with some sort of I complaint, so the ones that you, the, the symptoms that you would definitely want to ask about would be visual disturbance, lots of acuity of clarity. Since is the sort of visions muddied, even if, even if it retains security, but it's a sort of hazy, is it reaching associated with, with the symptom? Is there photophobia? So again, that can be Harold sign of, of uh wider problem. If you think about your uh meningitis type pictures are important to ask about any eye discharge or watering redness of the eye. Is it both eyes when I, is it just a particular area or is it sort of full, full blown red eye? Um is there any swelling or tenderness? And finally, there's any grittiness of dryness to try and help differentiate between what the cause of that, either red, painful i or loss of vision might be. So those would be sort of your top things that you would want to want to consider. Um Like I said, just very quickly running you through some communication skills. Um So introduce yourself clearly, um check why your patient's come in for the consultation of the visit. So in real life, as much as you know, you also do it in your exam, um start with open ended questions and then narrow down into specific. So it's quite good to sort of let the patient typically talk for like a minute. Some patient's will be very good in terms of they'll just volunteer up a lot of information and you can just sort of listen and then, but in, as in when you need to, with narrow questions, some patient's, you sort of have to just, they're a bit more with, it's just normal different people, um always remain very polite, professional, respectful, obviously. Uh but definitely in like a Noski station as well, like just make you very evident that you're wanting the patient to feel comfortable and that you're building that report with them. Um So have a good nonverbal communication to that and as well as it don't cross your arms, have decent eye contact, um like I said, try and leave the patient to talk for a minute roughly without like making any notes because it's a bit, it can be to some people a bit of putting a few as um a question and then you immediately sort of head down onto a piece of paper. So just let let the patient talk freely for about a minute or so against mine and not as appropriate. And then in terms of uh touching the patient, so different, different different people, like different mannerisms come more naturally. But I would say in history taking stations, there isn't really any reason to touch mock patient. So I would probably advise you to refrain from it. Um And finally, other I haven't mentioned, but yeah, just have a structured approach. So don't worry if you like forget bits as you go along, it's much, much more, more important to have a good structure and have a good report with the patient then like, remember every tiny little detail. So you feel, feel like the information today was a bit overwhelming. Listen, I'm happy to make the slides available. So if you wanted those Monix and acronyms to go through in your own time, that's absolutely fine. But it's, it's really just about if you go in and you have a structure in mind, then you're able to sort of um you're more flexible than with your history taking and you're able to work around the patient a bit better as opposed to if you don't have a structure going in, then you often sort of go down a rabbit hole, especially the patient is very like caught up on this one thing that they really want to tell you. You're like, oh but that's not really the bit that's that relevant to me. So yeah, just, just have a structure and stick with it. So, so go through your general history taking structure and then also those focus histories and that should cover your bases reasonably well, I think that's everything for me. So, um, let me just check. What time is it okay? So we were just a tiny bit longer. So I'm just going to open up the chat and see if there is any questions that have come through. But I'm happy to take any now as well. Any question, nothing in the chat so far. But if anyone wanted to write anything or I mean, yourselves, then please do. I'm happy to take any questions at this time. Uh huh. Um Yes, I want to know like is there a time limitation when you're taking the history because, you know, to be thorough with history taking in order to assist, you know, what the problem is. So do you sort of give a time limitation for that or, you know, because some patient's um seem to talk a lot, so you need to sort of, uh you know, cut them up and things like that, which is not, uh it is not like polite in one sense. So how do you deal with that? Excellent question. So question being, how do you deal with the potentially chatty patient? And how do you sort of limit the amount of time that they before? It's a bit of not so bearing in mind that your station is eight minutes long in the plaid too, right? And typically the examiner will stop you one or two minutes before your time is up to ask you questions, for example, about your differential diagnosis. So you kind of when you're doing your practice, you wanna time yourself to be able to get that history in about 5 to 6 minutes, right? Just to be on the safe side, which again, like you say can be very tricky if the patient is chatting. So was I I would say typically in exam situations, they try and avoid someone talking too much. What you can always do is politely, just try, let them talk for a bit, but politely try and interrupt them a little bit and say, can I just bring you back to asking you about this or say, oh, that's, that's a really good point. But I just had something else that I wanted to ask you very quickly about. Is that all right? Just because that's sort of, it's a polite way of butting in a bit and being like, so sorry, can I just, you know, get on with my questions? Hopefully, in an exam they wouldn't bring in anyone who's overly chatty. Um The, yeah, it's, it's a bit of an art. So when you practice your history, taking my advice would be 5 to 6 minutes time yourself. Just make sure you get through all of those bits and in real life, just have a few of those key phrases. Like, can I just stop you for a moment, please? May I just can't bring you back to that. And typically patient's then might if you've got that good report with them where you've like, let them speak for like that first minute and they've had their say, then they will understand that. Right. Obviously, you want to ask them questions. It's all about like a bit of that report, building skill as well. Does that answer your question? Is that all right? Yeah, that's fine. Thank you. Thanks. Just leave it a few more minutes in case there is a any more questions. Um In terms of you'll have me again this afternoon uh this afternoon um for uh lab to um examination skills. So we'll do part one today, I think uh two o'clock. Um So if, if anything does, if you're attending that session and if anything comes up in the meantime, or if you thought of a question, I'm more than happy to answer it at the end of that session as well in the Q and A. So don't worry too much. You okay. Question in the chat just popped up with history taking. There are many systems integrated. So how can we do efficient? Who takes simultaneous system history quickly in a timed manner? So I would say, um try and at the beginning of the station kind of hone in on what is it that the station wants from you? Ok. So for example, purposes be like, okay, this is an ob history, this is a Gynie history. This is like history, so kind of hone in on that. And that's why I think using that sort of structure, like I said, you can use the ones that I outlined today or you can write up your own. But having that structure of like, right abs history, these are my questions, this is what I'm going in with. It's very important for timekeeping. Um Typically, like I say, in an exam, you'll kind of get an idea from the brief or what system is it that they want you to take a history about for examine? Um If it's a specialist kind of more focused history, then do a very, very brief general history, but have your the majority of your attention on that focused history bit. Okay. If there isn't really a focused history, that's evident that they want you to take, then just do a really, really, really good general history, right? And that that should hopefully give you a decent list of differential diagnoses. But yes, in real life and the real life question is the real life answer to that is um So with the generic history, obviously know what the patient it has as they complained and then integrate any other bits that are relevant to it in, in, in an exam. It's a lot more about demonstrating that particular history of skill that they ask for you in the brief essentially. Yeah, perfect. Thanks. Brilliant. Thanks very much guys. So I think we'll finish it off there. Like I said, feel free to bring any questions to this afternoon, uh second club session of, of the day and I'll hopefully Seamus of you there. Um And like I say, you've got my uh emails well, in the recording. So if you wanted to drop me any messages, then please feel free to. All right. Thank you very much.