Taking A Clinical History

Front 1

Describe the order that a clinical history should be taken

Back 1

Front 2

Describe how to take a history in order

Back 2

1. Introduce self
2. Get consent for questions and writing notes
3. Ask what preferred to be called
4. Check name if necessary, age, sex, referral details
5. History of presenting complaint (SQITARS if pain)
6. Appropriate system review
7. Any current diagnoses
8. Past medical history
9. Any major operations and reaction to anaesthetic
10. Social history
- Who lives with
- Who can care / children etc
- Occupation or past occupation (exposure to hazards)
- Needs (e.g. mobility/continence)
- Smoking history (current or ex-smoker and what smoked)
- Alcohol units per week
- Recreational drugs
- Travel history
11. Medication and diets (specify route if non-oral, drug, dose, frequency, medical indication and consider over-the-counter and homeopathic remedies)
12. Allergies (NKDA)
13. Family history
14. Systems review
15. ICE
16. Any questions
17. Thanks

Front 3

History of presenting complaint - what questions do you ask for pain?

Back 3

SOCRATES
- Site
- Onset
- Character
- Radiation
- Symptoms associated
- Time course
- Exacerbating/relieving factors
- Severity

Front 4

What diseases are covered in past medical history?

Back 4

- Myocardial infarction
- Angina
- Stroke
- Deep vain thrombosis/ pulmonary embolism
- Endocrine disease (e.g. hyperthyroid)
- Epilepsy
- Jaundice / TB / Rheumatic Fever
- Peptic ulcer
- Hypercholesterolaemia
- Hypertension

Front 5

How do you calculate pack years?

Back 5

Number of cigarettes per day x number of years / 20

Front 6

What is 1 alcohol unit and what classifies binge drinking?

Back 6

1 unit =
- 1/2 pint normal strength beer, cider, or lager
- 25 ml or pub measure of spirits
- 50mls fortified wine e.g. sherry

Front 7

Systems review: CVS

Back 7

- Chest pain
- Dyspnoea / paroxysmal nocturnal dyspnoea (PND)
- Oedema (swelling)
- Palpitations
- Others (e.g. peripheral vessel disease)

Front 8

Systems review: RS

Back 8

- Cough
- Sputum
- Haemotypsis
- Chest pain
- Wheeze
- Dyspnoea
- Others e.g. Exercise tolerance (meters / miles)

Front 9

Systems review (GIT)

Back 9

- Chewing / swallowing problems
- nausea
- vomiting/ haematemesis
- heartburn
- weight loss
- jaundice
- abdominal pain
- diarrhoea / constipation
- bleeding PR
- Others

Front 10

Systems review (GUT)

Back 10

- Haematuria
- Burning/scalding
- Frequency
- Hesitancy
- Incontinence
- Others (e.g. nocturia)

Front 11

Systems review (CNS)

Back 11

- Headaches
- Blackouts
- Dizziness
- Weakness
- Depression
- Anxiety
- Visual problems
- Other (e.g. coordination problems)

Front 12

Systems review: Locomotor

Back 12

- Stiffness in joints
- Joint pain
- Swelling
- Rashes
- Locking of joints

Front 13

Systems review: Gynae

Back 13

- Last period
- Pregnancy?
- Presentation of normal period - regularity, heaviness etc