Histories

The psychiatric history is probably one of the most difficult histories to conduct, as the patient may present with no physical symptoms at all, just a general sense of feeling low. As a result, they may not give you much information at all and not be willing to engage with your questions. ‌ The biggest mistake that students make when taking a psychiatric history for depression is losing their structure. It is important to remember that we still want to find out about the presenting complaint – feelings of lethargy, poor sleep, loss of appetite are all symptoms and we

This is a history taking template for a young child where you will be taking the history from the parent.  Now that you are familiar with taking basic histories, there are some situations where we have to amend our general structure. Keep in mind, whether it be children, mental health patients or other specific conditions, we are still very much interested in finding out the presenting complaint, ICE and the past medical, family, drug and social history. The only difference in these histories is that we must also ask some additional questions to screen for problems specific to this group

The vomiting history is similar to cough – it is a symptom which has an onset, timing etc. but also we need details about the physical content of the vomit. So what are some differentials for vomiting? Neurological Tumour Raised ICP Idiopathic intracranial hypertension Hydrocephalus Bleed   Infection Gastroenteritis Infective colitis Malignancy Gastric cancer GI cancer   GI Pancreatitis Bowel obstruction Oesophageal varices Peptic ulcers Alcohol/gastritis It is very important to screen the abdominal system right from top to bottom. Notice how vomiting with constipation is more likely to suggest bowel obstruction, compared to with diarrhoea (more likely food poisoning). Unexplained vomiting

This history will usually refer to a middle-aged/elderly male complaining or urinary symptoms. The main purpose of the history will be to distinguish whether this condition is benign (BHP) or something more sinister, such as prostate/bladder cancer. In addition, for a younger patient, we might also be concerned with a STI. So what are some common conditions which might cause urinary frequency? Urinary tract Benign prostatic hyperplasia Prostate cancer Bladder cancer Over-active bladder Infection UTI STI Looking at these differentials, the systems we have to explore are the urinary system and possible sexually transmitted infections. Again when going through the symptoms, we should enquire

This history refers to patients who have experienced a loss of consciousness on more than one occasion. What are some common conditions which might cause this? Raised intracranial pressure Bleed Tumour Hydrocephalus   Neurological Epilepsy Cardiovascular Palpitations (AF) Vasovagal reflex Postural hypotension Looking at these differentials, the systems we are most interested in exploring during our specific systems review will be the neurological and cardiovascular systems. Remember, common things are common. Someone presenting with syncope is much more likely to have some form of vasovagal reflex, or a side effect of their blood pressure medication than epilepsy – but this is a diagnosis we do not

Rectal bleeding is a serious symptom which should ring bells. If we take the anatomical approach the main conditions which can cause this are bowel cancer, diverticulitis, IBD but also more benign conditions like haemorrhoids and an anal fissure. Therefore, in our GI specific systems review, we will need to work through the GI tract. Again, in any female of child bearing age (14 to 60) we should always query pregnancy and gynaecological conditions.   Introduction Good afternoon, my name is _______ and I am one of the student doctors here. Is it _______(patient’s name)? I just wanted to ask

As a medical student, this is actually one of the simplest histories to take. The reason is that apart from the heart, there are few things which can cause palpitations. Nevertheless, what we do have to concentrate on is taking a really detailed account of the presenting complaint – specifically when do the palpitations start, what brings them on, are they there all the time etc. In addition, we have to screen for cardiovascular and breathing symptoms, as these are connected to the heart. So what specific systems should we screen for?‌ Cardiovascular–> Chest pain, loss of consciousness Respiratory –> Breathlessness

Joint pain is one of the most common presentations you will see. Again we are interested in the onset, timing etc. A key aspect for joint pain is working out whether this is an inflammatory or non-inflammatory problem. The difference in prognosis, treatment of osteoarthritis vs rheumatoid is substantial. So an important symptom to explore is STIFFNESS. Is it worse in the morning? How long does it last? So what are the differentials for joint pain? Trauma Sports injury Fall   Non-inflammatory Osteoarthritis   Other Chronic fatigue syndrome Fibromyalgia Inflammatory Rheumatoid arthritis Rheumatoid variants Gout Pseud-gout Bursitis Septic arthritis Therefore,

When considering a headache, what are some common conditions which might cause this? Raised intracranial pressure Bleed Tumour Idiopathic intracranial hypertension Hydrocephalus   Infection Sinusitis Meningitis Encephalitis Brain abscess  Trauma Extradural/subdural hematoma   Neurological Epilepsy Migraine Tension headache   Infarction Ischaemic stroke Therefore, when conducting the specific systems review, we will need to ask questions that cover all of these differentials and allows us to narrow down (if not rule out) the most serious causes. This will most cover the head and neck and the nervous system   Introduction Good afternoon, my name is _______ and I am one of the student

Taking a history for a cough, vomiting, diarrhoea, and blood in the urine all fall into a group. Here you have a type of symptom which requires exploration not only about the onset, timeline, associated symptoms, but also about the physical content of the substance. A history which covers only one aspect will be inadequate and will mean that you miss out key information. Therefore, in these histories, do not forget to ask about the “S (specific questions)” in OATES. ‌ When considering a cough, what are some common conditions which might cause this? Chest infection Viral infection Pneumonia Fungus  

Chest pain is one of the most common reasons why patients present into A&E. So what are some of the differentials to consider? Cardiovascular MI Aortic dissection Palpitations Aneurysm Heart failure Pericarditis GI Gastro-oesophageal reflux Respiratory Asthma Pulmonary embolism Chest infection   MSK Pulled muscle Costochondritis Therefore, when conducting the specific systems review, we will need to ask questions that cover all of these systems, which will allow us to narrow down (if not rule out) the most serious causes. In addition, during the presenting complain, as you gain more experience, you will naturally learn to ask more specific questions,

With these different histories, whilst the overall structure will be identical to before, pay close attention to the presenting complaint and systems review sections – as this is what will differ.‌ For the presenting complaint, I have included the most common symptoms a patient is initially likely to tell you. Remember to screen fully, and only after you have fully screened for all the symptoms, you can follow SOCRATES or OATES to explore each one in detail. If there are symptoms listed in the example presenting complaints that the patient does not say, remember to ask about these in the

It is important to note that the example history before is just a model, and so it might not work in 100% of situations. However, it is a template which should always give you a base with which to work from and not panic in stressful situations. Below are some common queries which students have and how to get round them.   1. What if the patient mentions their family history or something different during a different part of the history? Whilst you might have this model template in your mind, the patient will not. They are just going to

Now that you have read a general template, let’s go through each aspect trying to understand exactly why we ask these specific questions, and what information we hope to gain from them.   Introduction Good afternoon, my name is _______ and I am one of the student doctors here. Is it _______(patient’s name) To begin within, it is essential that you introduce yourself to the patient and clearly explain what level you are i.e. whether you are a medical student, junior doctor, consultant. By doing this, the patient will be able to probably gauge your level of experience and knowledge

Below is a general template for taking a history. In a nutshell, we should aim to introduce ourselves politely and start with an open question thus allowing the patient to describe in their own words what the problem is. After this we can work through the different categories obtaining information to gain a full perspective of the patient’s illness and obtaining the most likely differentials. Do not worry if you do not understand why we are asking all these questions, it will be explained in much more detail on the next page.   Introduction Good afternoon, my name is _______

History taking is one of the most important skills required by a doctor. Many clinicians argue that 70% of the diagnosis can be found in the history, with follow up investigations, imaging and special tests only really required to answer initial doubts.‌ Each question in your history should be asked with a purpose. Let us imagine that someone has presented with vomiting. What are some differentials in this scenario? Gastrointestinal Infective colitis Pancreatitis Biliary conditions Bowel Obstruction Achalasia   CardioRespiratory Myocardial infarction   Neurological Cerebrovascular accident Extra/sub dural haematoma Raised ICP Brain tumour   Non-organic Drugs Alcohol Allergies   By

Overview Analysis of pleural fluid is important for the workup of a pleural effusion. A pleural effusion is the most common manifestation of pleural disease and it may occur from a wide range of aetiologies. It refers to an abnormal collection of fluid with the pleural space. Pleural fluid may be aspirated and analysed to help determine the underlying cause. Pleural effusions may be a manifestation of numerous conditions that requires a careful history, clinical examination, imaging (e.g. chest x-ray), and pleural fluid analysis to determine the cause. Sometimes the cause may be obvious (e.g. heart failure) and pleural aspiration is

Introduction The respiratory history should focus on key system-specific symptoms related to the respiratory system. A respiratory history focuses the consultation on the respiratory system. This is usually because a patient presents with a respiratory problem such as shortness of breath or wheeze. The idea of a system-specific history is to explore key factors that are relevant to the affected system during the consultation. In respiratory disease, this may include pertinent past medical history (e.g. asthma/COPD), inhaler use, smoking history, occupational exposures, and even childhood illnesses. History of presenting complaint Breathlessness is a major symptom of respiratory disease. Shortness of breath or

Overview Musculoskeletal disorders are often multi-system that requires a wide range of questioning in the history. A musculoskeletal (MSK) history focuses primarily on presentations affecting the musculoskeletal system including bones, joints, tendons, ligaments, and muscles. Remember that many musculoskeletal disorders are multi-system meaning a wide range of inquiry is required during the consultation to determine the involvement of other organ systems. Presentations may be acute and obvious (e.g. fractured bone after fall) or more chronic with vague extending over months to years. Be patient and listen to the patient. Finally, it is essential to ask what the functional and psychological impact of

Overview The gastrointestinal (GI) history should focus on key system-specific symptoms related to the GI tract. The gastrointestinal tract runs all the way from mouth to anus. Pathology can occur anywhere along the tract from oesophagus to the intestines to the bile ducts. Therefore, the GI history is a system-specific history that needs to focus on the different elements that can affect each part. Any GI history should focus on the presenting symptom of the patient (e.g. diarrhoea or dysphagia) and then proceed to ask more broad questions related to other parts of the GI tract History of presenting complaint Isolate

Introduction The cardiovascular history should focus on key system-specific symptoms related to the heart and cardiovascular system. A cardiovascular history should focus the consultation on the cardiovascular system. This is usually because a patient presents with a cardiovascular problem such as chest pain or palpitations. The idea of a system-specific history is to explore key factors that are relevant to the affected system during the consultation. In cardiovascular disease, this may include cardiovascular risk factors, medications (i.e. that prevent or provoke cardiovascular disease), lifestyle factors (e.g. obesity, smoking), and relevant family history. History of presenting complaint Chest pain can be described using the SOCRATES mnemonic.

Overview The breast history should focus of system-specific questions relating to disease of the breast. A breast history focuses the consultation on key clinical features that affect the breasts. The hallmark of breast disease is a breast lump and you should feel confident in exploring the features of a breast lump in full detail. It is important within your history to determine any systemic features that may indicate an underlying malignancy (e.g. fever, weight loss, loss of appetite) and to tease out any significant risk factors for breast disease. For example, mastitis is more likely to occur if the patient is

Introduction The art of medicine is to determine why a patient has sought help. The key skills to help establish the underlying cause of a patients’ symptoms (the diagnosis) is based on talking to the patient (the history), examining the patient (the examination) and requesting tests like bloods and x-rays (the investigations). The information gathered from the history and examination is used to form a hypothesis of the possible underlying diagnosis. Investigations can then be used to either confirm or refute this diagnosis. Some diagnoses can be made just by talking to a patient, while others are reliant on a specific test. As a medical student, student nurse, physician associate, or allied