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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 systems review.
For each history, just remember that there are several different systems which might be causing that symptom – this is what you need to ask about in the specific systems review. Remember to then always check for red flags in the general systems review. No worries, this should make more sense to you when you go through the histories.
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 you some questions about how you are feeling and what has brought you in to see the doctor today, and then I’ll take that information, relay it to the consultant and we can go from there.
- Before I start, are you comfortable or would you likely me to get you anything? Do you mind if I take a seat?
- So, what has brought you in to see the doctor today?
(P) Presenting Complaint
- Summarise patient’s answer and ask first screening question) – Apart from this, have you noticed anything else?
- (Ask second screening question) – Ok, anything else?
- (Ask third screening question) – Before talking more about your [symptom], are there any other symptoms?
- (Last screening question) – Are you sure that there is nothing else?
- (Once we are sure there are no other questions, we can now address each symptom in turn) – Now I just want to ask some questions about the symptoms you have been feeling? Go through each symptom using OATES or SOCRATES for pain
- Abdominal pain – Ok, so you mentioned that you have experienced some tummy pain, can you tell me a little bit more?
| Site | With regards to the pain, where exactly is it? Can you point with one finger |
| Onset | When did it first begin? Did it come on slowly or quickly? Can you remember what you were doing when it first came on? Is there anything that triggered this? |
| Character | Could you describe the pain for me? |
| Raditation | Does the pain spread anywhere? |
| Associations | Are there any other symptoms which are associated with this pain? |
| Time | Is it there all the time, or does it come and go? (If fluctuates, how long does it last?) |
| Exacerbations | Is there anything which makes it better, like lying still/going to the toilet? Is there anything which makes it worse? Does it hurt when you press it? |
| Severity | If you were to rate it on a scale of 1-10, how bad is the pain? |
- Diarrhoea – Can you tell me a little bit more about this?
| Onset | When did these this start? |
| Associations | Is this associated with any other symptoms? |
| Time | How many times has this happened? How many times are you going to the toilet? |
| Exacerbations | Is there anything which makes this better/worse? |
| Specifics | Can you describe the consistency? What colour is the stool? Is there any blood? (If yes, ask follow up questions) Is there any mucus? |
(I) Ideas, Concerns, Expectations
- Ok, you have been feeling these symptoms for some time, do you have any idea of what it could be?
- Are you particularly concerned about anything?
- What were you hoping to get out of the visit today?
(S) Systems Review
- (In response to them telling you their expectation from today’s visit) Ok, in order to do that, first I would like to ask you a few more specific questions just to get a more accurate picture of why you might be experiencing these symptoms.
Specific Systems Review
- Upper GI:
Have you been feeling sick or vomited?
Do you have any problems with swallowing?
Do you feel bloated?
- Lower GI:
Diarrhoea and constipation?
Is there anything you might have eaten which caused these symptoms?
- Gynaecological:
When was your last period? Was it normal?
Is there a chance that you could be pregnant?
General Systems Review: (Ask general questions to rule out red flags):
(Fever) Have you got a fever?
(Glands) Have you got any swollen glands?
(Weight) Have you noticed any weight loss?
(Appetite) Have you noticed any changes in your appetite?
(Bowels) Have you experienced any changes in your bowel movements?
(Waterworks) Are your waterworks all fine?
(Tired) Have you been feeling more tired than usual?
(Travel) Have you travelled anywhere recently?
(Night sweats) Do you wake up in the night drenched in sweat?
(Rash) Have you got any rashes?
(If woman, and abdominal pain, enquire about pregnancy) Are you on the contraceptive pill? Is there a chance you could be pregnant?
(P) Past Medical History
- And now, about your health in general, have you ever seen your doctor about something like this before?
- Do you have any other medical conditions, such as diabetes, blood pressure or asthma?
- Have you ever had any surgeries?
- Have you ever been admitted into hospital before?
(F) Family History
- Is there any incidence of tummy problems in your family?
- Are there any other conditions which run in your family?
(D) Drug History
- Are you currently taking any prescribed medication?
- Do you take anything else, over the counter?
- Do you have any allergies?
(S) Social History
- (Work) And now, a little but more about yourself in general, do you work at the moment? What do you do?
- (Home) Do you live with any family or friends? Are you married? Do you have any children?
- (Independence) Would you say that you are fairly independent?
And now these are some questions that we ask everyone:
- Do you smoke? (Have you ever smoked? / When did you start? / How many a day?)
- Do you drink? (How much a week? And for how long?)
- Is there any recreational drug use?
Conclusion
- Ok, just to recap to make sure I haven’t missed anything (quick summary.)
- Thank you very much, I’ll relay this information to the consultant and then we can go from there. Do you have any questions?
