History Taking Template

Station 2: History Taking Template/Backbone

  • Name and Age
  • Take a separate history for each problem eg. chest pain, rash, fever etc.
  • Timing questions
    • Since when
    • Sudden/gradual
    • All the time/come and go
    • Getting worse?
    • Previous episodes
      • If yes, how often? When does it happen? Ever investigated before? Any treatments?
    • HPC eg. If bleeding: quantity, colour, consistency, mixed with anything, smell
    • In your history taking ensure to cover differential diagnoses eg. chest pain- ask the CVS Q, Resp Q, GI Q, MSK Q
    • PMH:
      • Admissions, operations, anything they see the GP for?
      • Ask relevant PMH eg. haematemesis ask re. previous stomach ulcers
      • When and how were relevant diagnoses made?
    • Fx:
    • Dx:
      • Medications- have they got a list with them?
      • Compliance
      • Any side effects of medications?
      • OTCs, herbal meds, meds bought from internet
      • Vaccines
      • Allergies
      • Ask about any relevant medications eg. Cough- ACEI, bleeding- NSAIDs etc.
      • Are any medications new?
      • What treatment have they had for the condition in the past?
    • Sx: take a detailed social history- work life, home life, social life
      • Occupation
      • Smoking
      • Alcohol
      • Drug abuse
      • Driving
      • Housing and who do they live with? Carers?
      • Support network
      • Travel
      • Sexual history
      • Diet
      • Pets
      • ADLs
      • Impact on life
      • Mood
    • ICE- don’t forget to address concerns!
    • Is there a scoring system relevant to the PC eg.haematemesis and Rockall score- if so make sure you have asked all the questions you need to complete the score.
    • Are there risk factors relevant to the history? Eg. MI, osteoporosis
    • Assess severity of condition eg. COPD- home nebs, NIV, ITU admissions
    • Make sure you have covered Red Flags if relevant
    • Think around the subject eg. If COPD ask about vaccinations, pulmonary rehab, mood, seen in COPD clinic?
    • Systems Review:
      • General:
        • Fatigue/malaise
        • Fever/rigors/night sweats/swollen glands
        • Weight/appetite
        • Skin rashes/bruising
        • Sleep disturbance
      • CVS
        • Chest pain
        • SOB (and on exertion)
        • Orthopnoea
        • PND
        • Palps
        • Ankle swelling
        • Syncope, presyncope
      • Resp
        • Chest pain
        • SOB
        • Wheeze
        • Cough (and sputum colour, amount, consistency, blood, smell)
        • Haemoptysis
        • Exercise tolerance
      • GI
        • Appetite/weight
        • Dysphagia
        • Nausea, vomiting, haematemesis
        • Indigestion/heartburn
        • Jaundice
        • Abdominal pain
        • Bowels: change/constipation/diarrhoea/stool/blood/mucus/flatus
        • Bloating, tenesmus, urgency
      • MSK
        • Pain/swelling/stiffness in muscles/joints/back
        • Reduced range of motion/function
        • Power
        • Difficulty with ADLS
        • Raynauds, photosensitivity rash, hair loss, ulcers, dry eyes/mouth
      • GU
        • Frequency/dysuria/nocturia/polyuria/oliguria
        • Haematuria
        • Incontinence/urgency
        • Prostatic symptoms
        • Impotence
        • Menstruation (if appropriate)
        • Vaginal/urethral discharge
      • CNS
        • Headaches
        • Fits/faints/blackouts
        • Dizziness
        • Vision- blurring/double/bits missing
        • Hearing
        • Weakness
        • Numbness/tingling
        • Loss of memory/personality change
        • Anxiety/depression
      • Endocrine
        • Menstruation
        • Hirsutism/alopecia
        • Polyuria/polydipsia
        • Amount of sweating
        • Hair
      • Skin
        • Rash
        • Itch
      • Ask the patient if they have any questions? (they will have a prompt sheet with questions to ask you!)
      • Close the consultation
        • Any further questions?
        • Summarise
        • Propose solutions to problems
        • Explain possible diagnoses, investigations and management and followup to the patient

 

Summarise to the examiner

Tell the examiner your differential diagnoses, problem list and plan

Explain what investigations you would like to do: structure this answer: bedside tests, blood tests, radiological tests, histological tests for example.

Suggest treatment options

 

Points are for:

Communication skills

Addressing concerns

Formulating a differential diagnosis

Suggesting investigations and management

Maintaining patient welfare