History Taking

It all begins with taking a good history.

Step 1: GET CONSENT

Step 2: WASH YOUR HANDS

We always follow the following coat-hanger to assess the presenting complaint:

What
Where
When
Quality (get the patient to rank it on a scale of 0-10)
Quantity
Alleviating/ Aggravating factors
Associated Symptoms
Beliefs:
Ideas (what they might think caused this)
Concerns (what they are concerned about)
Emotions
Effect on life
Expectations (what they expect out of this consultation)

WWWQQAABICEEE for short. This works on the basis of if the patient is experiencing pain.

With any thorough history taking, there’s always the social issues to take into account. This can be summarized into a very unhelpful acronym of FPMADS.

Family history
Past medical history
Medications (including over the counter and supplements)
Alcohol and Allergies
Drugs (prescription and illicit)
Smoking

For adolescents, we have the HEADS:

Home
Education/ Employment
Activities/ Alcohol
Drugs
Smoking/ Suicide/ Sex

Makes kids seem all too rowdy for their own good. Remember to ask the patient about his family/ living situation, what work he does, if he has any support networks, etc etc. We must understand that there are many factors that contribute to health, not just pathology.

The current standard for acceptable number of drinks is 1-2 standard drinks with drink-free days in between. (let me check on this) If you have a patient who drinks more than the recommended amount, we go into the CAGE questions.

Have you ever felt you ought to Cut down on your drinking?
Have people Annoyed you by criticizing your drinking?
Have you ever felt Guilty about your drinking?
Do you need an Eye-opener in the morning to get going? (drink first thing in the morning)

Answering yes to these questions would clue you into what may be a drinking problem.

With regards to smoking, regardless of how much and how often they smoke (and what they smoke), remember to ask the golden question:

Have you thought about quitting?

Then we go into Systems Reviews. These are specific questions which are targeted at the different systems of the body. Memorizing these would do you wonders.

Musculoskeletal:

Painful/stiff joints
Morning stiffness
Red/Swollen joints
Dry/ red eyes
Skin rash
Back and neck pain
Dry mouth/ ulcers
History of rheumatoid arthritis or gout

Neurological:

Headaches (are they sudden /severe?)
Fits, faints, blackouts
Memory problems
Problems concentrating
Changes in hearing/ vision
Difficulty sleeping
Weakness or numbness in limbs
Dizziness

Cardiovascular:

Chest pains
Shortness of breath
Cough
Number of pillows used to sleep
Palpitations
Blackouts
Dizziness
Ankle swelling
Pain in legs
Cold hands and feet

Respiratory:

Shortness of breath
Cough (do you cough up anything? Please describe)
Coughing up blood
Wheezing
What is your work
Snoring
Easily falling asleep during the day
Night sweats
Shivers and shakes
Recent CXR
History of pneumonia or TB

Gastrointestinal:

Fever
Night sweats
Jaundice (ask the patient if their family has noticed them looking a bit “yellow”)
Vomiting
Change in appetite/ diet/ weight
Heart burn
Dysphagia (difficulty swallowing)
Abdominal pain
Bloating
Bowel movements (what is normal and how is this different)
Stool (frequency, consistency, color, smell, etc)
Recent overseas travel