Introduction
- Wash hands (and don PPE if needed)
- Introduce yourself (name and role)
- Confirm patient’s name and DOB
- Explain what history you’d like to take
- Gain consent to continue
Presenting complaint
- Start with open questions: “How can I help today?”
- Allow patient to talk and ask 1/2 more follow up open questions
History of complaint
Gather further details about the issue using SOCRATES
Site
Onset
Character
Radiation
Associated symptoms
Timeframe
Exacerbating factors
Severity
Ideas concerns and expectations
You often get a mark in OSCE just for this. Useful insight into the patients mind and allow them to say anything that’s bothering them
- Ideas - “Do you have any thoughts about what the problem is?”
- Concerns - “Is there anything that’s worrying you?”
- Expectations - “Is there anything that you were hoping I could do for you today?”
Systemic enquiry
Top to toe screen of other body systems that may or may not be related. Might also gain more useful information0
- Systemic - weight loss, fever
- Neurological - headache, sensory disturbance
- Respiratory - Sore throat, cough, SOB
- Cardiovascular - chest pain, palpitations
- Musculoskeletal - trauma, limb weakness, joint pain
- Gastrointestinal - eating and drinking, vomiting or diarrhoea, bloating
- Genitourinary - passing urine and stool, and pain or discomfort
- Dermatology - Rashes, itching
Past medical history
Anything that might be relevant to the presenting complaint
- Conditions
- Surgeries
- Hospital admissions
- Repeat episodes
- New symptoms to old diseases
Drug history
- Allergies - ask if the patient has any allergies
- Prescriptions - name, dose, frequency, form, route
- Over the counter medication
- Alternative therapies that might interact
Family history
If relevant to the disease - for something like a Sore throat this won’t be necessary
- Any history of disease in siblings/parents/grandparents
- Suspicious deaths/deaths at a young age
Social history
- Occuptation
- Smoking - number, recency, duration
- Alcohol - frequency, type, volume
- Possibly recreational drug use
- Diet if relevant
- Sexual history if appropriate
Closing the consultation
- Summarize the key points back to the patient
- Ask if they have any questions or concerns
- Thank the patient for their time.
- Dispose of PPE appropriately and wash your hands.