Wish Ko Lang September 03, 2022

Taking a records from a affected person is a talent integral for examinations and afterwards as a practising doctor, no remember which place you specialise in. It exams each your verbal exchange competencies as properly as your understanding about what to ask. Specific questions fluctuate relying on what kind of records you are taking however if you observe the normal framework under you have to acquire accurate marks in these stations. This is additionally a proper way to existing your history.

In exercise you may additionally now and again want to acquire a collateral records from a relative, pal or carer. This might also be with a toddler or an grownup with impaired intellectual state.

Procedure Steps

Step 01

Introduce yourself, identify your patient and gain consent to speak with them. Should you wish to take notes as you proceed, ask the patients permission to do so.

Step 02 – Presenting Complaint (PC)

This is what the patient tells you is wrong, for example: chest pain.

Step 03 – History of Presenting Complaint (HPC)

Gain as much information you can about the specific complaint.

Sticking with chest pain as an example you should ask:

• Site: Where exactly is the pain?
• Onset: When did it start, was it constant/intermittent, gradual/ sudden?
• Character: What is the pain like e.g. sharp, burning, tight?
• Radiation: Does it radiate/move anywhere?
• Associations: Is there anything else associated with the pain, e.g. sweating, vomiting.
• Time course: Does it follow any time pattern, how long did it last?
• Exacerbating / relieving factors: Does anything make it better or worse?
• Severity: How severe is the pain, consider using the 1-10 scale?

The SOCRATES acronym can be used for any type of pain history.

Step 04 – Past Medical History (PMH)

Gather information about a patients other medical problems (if any).

Step 05 – Drug History (DH)

Find out what medications the patient is taking, including dosage and how often they are taking them, for example: once-a-day, twice-a-day, etc.

At this point it is a good idea to find out if the patient has any allergies.

Step 06 – Family History (FH)

Gather some information about the patients family history, e.g diabetes or cardiac history. Find out if there are any genetic conditions within the family, for example: polycystic kidney disease.

Step 07 – Social History (SH)

This is the chance to locate out a bit extra about the patient’s background. Remember to ask about smoking and alcohol. Depending on the PC it may additionally additionally be pertinent to discover out whether or not the affected person drives, e.g. following an MI affected person can’t force for one month. You must additionally ask the affected person if they use any unlawful substances, for example: cannabis, cocaine, etc.

Also discover out who lives with the patient. You may also discover that they are the carer for an aged father or mother or a baby and your obligation would be to make sure that they are now not left out ought to your affected person be admitted/remain in hospital.

Step 08 – Review of Systems (ROS)

Gather a short amount of information regarding the other systems in the body that are not covered in your HPC.

The above example involves the CVS so you would focus on the others.

These are the main systems you should cover:

• CVS
• Respiratory
• GI
• Neurology
• Genitourinary/renal
• Musculoskeletal
• Psychiatry

Please note these are the main areas, however some courses will also teach the addition of other systems such as ENT/ophthalmology.

Step 09 – Summary of History

Complete your records through reviewing what the affected person has instructed you. Repeat returned the vital factors so that the affected person can right you if there are any misunderstandings or errors.

You have to additionally tackle what the affected person thinks is incorrect with them and what they are expecting/hoping for from the consultation. A beneficial acronym for this is ICE [I]deas, [C]oncerns and [E]xpectations.

Step 10 – Patient Questions / Feedback

During or after taking their history, the affected person may additionally have questions that they prefer to ask you. It is very essential that you don’t provide them any false information. As such, except you are without a doubt positive of the reply it is first-rate to say that you will ask your seniors about this or that you will go away and get them greater records (e.g. leaflets) about what they are asking. These questions aren’t always there to check your knowledge, simply that you won’t strive and ‘blag it’.

Step 11

When you are blissful that you have all of the statistics you require, and the affected person has requested any questions that they may also have, you should thank them for their time and say that one of the medical doctors searching after them will be coming to see them soon.

This information is designed for college students and doctors. If you are making use of for scientific faculty and would like extra data on the UCAT please take a look at out our whole information and our information on how to exercise for your exam. We’ve additionally organized a UCAT Practice Test to assist you put together for the exam.