A 24-year-old female presents to her GP with abdominal pain. The document provides guidance on taking a thorough patient history, including asking open-ended questions about the chief complaint, conducting a review of systems, enquiring about medical/surgical history, medications, lifestyle/social factors, and family history. It emphasizes asking follow-up questions to fully characterize the patient's symptoms and assess for potential serious underlying conditions.

2. 24 year-old female presents
to GP with abdominal pain
HISTORY TAKING

3. HISTORY TAKING

4. ash Hands
ntroduce self, check patient details
ermission
xpose patient (examination only)
ight-hand side of bed (examination only)
HISTORY TAKING

5. HISTORY TAKING
OPEN QUESTIONS:
“Why have you come in today?”
“Could you tell me more about the……….?”

6. For PAIN, use a mneumonic:
ite
uality
ntensity
iming
ggrevating and relieving factors
ymptoms associated
HISTORY TAKING

7. HISTORY TAKING
SUMMARISE the
presenting complaint

8. HISTORY TAKINGHISTORY TAKING
Medical conditions
Hospitalisations
Serious illnesses / injuries
Operations

9. HISTORY TAKING
Current medications:
• Prescribed
• Over-the-counter
• Name
• Dose
• Frequency
Recreational drugs

10. HISTORY TAKING
Anyone in family had similar problem?
Any serious illnesses in the family?

11. HISTORY TAKING
• Current smoker?
• Past smoker?
• How many years?
• Cigarettes/ roll-ups / cigars?
• How many per day?
• Who lives at home – partner? Children?
• Stairs at home?
• Need help with housework, shopping, cooking?
• Do you drink alcohol?
• What? Wine? Beer?
• How much?
• Calculate units/week

12. Couple of questions for each body system e.g:
• Fits, faints, funny turns
• Headaches
• Vision problems
• Shortness of Breath (SOB)
• Cough – blood (red flag)
• Chest pain
• “Heart fluttering” (palpitations)
• Ankle swelling
• Change in bowel habits – blood (red flag)
• Nausea or vomiting
• Weight loss – red flag
• Change in waterworks
• Blood in urine
• Menstrual problems
• Joint or muscle pain
• Skin rashes
• Lumps or bumps
HISTORY TAKING

13. HISTORY TAKING

14. “Is there anything you’d like to add or
think I’ve missed?”
“Do you have any questions?”
THANK the patient!!!!!
HISTORY TAKING

15. HISTORY TAKING
ite
uality
ntensity
iming
ggrevating/relieving factors
ymptoms associated
ite
nset
haracter
adiation
ssociated symptoms
iming
xacerbating/relieving
everity

16. HISTORY TAKING
Symptoms that may indicate
serious underlying condition
Different for each body system
e.g. coughing-up blood
(haemoptysis) and lung cancer

17. HISTORY TAKING
“I’d like to ask you about ….”
• Your general health
• Your previous health
• Your background
• etc
WHY?
Patient and examiner
know you have a structure

18. HISTORY TAKING
THANK YOU