History taking

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History taking

  • Presenting complaint - "Tell me about why you've come in today?"
  • History of presenting complaint - exploring more about the condition. "When did it start?", "What were you doing when it started/happened?", "How long did it last for?", "Have you ever experienced that before?"
  • Past medical history - "Have you got any other ___ (e.g. cardiovascular) related conditions?" 
  • Family history - "Are there any conditions that run in your family?"
  • Drug history - "Are you on any medications?", "Any over the counter medications?", "Any allergies?"
  • Social history - "Do you/Have you ever smoked?", "Do you drink?", "Who do you live with?", "What's your occupation?", "How has your condition impacted your life?"

End with "Is there anything that you're particularly concerned about?"

Thank the patient for their time

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Cardiovascular history taking

  • PC - "Can you tell me about why you've come in today?"
  • HPC - use SOCRATES for chest pain (Site, onset, character, radiation, associated symptoms, time/duration, exacerbating/relieving symptoms, severity). 
  • Ask about: Dysnoea, Orthonea, Paraxysmal nocturnal dysnoea
  • Family history - cardiovascular related conditions?
  • Drug history
  • Social history 
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