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Format For History Taking

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108 views4 pages

Format For History Taking

Uploaded by

philiplabuda65
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© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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History taking:

P2MAFTOsA, DESA, psychosocial history

You will talk to the patient and ask questions in this order:
1. Explore presenting complaints
2. If pain we do SOCRATES; T for timing (is there a specific time you have it, does it come
and go, or is it always there); and ODIPARA for cough, SOB, etc
3. Anything else (ask this question: besides this XXXXXXX you are experiencing, do you have
any other symptoms)
4. Do a review of systems or ask specific questions about your working diagnosis (for ex: if
patient has chest pain, ask about cough, SOB, fever, etc; if patient has chest pain that
radiates to the jaw or left arm, you’re obviously thinking of myocardial infarction, the
RoS questions you should ask is to ask about palpitations, sweating, leg swelling/edema)
5. FLAWS (fever, lumps and bumps, tiredness/anemia, heart racing, loss of appetite, weight
loss, and sweating); this is typical for cancer patients but can apply to other cases, simply
ask about FLAWS in every case scenario
6. Try to rule out other life-threatening or similar conditions (emergency conditions) like MI
or PE (pulmonary embolism)
7. P2, previous episode of the presenting complaint, and past medical or surgical history so
have you been managed for any medical conditions
8. P2MAFTOSA, M for medications, A for allergies, F for family history, T for travel history, O
for occupation, S for social history like living status, A for anything else
9. DESA
10. Psychosocial history (eg, menstrual history and sexual history)
11. ICE the patient, you always ICE for everything

For travel history, you can ask about blood clots, since blood clots occur when sitting for
prolonged periods of time kind of like on long flights
For occupation, you can ask “what do you do for a living?”, and also “how has this pain affected
your work?”
For social history, you can ask “who do you live with?” And “how are things at home?”, “do you
get support from your family members?”

Btw, ODIPARA for cough, SOB, etc

DESA: diet, exercise, smoking, alcohol and recreational drugs

When patient is drinking alcohol, you want to do CAGE, C for cut down, A for angry, G for guilt,
and E for eye opener (do you need a drink first thing in the morning to stay alert?)
ODIPARA
Onset: when did this cough start?
Duration: how long have you had it for?
Intensity: has it been getting worse?
Progression: what caused it to get worse?
Aggravating factors
Relieving factors
Anything else or associated symptoms or any other symptoms

ODIPARA

Onset: when did this cough start?


Duration: how long have you had it for?
Progression: since you’ve had it, did you noticed if it’s getting worse?
Intensity: how much worse has it gotten?
Aggravating
Relieving
Anything else
For other questions, is it a dry cough or productive cough (as in wet cough, coughing up phlegm,
dry cough there’s nothing, it sounds dry)

For cough, vomiting and diarrhea, you can ask about the amount of phlegm or vomit produced,
you can ask about color of the phlegm or vomit, if it’s yellow or greenish, it’s infection, if it’s
bloody, well it’s blood, you can ask about odor, and whether there’s blood inside

For tiredness,
Questions for tiredness
When did you notice the tiredness?
Does the tiredness get better with activity?
Do you feel better when you rest?
Is there any time of the day you get tired?
Do you feel rested?

Signposting:
Let me ask you some questions about …
It could be about their family so family history, etc
It could be about their sexual history or past medical history, etc
If you just jump from question to question without signposting, the patient will think wtf is
wrong with this doctor

Screen the symptom


Given the pain you have at the moment, are you able to continue this discussion?

When you move onto anything else, you shouldn’t say “anything else”, instead ask “is there any
other symptoms you are experiencing that you would like me to know?”

ICE the patient

This is the order which you’ll be asking the questions:


Elaborate presenting compliant
SOCRATES/ODIPARA
RED FLAGS
Review of Systems questions (associated questions, like asking for sweating and fever if you
suspect MI or asking about history of blood clots if it’s pulmonary embolism)
P2MAFTOSA
DESA
Psychosocial history
FLAWS
ICE

Examination (chest exam, knee exam, etc, whatever it may be)


(Is it alright if I examine you?, I ensure a chaperone is present to ensure your privacy)
I would like to look, feel, tap and listen (inspection, palpation, percussion, and auscultation)

Management
If discuss with examiner, discuss with examiner, if discuss with patient, discuss with patient
If the case is an emergency and you feel like you need to admit, then admit the patient
If patient has MI, you admit the patient, and you do investigation which is 1) bedside: ECG, urine
dipstick; 2) bloods: cardiac markers, troponin, FBC; 3) imaging: CXR, CT scan
Symptomatic treatment: UTI: antibiotics for infection and paracetamol (antipyretics) for the
fever, or PPI for GERD, or painkillers (paracetamol) for pain, antiemetics for nausea

Ensure you carry the patient along a lot


I know this is difficult for you, I can see this is quite challenging for you, I can see you are in
quite a bit of pain this time, I’m sorry to hear about your pain, I’m sorry you’re experiencing this

Ensure chunk and check


Are you following me? Is it alright?

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