HISTORY TAKING

INTRODUCTION

My name is. I would like to ask you a few questions is that ok? Can you tell me
your full name and age please? And where do you live? Do you work? Are you
married?

PRESENTING COMPLAINT

Why did you come here today? How can I help you? (N.B for OSCE we are probably
going to get a patient with pain, cough or fever..so we only did these 3)

1. PAIN

S-SITE Where is the pain?

O-ONSET When did it start?

C-CHARACTER sharp/dull/stabbing/crushing/burning

R-RADIATION Did it spread anywhere else?

A-ASSOCIATED SYMPTOMS e.g nausea, dizziness, blurred vision

T-TIMING How long did it last? Does it come and go or is it continuous?

E-EXHASERBATING AND RELIEVING FACTORS

S-SEVERITY How would you grade the pain on a scale of 1-10 (10 being most
severe)

OR

O-ONSET

P-POSITION

Q-QUALITY

R-RADIATION

S-SITE.SEVERITY

T-TIMING

A-ALLEVATING FACTORS

A-AGGRAVATING FACTORS
 A-ASSOCIATED FACTORS

Depending on the location of the pain you will ask about specific associated
symptoms.

Headache: Ask about fits

Chest: Ask if the patient has shortness of breath, any sweating, nausea,
vomiting and if they feel as though their heart is racing
Belly ache: Ask about nausea, vomiting, diarrhea

2. COUGH
Ask about onset
Ask about duration
Ask about progression
Ask if they are bringing up anything when they cough..If yes ask : how
much?color?Does it have a smell?Any blood?..If there is blood ask if it is
bright red or if there are streaks of blood (N.B bright red blood indicates
severe pathology; may indicate pulmonary embolismStreaks of blood
may indicate airway irritation.)
Ask about any associated symptoms such as shortness of breath, chest
pain or wheezing

3. FEVER
Ask about onset..How long now do you have this fever?
How do you know it is a fever?Did you measure your temperature using a
thermometer? If yesWhen?What was the reading?What part of your body
did you measure the temperature?
Ask about alleviating factors
Ask about interventions..What did you do? Did you take any medication?
Tepid sponging?Fan therapy?
Ask about associated symptoms such as thrills, rigors and excessive sweating

REVIEW OF SYSTEMS

Im going to ask you a few questions. (yes or no)

CNS:

Any headaches? Dizziness? Blurry vision? Ringing in ears? Fainting? Loss of

consciousness? Any weakness?

CVS

Any chest pain? Any shortness of breath? Do you wake up during the night with
SOB? How many pillows do you sleep on? Any palpitations? Any cyanosis? Any
nausea?
RESP

Any shortness of breath? Any coughing? Any chest pain? Any wheezing? Any
rhinorrhea? Any sputum? Any haemoptysis?

GIT

Any abdominal pain? Any nausea? Any vomiting? Any diarrhea? Any constipation?
Any blood in the stool? Do you have an increased or decreased appetite? Have you
lost or gained any weight? Do you have normal bowel movements? Look for
yellowing of the eyes (jaundice)

URINARY

Do you have any problems passing urine? Does it have a normal flow? A normal
frequency? Do you have any pain when passing urine?(dysuria) Does it have a
strange smell? Is there any blood in the urine?(hematuria) Do you wake up at night
to pass urine?(nocturia)

MBJ

Do you have any muscle pain? Any joint pain? Any rashes? Any swelling?

PAST MEDICAL HISTORY

H-high blood pressure

I-ischemic heart disease

D-diabetes

E-epilepsy..but dont ask about epilepsy..ask about fits

A-asthma

B-blood disorderse.g sickle cell or thalassaemia

C-cancer

PAST HOSPITALIZATION

Have you ever been hospitalized before? When? Why? How long did you stay? What
was the outcome? What treatment did you receive? Did you recover?
PAST SURGICAL HISTORY

Did you ever have any surgery done? When? For what? Any complications?

DRUG HISTORY

Are you taking any medication? Do you know the name? And the dosage? Are you
taking your medication? How often?

ALLERGIES

Do you have any allergies that you are aware of? To what? What happens when you
eat.?

FAMILY HISTORY

Ask about any family history of HIDEABC (refer to past medical history)parents,
brothers, sisters and grandparents

SOCIAL HISTORY

Do you smoke? If no..have you ever smoked?...If yes..do you smoke

cigarette?marijuana? How often?

Calculate no. of pack years

No of pack years = No. of packs per day * No. of years

e.g 2 packs per day for 5 years = 10 pack years

Do you consume alcohol? How often? What do you drink?

Inquire about living conditions. Who do you live with? How many bedrooms?
Do you have running water? And electricity? Is your washroom inside or
outside? How often do you take out the garbage?

THANK THE PATIENT AND SUMMARIZE

Summary :

Example
This is.who presented with chest pain for 2 days. It was of sudden onset graded 8
and radiated to the left arm. Other symptoms included shortness of breath, nausea,
palpitations and diaphoresis. He/she had a positive family history of heart disease.
There were no significant medical conditions and no past surgical history. Mr/Mrs.. is
not currently on any medication and there are no known allergies.