History taking in ELM

This will have symptoms and such

This is built from initiating the session and gathering information parts of the CCG

General history taking

Generic structure

1. Introduction
   1. my name is … i am an elm student.
   2. are you (patient name), how would you prefer to be addressed?
   3. may i have your permission to proceed
2. Reasons for consultation
   1. Identify presenting complaint (Tell me whats going on)
   2. Confirm list and screen for further problems (Is there anything else)
   3. Negotiate agenda (lets start with X and cover y later)
3. dive into specific complaint (recursive)
   1. Biomedical history (doctors agenda) (make sure you are asking about and analysing relevant associated symptom and asking about and exploring relevant features of the presentation)
      1. sequence of events (while obtaining specific info if needed)
         1. onset
            1. When did everything start
            2. When were you last completely well
            3. Mode of onset, sudden, rapid, or gradual (how quickly did the symptoms come on)
         2. precipitants
            1. What occurred before the symptoms (could be a big fall or even drinking a coffee)
         3. What has happened since symptoms first started until now
         4. patterns
            1. Frequency (How often?)
            2. Duration of symptoms (how long when they do start?)
            3. time pattern (is there a pattern oin time that the symptoms follow?) worse in the morning for example
      2. Symptom analysis (do this for each symptom)
         1. Site
         2. Onset
         3. Character
         4. Radiation
         5. Associated symptoms but dont do this now
         6. Timing
         7. exacerbating and relieving
         8. Severity
      3. Associated symptoms
         1. This will depend on the type of complaint recieved, eg MSK or Respiratory
      4. general symptoms (SWEAT-M)
   2. Patient feelings and perspectives (patients agenda)
      1. ideas
      2. concerns
      3. expectations
      4. effects
      5. feelings
4. Background info
   1. Medical history
      1. What is your health usually like
      2. has this happened before?
      3. do you have any long term health problems?
      4. have you ever been to a hospital before?
      5. How is your general mental state?
   2. Medications
      1. Are you on any medications?
   3. Allergies and ADRs
      1. Do you have any allergies or had any reactions to medications?
   4. Family history
      1. Is there any illness in the family?
      2. Has anyone in your family had something like this before?
   5. Personal and Social history
      1. Physical Living situation
      2. Physical activity
      3. Diet
      4. Domestic (Spouse or kids)
      5. Employment
      6. Pets
      7. Support systems
      8. Hobbies
   6. Substance screening
      1. vaping
      2. smoking
      3. Alcohol
      4. Recreational drugs

MSK History

Associated symptoms

• pain
• weakness
• locking
• deformation
• heat
• creptius
• stiffness
• joint swelling
• instability
• altered functional capacity (catch all)
• extra articular symptoms
  • skin rash, discolouration redness, dry mouth, dry eyes mouth ulcers, skin rashed

CV History

Important aspects to be aware of

Pattern of joint involvement

the number of joints affected is important, as well as if the afflixion is symmetrical or not.

Acute or chronic

if less than 6 week duration the illness is acute

Trauma

is there a history of trauma

Surgery

has there been any orthopaedic surgery

Associated symptoms

• Pain
• Palpitations
• dyspnoea
  • orthopnoea
  • Paroxysmal Nocturanal dyspnoea
• oedema
• claudication
• Syncope and presyncope

Very relevant general symptoms

• Fatigue
• Sleep disturbance
• Weight change

Respiratory history

Associated symptoms

• Chest pain

• Dyspnoea (breathlessness) • Wheeze • Hoarseness

• Cough productive? • Sputum (how much what colour) • Haemoptysis (coughing up blood)