Scenario worksheet

History taking scenario

The patient is 14 years old and is attending today with abdominal pain. The mother calls the GP surgery, concerned re pain.

Let’s take a history:

PC- abdominal pain

HXPC- – lasting 24 hours- hasn’t passed stools. She has been vomiting 4+ times and cannot keep down food. Feels hot.

SOCRATES U

Lower right-hand side of the abdomen- right iliac fossa

24 hours ago

No radiation

No alleviating factors

Constant pain

It makes it worse to lay flat- has to stay in the foetal position

Severity 8/10

She thinks she’s dying

PMH- nil

Surgical history- nil

Medications- nil

Allergies- nil

Family History- father has type two diabetes, the mother has hypertension

Social history- lives at home with mother, father and 3 siblings, attend school, no recent travel, up to date with imms. Lives in a house with no carers.

Would we want to ask about sexual history?

LMP- 2 weeks ago

No UPSI

What is our differential diagnosis?

What else might we want to know?

Question worksheet

Q1. Why is history taking important?

Ans: Medical history is important because when GPs have more information about a patient’s medical history, health care professionals can deliver the most appropriate and effective treatment or support for their concerns. Genetic makeups, environments and lifestyle factors shared by family provide better insight into a medical condition the family may encounter. With the information collected, GPs can also understand patterns of the cause of the diseases or disorders and make a medical diagnosis more likely, which is particularly important in catching something harmful early.

Q2. Do you use any acronyms for history taking?

Ans: SOCRATES

Site (e.g., where, location, area, internal, external, etc.)
Onset (e.g., time of onset. sudden/gradual, etc.)
Character of pain (e.g., dull, sharp, crush, etc.)
Radiation of the pain (e.g., did the pain spread, at particularly sport, etc.)
Associations (e.g., symptoms associated with the pain, vomit, nausea, etc.)
Time course (e.g., any time pattern (morning/evening), duration, etc.)
Exacerbating/Relieving factors (e.g., what makes it worst / what makes it more comfortable.)
Severity (e.g., rate pain score 0 to 10, “zero” no pain, “10” severe pain.)

Top tip- 70% of the time, you will make a diagnosis based on the history taken alone.

Q3. How do you open a consultation?

Introduce myself, show empathy and confirm patient identity (e.g., DOF, Address, NHS no.). Observe any abnormalities (e.g., physical – severe external bleeding, disabilities, etc. Psychological and emotional distress, etc.)

Q4. A patient profile- What do you want to know that’s non-medical?

Ans: Any lifestyle change, allergy, disabilities, family medical history, and any family members who had presented similar symptoms. Any use of substances (e.g., alcohol, drugs).

Q5. How would you ask the patient for the chief complaint?

Ans: Ask an open question (e.g., what can I do for you? / What brings you here, how may I help you.) and allow the patient to express their concerns and needs. Active listening and with an open posture, acknowledge and ask for clarification if needed.

Q6. Do you want to ask open-ended, closed, or leading questions? Are these appropriate?

Ans: Most of the time, ask open-ended questions as medical diagnoses need to be evidence-based, collection of information and diagnosed with critical thinking skills. A closed question limits the information collected from the patient. However, it may be used sometimes, e.g., asking for any SOB – shortness of breath, cough, etc. Try to avoid the leading question, as they may mislead the patient and cause misdiagnoses.

Q7. What does SOCRATES stand for?

Ans: Site, Onset, Character of pain, Radiation of the pain, Associations, Time, Exacerbating/Relieving factors, Severity

Q8a. How would you determine the severity of the pain?

Ans: Plain scale “zero” to “10”. “Zero”, no pain and “10” sever pain.

Q8b. What about with a child?

Ans: Pain scales, behavioural (how the child behaves), physiological (how the child’s body responds) indicators assessment tools and the child’s pain history. Some tools are listed below:

• Visual analogue scales (Marked, indicate pain intensity by children)
• Numerical analogue scales (Marked, indicate pain intensity by children)
• Face Pain Scale (Visual)
• Drawings
• Faces, Legs, Activity, Cry, Consolability (FLACC) (behavioural indicators to assess pain
• Premature Infant Pain Profile (PIPP) Stevens B, Johnston C, Petryshen P, Taddio A. The premature infant pain profile: Development and initial validation. The Clinical Journal of Pain.1996;12(1):13-22.
• Non-Communicating Children’s Pain Checklist
• Obtain pain history from parents

Reference available at: https://www.mygp.com/why-is-medical-history-important/

Q9. Map out your history-taking process…

1. Chief complaints / Presenting complaint (PC)
2. SOCRATES
3. History of presenting complaints (HxPC)
4. Past Medical History
5. Personal / Social History (e.g., sexual orientation, occupation, etc.)
6. Family History
7. Drug / Treatment History

Q10. Make a list of each system- what would you assess?

For example- Respiratory- SOB, Cough, Sputum production, Chest pain, Haemoptysis, Wheeze, sputum colour, and thickness time of when sputum is produced.

Ans:

• Integumentary System
  • Condition of the skin (dry, wet, warm, cold)
  • Temperature (Hypothermia/Hyperthermia)
  • Speech (fluency, incomplete, confuse)
• Skeletal System
  • Fracture (Open/close), posture abnormalities
• Muscular System
  • Contract/extend difficulties
• Nervous System
  • Voluntary/involuntary reflexes
• Endocrine System
  • Sputum production (thickness, colour), any indication of infection
• Cardiovascular System
  • Pulse Rate (Rapid, strong, weak, regular or irregular)
  • Blood pressure (Hypotension/Hypertension)
  • Circulation (capillary refill)
  • Chest pain (crush, frequency, intensity, radiation), any indication of MI/cardio disease
• Lymphatic System
  • Submandibular Nodes (any enlargement, infection indicator)
• Respiratory System
  • Respiration Rate (SOB/hyperventilation)
  • Airway (wheeze), any indication of bronchoconstriction, asthma
  • Cough (Haemoptysis) indication of problems related to respiratory organs/tissues
• Digestive System
  • Vomit or diarrhoea (GI tract infection)
• Urinary System
  • Bowl/urinary retention
• Reproductive System
  • Difficulty/Disability