Clinical history taking with patient example

hello my name is Gemma Hurley I'm a senior lecturer at Kingston University George's University of London I'm also a nurse practitioner where health history forms a key part of my Rome history taking forms have set the cornerstone of patient health assessments and so I would like to take you through the core principles of history taking to do that I'm going to bring in a patient and demonstrate the key steps involved in history taking you come on in and have a seat thank you okay hi my name is Gemma Hurley I'm a nurse practitioner and you are Paul Collins okay mr. Collins how would you like to meet accordion son okay all right and well for me to be able to help you today I need to take a history which will involve me asking you questions about your health and also put your social circumstances is that okay with you okay before we start I just wanted to confirm your details so it's Paul Collins and you're 46 years old and is this your address that's right perfect great okay excellent so how can I help you today well I've had a call for a few days just driving me nuts really ride how long has the cough been there for I suppose about three or four days now has it and have you got any other symptoms with that cough I've got cost sore throat that's that's quite bad as well right and a sore throat has it been there the same amount of time yes both long time gosh okay and the cough and sore throat is it worse any particular time for the day or night well cops probably worse first thing in the morning I noticed it killing when I get up sore throats there all the time really I said are you able to swallow with that sore throat yes you can you can drink okay and the cough can you describe it for me it's just a sort of fairly me tea coffee down cocking up all sorts amok really right okay and what color is the muck that you're coughing up green is it is it large amounts or feral is that is there any bird in it no I'm seeing you glad okay and how bad on a scale of not 210 is that coffee you tending to worth possible I suppose it's about six or seven really right and is there any area in your throat or anywhere in your chest that's painful well mom in my throat and Nick I saw when I call right after them that no they're just it's just the sore throat okay does it travel anywhere else the sore throat Eddie sort of radiation of pain no okay okay and has any other person's been affected by just have they been sort of coughing around you've been in contact with anyone well my girlfriend she said she had a cough last week I she okay and has she been well in the south oh she's out she was over for a few days okay okay okay what makes a cough and sore throat better for you is there any relieving factors well a cough nothing really you know I've tried over the counters of stuff on the chemist and that didn't work it didn't tear the throat war drink that helps okay okay anything make it worse at orders cough no not really nothing at all okay what do you think it is I don't know I need some antibiotics right okay okay I just want to ask you more specific questions now you said there's no blood in the phlegm and but is there any fever and you feeling sugary ah first day I was little I was a bit bit bit shaking like that now not okay and what about breathlessness so you've got any breathing problem or chest tightness nothing at all okay and when you go to bed at night be able to lie on your same amount of pillows yes you are okay and what about are you feeling because are you coughing up lots of greens them is any dripping at the back of your throat at all no nothing like that okay and have you had any unexplained weight loss at all no not at all okay any recent travel abroad months okay okay I just want to go through some of your key sort of body systems Paul just define about your overall health and can you tell me about you have you do suffer with headaches at all sometimes I get headaches do you okay how often do you get headaches once the B month something like that is it and have you seen your doctor for that no I just just take some painkillers and they go away they go away okay have you ever had any head injuries no okay good okay and what about your vision do wear glasses no okay visions good yeah okay do you ever suffer with nasal congestion or sinus problems the only time I do is with cats really and they set you off right are you allergic to cat I think I must be Oh shame okay and what about your aunt tastes any change and tastes okay do you get mouth ulcers at all sometimes I do do you okay busy at work or something right okay and you have a sore throat now but you that recurrent sore throat so we don't use okay good and any sort of problems with your chest in terms of heart problems breathing problems no okay okay and your bowels working alright fine good water works okay excellent I don't I hope you don't mind but could I just ask a little bit about your sexual history are you in a relationship okay are you a heterosexual oh yes okay and contraception to use barrier methods on the pill okay and it's a long-term relationship is it okay okay and what about your bones any joint problems well your breaks and pains is your work okay good okay and how's your mood how do you feel in yourself fed up at the moment no I did but I just will get rid of course okay but no sleeping problems and feeling low moods intense good excellent a little bit about your surgical in the past have you ever had any operations I had an operation there must be 20 years ago some school operation on my back all right would you remember recall a PI something higher than pilonidal sinus okay okay and has it been all right since then okay and no other operations okay I'm just going to list off just to probe your mind a bit in terms of medical history have you or any of your first-degree relatives of mom dad siblings ever suffered with any jaundice where you seen yourself go yellow oh okay any anemia at all I am officially good okay have you ever had a heart heart attack or any member of your family not okay and what about TB anybody would TB or you've been hunting Rossano could any thyroid problems okay any through matic fever or rheumatoid arthritis good okay any heart problems any high blood pressure high blood pressure oh you have okay and when was that diagnosed diagnosed what two years ago now was it and is it well controlled well I'll go yeah think so the dots regulate blood pressure checked so she's okay perfect when was it last checked it was last checked about two weeks ago and everything was great yeah I think so perfect was okay okay and what about diabetes do you have any diabetes yes yes are you doing your some diabetic right and do you know what type that's one of the tablets okay so you take tablets okay and when were you diagnosed with type diabetes that was about three years ago okay and when was your last checkup for your diabetes so I had that the same times I my blood pressure drugs she knows perfect and they were happy okay okay perfect any asthma at all no okay any strokes you had any many sort of numbness or family members all right too easy else right okay how old is he I'm 72 72 okay and any cancers in the family or you've been take it okay brilliant I just want to move what move you along a bit further and do you take any prescribed medicines I know you've got diabetes and high blood pressure I do I take I take a bleep rule okay and I take metformin and there's another one begins with G for the diabetes so good clickers or clickers are excellent okay and you're not a dosage of the ramipril I think it's five milligrams five milligrams and you take it regularly oh yeah good every and no side effects with it I do have an awful cough to start with but that's that stop it settled please okay and you know and the metformin do you take it did in a dosage and how often I take it three times a day but I don't know what those days okay we can check that out we can follow that up okay and what about allergies are you allergic to anything it will the only thing I think cover their tattoos cats with no one's have told me that okay so that's the environment do you know if you've got any drug allergies and any foods like not allergy or anything like that no okay perfect good okay I need to ask you this do you take any recreational drugs at all many things do them excellent good any over-the-counter you said you've been too well at some had some cough medicine okay Benny I think it was right help like many types of paracetamol occasionally but not and have you had paracetamol recently I had a few days ago for the sore throat which he helps bit it helped a little bit okay and you do any herbal remedies at all nothing at all excellent that's brilliant okay and well a little bit about your social background if you don't mind me asking what's your occupation our builder right okay and what was have you been lately exposed to dust or any sort of new substances no no sounds very standard you build at the moment okay and you're happy with work yeah plenty work at the moment that's good great excellent and what about it you said you've got a girlfriend you live with her Auggie right okay and you're happy everything's good at home no stresses no excellent okay and you live in a house or a flat oh that's too big house it's a two-bedroom house and are you house oh no are you oh yes you own your house excellent kid can I ask you do you smoke at all do you okay and can I ask what your smoke just smoke cigarettes no tar cigarettes no tar and how many cigarettes do you go through in a day what about three packs though about two packs every three days is that okay and what at what age did you start smoking uh it was about thirty age thirty okay have you thought about giving up well it's not really all about you don't want to consider that at the moment okay well when you do and we're here any time we've got lots of support strategies in place so whenever you feel you would like to talk about stopping smoking we're here just to let you know okay I just not ask you what your alcohol intake do you drink I do drink okay what do you normally drink wine okay and how much wine do you drink not a lot really cut it last a week anyway lots of it take it and you're dieting eat well ya know eat really well my girlfriend's really into healthy eating so we grow our own vegetables at home one excellent great and you exercise not really because I'm just on site so much busy all day I was very active during the day I don't exercise alright suppose if we could find that time it will be relaxing I supposed to help you know good for your diabetes as well that if we could I just want to sum up Paul if you don't mind and please correct me if I've got any of it wrong you've had this coughing sore throat for the last three days it's sort of nothing makes it really better or do you have taken do a paracetamol that's helped a little bit you've not had any blood in that phlegm no fever no unexplained weight loss breathing's okay as well you've got type 2 diabetes you take tablets for that and it's well controlled and so is your blood pressure your dad died said live a stroke and you live with your girlfriend and you're quite happy work is good and you just really want us to sort out your sore throat and cough yes okay okay is there anything else you want to add to that before we move on all right okay well what we need to do now is to check some vital signs and I need to examine you before we could decide you know what's going on with your sore throat and cough and take it from there is that okay with you good thank you well that concludes our demonstration of the history taken process Paul is a senior lecturer at the University and has kindly offered to give feedback from a patient perspective the key principles used in the history taking process was first and foremost me as a practitioner ensuring that the environment was safe and accessible for the patient I was also mindful to avoid interruptions does maintaining the patient's privacy and confidentiality as I called a patient in I was mindful not to use the patient's first name but to seek permission so how did you feel about that poor I thought that was quite appropriate and I felt that you respected my right to be called mr. Collins or Paul accordingly and I was happy to be Paul called Paul great I also felt it was imperative that I gained informed consent and so I told a patient at the outset what was to be expected and seeked content from him I also thought that it was important that I use an open-ended question at the outset so that the patient could tell his story in his own words how did you find that I thought that was good and I certainly had the opportunity to talk about what was concerning me which was obviously a cough so yeah I got that way quite quickly I think great or good the other thing is although unloading the patient to tell their own story I also am mindful of the red flags thus ruling out life-threatening causes I tried to be systematic but I also wanted to respond to the patient keys as well and so whenever the patient gave a leading answer I would allow him the scope to explore that further I then went through the key processes of history taking and then allowed at the very end to sum up thus allowing the patient to clarified from their perspective I was mindful as well not to use jargons but how did you feel to up because sometimes we get lost as practitioners and we see medical jargon as normal terminology I think on the whole that was very good and for the most part it was fairly free of medical jargon although no one point you did ask about social history without which I think we had potential to confuse somebody of course I didn't think of it that that but that's so right absolutely well I mean the questions once you want you take you're going to ask about social history I think the questions were absolutely fine closed is that just that headlining really about particular areas for joking about that and that's important for me to note as the practitioner well that concludes the key steps in history taking process and we hope that we've helped you to add structure and depth to your history taking in the clinical setting and I will put some referencing on line for you that will help you to explore further the key issues surrounding history taking thank you very much you