Giles Kisby

History Taking

Contents:
Basic History Structure
Targeted Systemic Reviews

Basic History:
- First:
o Patient’s personal details
1. ME
2. Purpose/Process & Permission
3. Them: Px Name, Age and DOB
o PC: Presenting complaint & HPC: History of presenting complaint
 OPEN
 While still at open phase
 So what brought you in to see us today?
 Can you tell me more about it…
 Repeat info back to them as they say it
 Look out for cues from the patient and follow them up
 SOCRATES
 1. Site, Character, Radiations? Severity?
 2. Time course: Onset, Change through time
 Ever had this Before?
 “What were you doing at the time?”
 “When did your symptoms start?”
 Change through time?
 Were they completely well beforehand?
 “Fine the day before?” “Fine the day after?”
 3. Positive / Negative Associations + Triggers: Alleviating / Exacerbating:
 Time of day/Night?
 Time of year? (atopy etc)
 ‘Eating?
 ‘Coughing?
 Position?
 Exercise?
 ‘Weather?
 ‘Pets?
 4. Associated symptoms:
A. SYSTEMS REVIEW - **ESSENTIAL in all cases – refer to later notes
further below** of systems mentioned/relevant
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B. RED FLAG QUESTIONS - to rule out sinister causes – “WHAT MUST I

NOT MISS?” – Refer to below
C. CAUSES (RFs) - for the Leading Differentials
D. CONSEQUENCES (Symptoms Expected) - for the Leading Differentials
and rule out other differentials!
 ICE / Gosh / Oh I’m so sorry to hear that / [Repeat back and recognise their
concern(s)] / You’ve done absolutely the right thing to come in / We’ll do
everything that we can to get them/you better as soon as possible / If there’s
anything you think of later don’t hesitate to ask us (even works in emergency)
[Mark scheme: Empathy & checking Understanding] [NB LINKS TO
COUNSELLING APPROACH – MAY BECOME COMMS STATION!]
1. Do you have any Ideas on what might be going on here?
2. Is all this worrying you or are you not too Concerned? /
Do you have any specific concerns? Why Today?
o Well I just want to reassure you that you have done exactly the
right thing in coming to see us and we’ll do our best to
difinitively rule that out for you…and do our best to solve this
problem as quickly as possible…what makes you think that/I
just have a few more questions…
3. Has this been affecting the things you usually do? ADLs - How is it
affecting your day to day life? (Mark Scheme want Psychosocial
consideration!!!) [ie can do this for each problem that comes up]
4. Is there Someone at home/a friend that you can speak to/who can
offer you some support with this?
5. Did you have any specific thoughts on what we might be able to do for
you today? - Expectations
 Bonus: “How are you feeling about that?” – ie can use vs any
complaint that they state (instead of just focussing on the medical F/U
Qs)
 SUMMARISE
 If are unclear on the Picture/Story
 Valuable opportunity to get story straight, fill in gaps and be safe
- PMH
o “Had this before?”
o “Any underlying health problems?”
 “Are you Asthmatic, Diabetic or Epileptic?”
o “Anything you see your GP regularly for?”
o “Any past Surgery?” [Key in Sx Px’s!!] Past Anaesthesia?
o “Are you Pregnant?” – All women of childbearing age or test urine
 Relevant for Dx
 Relevant For Ix CT
 Relevat For Mx Drugs
o Say the list back to them and place in this “heading”
o [DDX Q’s]
o MJ THREADS
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 Cardiac: MI / HTN
 Abdo: Jaundice
 Lung: TB
 HTN
 Rheumatic fever
 Epilepsy
 Asthma
 Diabetes
 Stroke
o SxH
- DH
o Any regular medications? Do you know the dose?
o Dose, route, frequency, compliance for each
o Any Blood thinners? Aspirin? Warfarin?
o OTC medications
o Allergies? What happens if you take it?
o [DDX Q’s]
- FH
o “Any diseases that run in the family?”
o “Any history of sudden death in the family?”
o “Has anyone in the family had a similar thing?”
o <55 = significant for cardiac disease
o [DDX Q’s]
- LH
o Smoking?
o Alcohol? – Eg Just report as “Social Alcohol”
o Recreational Drugs? – neuro, cardiac…
o Sexual History? (adolescents)
o Diet? – abdo, cardiac…
o *Exercise Tolerance? – abdo, cardiac, resp…
 “How far can you walk in one go?” “What Stops you?” “What do you do to
recover/How long?” – ie Standing rest? Leg up rest?
o Driving? DVLA Informed?
o [DDX Q’s]
- SH
o “Who’s at home with you?”
 Living on your own or with others?
 Coping?
 Walking aids
 Personal ADLs:
o Dressing
o Washing
o Toileting (is the bathroom on the same floor that you sleep on?
Do you have any aids for moving around the home?)
 Domestic ADLs:
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o Cooking
o Cleaning
 Support at home? “independent with ADLs”
 Carer
 District nurses
o ~Housing
 House / flat re number of flights of stairs
 Distance to bathroom from bed
 Height and comfort of bed
o Occupation – both now and in the past
o Travel? – ie key in DVT/PE/Chest pain/Infection histories
o Pets? – if anything at all to do with Respiratory or Atopy
o [DDX Q’s]
- End
o Anything in particular that you are concerned about?
o “Is there anything in particular you were hoping for from seeing us today?”
o Anything you would like to ask me?
o Mark scheme: Attends to Px Safety, Comfort and Dignity
o Thank you for taking the time to talk to me - I’ll go and report to the doctor now

Systems Review:
ABC (AMPLE)
 Allergies
 Medications
 PMHx
 Last ate/drank
 Events (“What were you doing at the time?” [ie a good onset question)

Resp
 Wheeze?
 Breathlessness?
 Exercise intolerance – “How far can you walk on flat ground?”
 Cough?
 Sputum?
 Haemoptysis?
 Wt loss?
 “Recent Travel?”
 Swollen Calf?
 Fevers? (Key for DVT vs Cellulitis and identifying infective/malig cause)
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Cardio
 Chest Pain [Ensure to palpate on Ex]
 SOCRATES?
 Pain in Back?
 Worse on Breathing in? (Pleuritic eg PE)
 Sweatyness?
 Exercise intolerance - “How far can you walk on flat ground?”
“What stops you?” (Work out the CCS clasification)
 Palpitations?  Tap out the rhythmn with the patient
 Shortness of breath (Work out NYHA classification if possible HF)
 Orthopnoea “How many Pillows?”
 PND
 Dizziness, Lightheadedness, Faintness, Loss Of Consciousness
 Leg Swelling? - HF
 Leg Pain? - Claudication
+/-  RFs: DM? HTN? HChol? FH? Smoking?

Abdo
o GI
 Dysphasia (Difficulty Swallowing? Solids? Liquids?)
 Odynophagia (Pain on Swallowing?)
 Nausea/Vomiting – Frequency? Rel to food? Blood? Black? Bile?
 Reflux/Indigestion after meals? (Acid? Bloating? Cramping?)
 ‘Abdominal Pain [Upper Umbi&local=SI; Umbilical&vague=Large bowel]
 ‘Jaundice (pale stool, dark urine = biliary obstruction)
 ‘Weight Loss (Loss of appetite? Unintentional? Food Avoidance? Anorexia?)
 Change in Bowel Habit?
 Diarrhoea:Freq? Consistency? Urgency? Night? Hard to flush? Oily?
 Constipation
 Blood in stool? Black Stools?
 Bright red blood per rectum (= BRBPR = Hematochezia; not R Colon)
 Foul smelling dark black tarry stools (= Melaena)
 SOB? (IDA)
 Fatigue? (IDA)
 ‘Tenesmus (feeling of incomplete emptying?) [Cancer or Proctitis]
 ‘Pain on Passing Stool
 ‘Last Bowel Movement?
 “Recent Travel?”
 Fevers? (Key in helping differentiate appendicitis vs stone/ruptured cyst
etc but not difinitive)

o Renal
 Fevers? (Pyelonephritis)
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 Back Pain? (Pyelonephritis)

 -Haematuria? (Nephritis)
 -Frothy urine? Swelling in legs? (Nephrotic)
  ‘Anaemia symptoms?
  ‘Hypocalcaemia symptoms? (Renal Osteodystrophy)
  ‘Uraemia symptoms? (Confusion, Pericarditis pain, Vomiting, Itching,
Impotence)
 PMH:
 HTN?
 Gout? (failure of uric acid excretion)

o Urology
 ****LUTS: [“FUNI PHISST PHD CV”] (non specific)
 Storage problem (high flow)
 Frequency
 Urgency
 Nocturia
 Incontinence
o Stress
o Urge
o Obstructive
o Other
 Diuretics
 Dementia
 Immobility
 Voiding problem (low flow)
 Poor flow
 Hesitancy
 Intermittency
 Straining to start
 Sensation of incomplete emptying
 Terminal dribbling
 Other:
 Proteinuria: As evidenced by Frothy Urine
 Haematuria
 Dysuria (“Pain, Burning, Stinging on passing urine?”)

 Caffeine?
 Vaginal delivery?
 Smelly urine?
 Occupation? (eg Cab drivers are at most risk of stones)
 Genitalia:
 Testicular Pain? (Will not be tortion in the exam!!)
 Testicular Lumps?
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 Pain on Ejaculation? (pain here = prostatitis)

 Blood on Ejaculation
 Past STI? (Chlamidia and Gonnorhoea give urethral strictures)

Neuro
 General brain:
 Headache (…Migraines in Past? – V low threshold to ask in Neuro!)
 Dizziness (World spinning) VS Lightheadedness (Feeling faint)
 Loss Of Consciousness
 Fits, Seizures
 Speech problems
 Higher mental function (learning or calculations)
 Psychiatric symptoms (change in personality)
 Motor & Sensory:
 Limb Weakness
 Numbness Sensation [pins and needles (paraesthesiae) or
numbness]
 Handedness? (ie ask in any neuro Hx)
DANISH (coordination, poor balance/dizziness, nausea, speech)
 Special senses
 Sight, Smell, Hearing or Taste changes?
 Autonomic:
 Bladder or Bowel disturbance? (Sphincters)
 Cerebellar:
 Balance problems / Unsteadyness?
 Cognitive & Conciousness:
 Altered Conciousness: Altered Mental State: (Irritability, Lethargy)
 Clouding of Consciousness (Drowsiness),
Confusion?, LOC, Fits, Coma (LOC & Fits covered ^)
 Meningism:
 [Headache]
 Photophobia? (If true is properly painful to look at lights)
 Painful Moving Neck? (If true is properly painful to move)
 Nausea? Vomiting? [Key to ask in many Neuro Sys Rev’s!]
 Fever?
 Rash?

Systemic – NEVER FORGET TO CONSIDER!

 Fever
 Lethargy
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 Appetite change
 Weight loss
 Sweats at night

Ortho
o Ortho (“CISI  Hx”)
 Core:
 Pain - SOCRATES – inc Night Pain? – Infection or Malignancy (key red
Flag); inc Point with 1 finger where is worst?
o Joint Pain?: Dull and Achy, and very Localized
o Muscle Pain?: Dull and Achy, Hard to Localize
o Arterial pain?: Cramping
o Venous pain?: Bursting
o Nerve Pain?: Sharp, Bright, Burning, or Shooting
 Stiffness
 Swelling (/ Deformity) Differentialtion:
o On field = ACL = Problem with stairs
o Several Hrs = Meniscus = Problems with squatting
o Beyond a few hrs, if at all = MCL>LCL = Problems turning
 Innervation:
 ‘Limb Weakness (“Do you often catch your feet on rugs or paving
stones?”)
 ‘Sensation (“Numbness? Tingling?”)
 ‘Handedness?
 Structural:
 Decreased ROM
 Locking: meniscal tear → mechanical obstruction
 Instability (Giving way)
 ICASE: Function:
 Baseline activity? (Sportsman?)
 Impact on ADLs?
 Problems with Stairs? Problems with Driving? (dep on legs vs arms)

 PMH:
 Osteoporosis?
 Trauma?: Mech (eg knowing is fall on outstretched hand would be key)
 Cancer?
 DH: What Have you Tried?: Analgesia, Physio, Surgery
 FH:
 LH: How active were you when you were younger? (knowing about past sport
etc is key for OA) Alcohol?  Osteoporosis
 SH: Occupation? Support/Carers Situation?
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Vasc
 Pain
  SOCRATES?
o Exas: Walking; Relieved: Rest
o How far can you walk without pain?
 (Intermittent) Claudication?:
o “Cramping pain in Calves/Buttocks with Walking, Relieved with
Rest?”
 Chest Pain?, Shortness of breath?
 Post-prandial Gastrointestinal Pain? with Recent Weight Loss?
o Ischemia of celiac or superior/inferior mesenteric arteries
 Buttock Pain? Erectile Dysfunction?
 Numbness?
 Skin Lesions?  SOCRATES
 PMH: eg DM, HTN
 DH: eg Anticoagulants, OCP, HRT
 FH: eg Haemophilia
 LH: eg Smoking
 SH: eg Occupation

Opthalmology
o “SAD Vision”:
 Sensation
o Pain
o Itching/Irritation
o Photophobia
 Appearance
o Redness
o Lumps
o Puffiness
 Discharge
o Watery (~Viral; or Inc production/Dec drainage)
o Sticky (~Bacterial)
o Stringy (~Allergic)
 Vision
o Blurring/Visual Loss?: ↓ Acuity? Scotoma? Perip vision loss?
o Colour Vision? (Optic Neuritis) Night Vision? (Retinitis Pig.)
o Double Vision?: Diplopia?
o Haloes? Glare? Floaters? Flashes?
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o Past Ophthalmic History (POH)

 Glasses? Contact lenses?
 Previous Eye Problems? Operations?
o PMH: Past Medical History
 “Any underlying health problems?” [Good question even if short on time]
 ie Systemic disease may have eye signs
o DH: Drug history
 Do you take any regular medication? - Dose, route, frequency, compliance
 Treatment History? Eye drops?
 Do you have any Allergies?
o FH: Family history
 Any Eye diseases in the family?
o LH: Lifestyle History
 ~Alcohol, Smoking & Substance use~
o SH: Social History
 Occupation? – Key to assess how stringent the demands on vision are
 Hobbies? – Key to assess how stringent the demands on vision are
 DRIVING? – key as may need to inform DVLA if so
 Who is at home who might be able to offer support?

ENT
 Ear: “Hearing SAD”:
 Hearing
 Hearing Loss? (unilateral more worrying)
o Noise exposure?
 Tinnitus? (Describe the sound? Pulsatile? – vascular tumour or
malformation)
 Sensation
 Pain? (Otalgia) [But Nb may be referred from many other sites within
the head and neck]
 Fever?
 Appearance
 Dizzyness?  True Vertigo? (Associations? Eg light headed on standing
or worse on closing or opening eyes) [If after taking the history you do
not have a suspected diagnosis, the examination and investigations are
unlikely to give it to you]
 Cerebellar
 Vestibular
 Proprioceptive
 Discharge
 Discharge? (Otorrhoea) (Wax/Blood Stained/Purulent/Watery??)
 Other: Non-CN VIII Questions:
 +/- Facial Weakness? Noise sensitivity? Taste change? (Facical nerve)
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 Nose: “Smell SAD”:

 Smell
 Loss of Smell? (Anosmia)
 Sensation
 Pain? - in Forehead, Cheeks or across Bridge of Nose? (sinus
involvement)
 Fever?
 Appearance
 Obstructed?: Can Breath through Both? (Uni or bilateral? Constant or
intermittant?
 Discharge
 Runny Nose? - Rhinorrhoea? (Runny nose) – Benign or CSF Rhinorhoea
 Bleeding? - Epistaxis?

 Throat: “Speech SAD”:

 Speech
 Hoarseness?
o Indigestion? [Reflux  Hoarseness]
o Recent URTI?
o Overuse?
o Smoker? (gradual onset common and not always pathological
though must exclude Ca too)
 Sensation
 Pain? - Sore Throat / Tonsillitis SOCRATES (Tonsilitis Pain); Mouth
swelling increasing in size or pain with eating? (Salivary gland Pain)
 Fever?
 Appearance
 Neck Lump? - SOCRATES [nb recent infection is suggestive of a ‘reactive’
node]
 Discharge
 Mucus in the throat?
 Swallowing Problem? / Feeling of a Lump in the throat? [Ca may
present like this]
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o Rheum
 Hair Loss
 Red Eyes, Dry Eyes
 Mouth Ulcers, Dry Mouth
 Rash, Genital Ulcerations
 Joint symptoms: (see Ortho)
Endo
 ‘Polyuria
 ‘Polydipsia
 ‘Bowel habit
 ‘Periods
 Nausea, Vomiting
 Dizzyness (Addisons)
 ‘Headache
 ‘Visual Problems
 LAWS:
 Lethargy
 Apetite
 Weight Loss or Gain
 Sweating
Derm
 SOCRATES the Lesion
 Any lesions anywhere else or in past?
 PMH: eg DM  necrobiosis lipoidica
 DH:
 FH:
 LH: eg Alcohol linked to psoriasis
 SH: eg Occupation or Hobbies giving chemical exposure

o Obs & Gynae

 Contraception?
 LMP?
 +/- …. [Refer to full Hx notes]
 [Do Preg test in all abdo pain: All women are pregnant until proven
otherwise!!]
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 Relevant for Radiation investigations

 Relevant for Ectopics
 Relevant for deciding on drugs to prescribe

Red Flags “what must i not miss?”

o Think particularly of RFs that won’t be covered by the rest of the history
o Think of in terms of the headings of the rest of the history: this is how the academic
notes will be made
o Ie bring relevant parts from rest of hx up to here such as:
 Resp:
 Trauma?
 Foreign body?
 ACEi?
 Bone pain?
 Swelling to tongue?
 Muscle weakness?
 Stressful job / anxiety?
 Chemical exposure?
 Atopy / Allergy
 Pets / new house or job
 Recent air travel / surgery / clotting problems / past DVT
 Smoking
 FH asthma
 Fever? PPROM? GBS? (eg if just born & SOB)
 Any meconium staining to the Liquor? (eg if just born & SOB)
 Cardiac:
 Trauma?
 Warfarin?
 Nosebleeds / bleeding disease?
 Stressful job / anxiety?
 Recent air travel / surgery / clotting problems / past DVT
 DM, HTN, Cholesterol, Diet, salt, smoking, Clots, DVTs, exercise, FH
 Shoulder Tip pain?
 GI:
 Travel?
 Trauma?
 Stressful job / anxiety?
 Possible you are pregnant?
 IV drugs, Transfusions, Tattoos/piercings, Sexual history, Travel?
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 Pruritis?
 Hot / cold intolerance?
 Fatty food in diet?
 Eat a lot of foods high in calcium?
 Chemical exposure?
 Eaten something different recently?
 Neuro:
 Trauma?
 Neck stiffness/Photophobia/Rash/N&V?
 Tender on side of head?
 Morning headaches?
 Seizures?
 Fits, faints or funny turns?
 Muskscel:
 Muscle weakness?
 Trauma?
 Tender?
o Reason: less of a problem if run out of time later and at least in sensible position ready
for reporting

Other Hx Related stuff:

**PACES: May not be scenario based…
 “Can you tell me a bit about the problem that Has brought you to the exam?”
 Presenting Symptoms
 Date of Diagnosis
 Visits to hospital: ask if they’ve been to hospital at all recently and if so what
brought them in  …etc for hosp visits and each presentation
 If they say Dx then is normal Hx but also ask about:
o Investigations? Disease Site?
o Medical Therapy: Drugs?
o Surgical Therapy: Operations?
o Admissions?
 Current Symptoms

  PRESENT: Try to present current condition in context of overall Condition

Fall / Collapse
o Do you Have Epilepsy?
o Has it happened before? (tumour, chronic problem)
o How were you when you woke up in the morning?
o When had last eaten (hypoglycaemia?)
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o Are you diabetic (hypoglycaemia / hyperglycaemia – HHS?)

o Any fevers or feeling unwell beforehand? (sepsis)
o Medications (medical cause eg Sedative/hypnotics such as benzodiazepines,
Barbiturates)
o Alcohol / Recreational drug use - What drugs / alcohol have you taken today?
o Warning: If feel will fall / unsteady / palpitations / dizzyness
o Did they bang their head beforehand? (ie neural cause – if hit head and on warfarin
then they all get a CT scan)
o What were doing at the time (had recently stood up? Could it have been a mechanical
fall?)

o Maintain consciousness / gaps in memory around the event (neurological dysfunction

either primary or secondary)
o Witnessed?
o How long on floor?
o Bite tongue (seizure)
o Incontinence
o Any injuries as a result? (especially if on warfarin)

o Confused or tired after (occurs in epileptic seizure)

o The San Francisco Syncope Rule (SFSR)

 For evaluating the risk of adverse outcomes in patient with fainting or
syncope: Do they Have 1x or more?: CHESS
 C - Congestive heart failure (ie known)
 H - Hematocrit < 30%
 E - Abnormal ECG
 S - Shortness of breath
 S - Triage systolic blood pressure < 90
 A patient with any of the above measures is considered at high risk for a
serious outcome such as death, myocardial infarction, arrhythmia,
pulmonary embolism, stroke, subarachnoid hemorrhage, significant
hemorrhage, or any condition causing a return Emergency Department
visit and hospitalization for a related event.
 SFSR has a sensitivity of 74-98% and specificity of 56%.[1][2] This means
that in patients with none of the above criteria, 74-98% had no serious
outcome and may be considered as suitable candidates for outpatient
monitoring

Haematology / Lymphatics
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 Tired (Anaemia), SOB (Anaemia), Infection, easy Bleeding

 [nosebleeds, skin: Severity: Petechiae  purpura  ecchymosis],
easy bruising, hemolytic diseases screening, use of anticoagulant
and antiplatelet drugs (including aspirin), family history of
hemophilia, history of a blood transfusion, if been refused for blood
donation

Breast
o SOCRATES Lump / Pain
o Local associated symptoms
 Discharge? Bleeding?
 Nipple inversion? – Is this new or has it always been the case?
 Skin changes overlying the lump or elsewhere on the breast?
 Eczema
 Dimpling
 Ulceration
o Systemic symptoms
 FLAWS
 Pain elsewhere – e.g. spine / axilla / abdomen
o Obs:
 Age at Menarche, Age at Menopause
 Parity, Age at first pregnancy
o PMH:
 Previous Breast Disease?
 Recent Breast Trauma?
o DH:
 Hormonal Replacement Therapy or Oral Contraceptive Pill
o FH:
 FH is v relevant
o LH:
 Smoking
Disease Hx
 Sys Rev
 FLAWS
 System Components (Resp Cardio, Abdo, Neuro, Systemic ~ Sys Rev)
 Related Components (Cause pictures, Complication Pictures)
 Mets Component
 Ask About Cause (Symptoms [May be crossover w above] but also Non
Symptoms)
 Ask About Complications (Symptoms [May be crossover w above] but also Non
Symptoms)
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Pre-Op Assessment/Checks (Best):“OP CHECS”[See 0.5 notes too]

o Operative fitness:
 Cardiorespiratory Comorbidities: MI, Jaundice, HTN, Epilepsy, Asthma, DM
  If any present will need up to date relevant Investigations
demonstrating severity (eg CXR, Echo, ECG, Spirometry, etc)
 Baseline exercise tolerance? (& What makes them stop – SOB/Chest
pain/Claudication?)
 Recent illnesses? (Last 2 weeks)
o Pills
 Anticoagulants? – MDT Risks benefits decision.
 OCP? – Ideally stop 4 weeks before elective surgery.
 Steroids?
 Allergies?
o Consent
o History
 Complications of Anaesthesia?: eg Past VTE?, eg Anaphylaxis?
o Ease of intubation:
 Neck Arthritis?, Dentures?, Loose Teeth?
o Clexane:
 DVT prophylaxis: Compression stockings at admission, LMWH started post
Surgery if low bleeding Risk (Continue both until no longer restriction to
mobility)
o Kitchen:
 NBM: ≥2h for clear fluids, ≥6h for solids
o Site:
 Correct and Marked?

Anaesthetics & Pre op Assessment

 Recent illnesses? (Last 2 weeks)
 Baseline exercise tolerance? (& What makes them stop – SOB/Chest
pain/Claudication?)
 Sleep Apnoea symptoms? (PND, Daytime sleepiness, Morning headaches)
 PMH:
 HTN?, DM?
 Asthma?, COPD?
 IHD?
 Previous Anaethetic? Reactions?
 DH:
 Anticoagulants?
 Steroids?
 Allergies?
 FH:
 FH of Anaesthetic reactions?
 LH:
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 Smoking?
 SH:
Surgical
o Pre
 Pre op Assessment (see above)
 Quality of Life
o Post
 Passed urine?
 Bowels open? (If not, Passed Gas?)
 Pain under control?
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Ophthalmology History
- PC/HPC:
 NB Prior: PERSON: My Grade, Px Age, PLACE: Read Setting, TIME: Tasks
o Patient’s personal details
4. ME [be confident and keen to give a thorough and personal introduction]
5. Purpose/Process & Permission
6. Them: “Can you confirm your Name and your DOB/Age for me?”: Px Name,
Age and DOB  can I call you “john” (then use in history)
 NB will try and do history relatively quickly so can PAUSE BEFORE
REPORTING “let me just take a minute to collect my thoughts” – the
outcome will be better!
 NB Viva: (they may ask for summary of a certain aspect but would never ask
for full Hx report) – this 4 mins is mainly for various questions relating to the
case: DDX, Ix, Mx is common.
o PC: Presenting complaint & HPC: History of presenting complaint
 While still at open phase
 So what brought you in to see us today? So tell me about what’s
been troubling you (even if know from the notes why they have
been referred it is still key to find out what is their main issues at
that specific time)
 Can you tell me more about it… Let them talk for one min tops,
then quickly tighten the structure to follow the structure that will
need to report in. OSCE: focussed history – so once get PC then
should just be a barrage of predetermined questions.
 Repeat info back to them as they say it (to help me remember
salient points) [All current issues get subheading] – “before we go
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into that further is there any other symptoms of any kind that you
have been having?”
 Look out for cues from the patient and follow them up – if is being
cagy about something say “Unfortunately I have only a short time
today to speak with you – can you think of anything that you think
it might be important that I know?”
 SOCRATES
 1. Site, Character, Radiations? Severity?
 2. Time course: Onset, Change through time
 “When did your symptoms start?”
 Change through time?
 Circumstances of your admission?
 When did you last feel well?
 Had this before?
 3. Positive / Negative Associations + Triggers: Alleviating / Exacerbating:
 Trigger?
 Anything that helps?
 Time of day/Night?
 Time of year? (worse in winter = seasonal affective disorder)
 4. Associated symptoms:
 SYSTEMS REVIEW - **ESSENTIAL in all cases**
1. Ophthalmology Hx: See Below
2. Further Systems Review: See Below
3. FLAWS
 RED FLAG QUESTIONS - to rule out sinister causes – “WHAT MUST I
NOT MISS?”
 CAUSES (DDX Time: RFs) - For the Leading Differentials And to rule
out Other Differentials!
 CONSEQUENCES (DDX Time: Symptoms Expected) - For the Leading
Differentials And to rule out Other Differentials!
 FLAWS
 Should have already done if needed
 ICE / Gosh / Oh I’m so sorry to hear that / [Repeat back and recognise their
concern(s)] / You’ve done absolutely the right thing to come in / We’ll do
everything that we can to get them/you better as soon as possible / If
there’s anything you think of later don’t hesitate to ask us (even works in
emergency) [Mark scheme: Empathy & checking Understanding] [NB
LINKS TO COUNSELLING APPROACH – MAY BECOME COMMS STATION!]
6. Do you have any ideas on what might be going on here?
7. Is all this worrying you or are you not too concerned? /
Do you have any specific concerns?
o Well I just want to reassure you that you have done exactly the
right thing in coming to see us and we’ll do our best to
difinitively rule that out for you…and do our best to solve this
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problem as quickly as possible…what makes you think that/I

just have a few more questions…
8. Has this been affecting the things you usually do? How is it affecting
your day to day life? (Mark Scheme want Psychosocial
consideration!!!) [ie can do this for each problem that comes up]
9. Is there someone at home/a friend that you can speak to/who can
offer you some support with this?
10. Did you have any specific thoughts on what we might be able to do for
you today?
 Bonus: “How are you feeling about that?” – ie can use vs any
complaint that they state (instead of just focussing on the medical F/U
Qs)
 SUMMARISE
 If are unclear on the Picture/Story
 Valuable opportunity to get story straight, fill in gaps and be safe
- Systems review:
o Ophthalmology “Systems Review” Hx: - “SAD – Vision”
 Sensation
o Pain
o Itching
o Irritation
o Photophobia
 Appearance
o Red
o Lump
o Puffy
 Discharge
o Sticky (~Bacterial)
o Stringy (~Allergic)
o Watering (~Viral; or Inc production/Dec drainage)
 Vision
o Blurring? Diplopia?
o Pheripheral vision loss? Scotoma?
o Floaters? Flashes?
o Systems Review: REFER TO OTHERS FOR FULL SR
 FLAWS
 Weight changes particularly important if suspecting pregnancy etc
  THEN MAKE SURE TO GO BACK TO Obs (if not yet done),
RFs/C/C & ICE BEFORE MOVING ON!!!
 RED FLAG QUESTIONS - to rule out sinister causes – “WHAT MUST I
NOT MISS?” – refer to paeds red flags section
 CAUSES (DDX Time: RFs) - For the Leading Differentials And to rule
out Other Differentials!
 CONSEQUENCES (DDX Time: Symptoms Expected) - For the Leading
Differentials And to rule out Other Differentials!
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 FLAWS
 Weight changes particularly important if suspecting pregnancy etc
 ICE / Gosh / Oh I’m so sorry to hear that / [Repeat back and recognise their
concern(s)] / You’ve done absolutely the right thing to come in / We’ll do
everything that we can to get them/you better as soon as possible / If
there’s anything you think of later don’t hesitate to ask us (even works in
emergency) [Mark scheme: Empathy & checking Understanding] [NB
LINKS TO COUNSELLING APPROACH – MAY BECOME COMMS STATION!]
1. Do you have any Ideas on what might be going on here?
2. Is all this worrying you or are you not too Concerned? /
Do you have any specific concerns?
o Well I just want to reassure you that you have done exactly the
right thing in coming to see us and we’ll do our best to
difinitively rule that out for you…and do our best to solve this
problem as quickly as possible…what makes you think that/I
just have a few more questions…
3. Has this been Affecting the things you usually do? How is it affecting
your day to day life? (Mark Scheme want Psychosocial
consideration!!!) [ie can do this for each problem that comes up]
4. Is there someone at home/a friend that you can Speak to/who can
offer you some Support with this?
5. E: Did you have any specific thoughts on what we might be able to do
for you today?
 Bonus: “How are you feeling about that?” – ie can use vs any
complaint that they state (instead of just focussing on the medical F/U
Qs)
 SUMMARISE
 If are unclear on the Picture/Story
 Valuable opportunity to get story straight, fill in gaps and be safe
- Rest of Hx:
o Past Ophthalmic History (POH)
 Previous Eye Problems? Operations?
 Glasses? Contact lenses?
o PMH: Past medical history
 “Any underlying health problems?” [Good question even if short on time]
 ie Systemic disease may have eye signs
o DH: Drug history
 Do you take any regular medication? - Dose, route, frequency, compliance
 Treatment History? Eye drops?
 Do you have any Allergies?
o FH: Family history
 Any Eye diseases in the family?
o LH: Lifestyle History
 ~Alcohol, Smoking & Substance use~
o SH: Social History
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 Occupation? – Key to assess how stringent the demands on vision are

 Hobbies? – Key to assess how stringent the demands on vision are
 Driving? – key as may need to inform DVLA if so
 Who is at home who might be able to offer support?
- End
o Anything in particular that you are concerned about?
o “Is there anything in particular you were hoping for from seeing us today?”
o Anything you would like to ask me?
o Mark scheme: Attends to Px Safety, Comfort and Dignity
o Thank you for taking the time to talk to me - I’ll go and report to the doctor now