Overview
This transcript features a demonstration of patient history taking in a clinical setting by Jemma Hurley, a senior lecturer and nurse practitioner, followed by a reflective discussion on best practices and patient feedback. The interaction addresses both the technical and interpersonal aspects of collecting medical history.
Introduction to History Taking
- Emphasized importance of history taking as the cornerstone of health assessment in clinical practice.
- Outlined the intention to demonstrate the key steps involved in obtaining a comprehensive patient history.
Patient Introduction and Consent
- Confirmed patient identity (Paul Collins, 46 years old, address verified).
- Sought and received patient consent to ask questions regarding health and social circumstances.
- Asked for patient’s preferred form of address, confirming patient comfort.
Presenting Complaint and Symptom Exploration
- Main complaint: Cough for 3–4 days, bothersome to patient.
- Associated symptoms: Sore throat (persistent), worse in the morning, productive cough with green sputum but no blood.
- Symptom severity: Cough rated 6–7 out of 10.
- Onset, relieving/aggravating factors, and patient’s self-treatment with over-the-counter medicines discussed.
- Exposure to illness: Girlfriend recently had a cough, now recovered.
Review of Symptoms and Further Exploration
- No fever or ongoing chills aside from initial day.
- No breathlessness, chest pain, or sleep issues due to symptoms.
- No recent weight loss or travel abroad.
- Systematic inquiry into other systems: intermittent headaches, mild mouth ulcers under stress, no recurrent sore throats, no significant chest or bowel/urinary problems.
- Brief inquiry into sexual history and contraceptive use (long-term relationship, partner uses pill).
Past Medical, Surgical, and Family History
- Medical history: High blood pressure (diagnosed 2 years ago, well controlled), type 2 diabetes (diagnosed 3 years ago, on oral medication).
- Past surgical history: Operation for pilonidal sinus 20 years ago, no ongoing issues.
- Family history: Father died of stroke at 72, otherwise negative for heart disease, diabetes, cancer, TB, rheumatic fever.
Medication, Allergies, and Substance Use
- Current prescribed medicines: Ramipril (5mg daily), metformin (3 times daily, dose unknown), gliclazide (for diabetes).
- History of initial cough with Ramipril, now resolved.
- No known drug or food allergies; possible cat allergy.
- Over-the-counter: occasional paracetamol and recent cough medicine; no herbal remedies.
- No recreational drug use.
Social, Occupational, and Lifestyle History
- Occupation: Builder, no recent unusual exposures.
- Lives with girlfriend, satisfied with work and home life, owns a two-bedroom house.
- Smoking: Cigarettes, started at age 30, approximately two packs every three days, not currently interested in quitting.
- Alcohol: Moderate wine consumption (a couple of glasses per week).
- Diet: Healthy, home-grown vegetables.
- Exercise: No structured exercise, but active at work.
Summary and Next Steps in Clinical Process
- Clinician summarized findings with patient for confirmation and accuracy.
- Agreed to proceed with checking vital signs and a physical examination to further assess the complaint.
Feedback and Reflection on History Taking Process
- Practitioner ensured a safe, accessible, and confidential environment.
- Avoided first-name use without permission; sought and obtained informed consent.
- Used open-ended questions initially, then explored red flags and responded to patient cues.
- Maintained systematic approach, avoided medical jargon, and summarized for patient clarification.
- Patient feedback: Felt respected regarding his name, appreciated opportunity to express concerns, felt questions were appropriate and clear, minor note on potential confusion over the term "social history".
- Practitioner reflected on continuous improvement, especially in terminology and communication clarity.
Recommendations / Advice
- Practitioner advised patient about resources available for smoking cessation if interested in the future.
- Encouraged the value of structured exercise, particularly in supporting diabetes management.
Action Items
- TBD – Clinician: Check and record precise dose of metformin for the patient.
- TBD – Clinician: Measure patient’s vital signs and conduct a physical examination to inform further care decisions.