hello my name is Jemma Hurley I'm a senior lecturer at Kingston University and St George's University of London I'm also a nurse practitioner where health history forms a key part of my role history taking forms a set the Cornerstone of patient Health assessment 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 come on in and have a seat thank you okay hi my name is Gemma Hurley I'm a nurse practitioner and you are uh Paul Collins okay Mr Collins how would you like me to call you Paul S is that okay all right um 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 about your social circumstances is that okay with you it's fine 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 cough for a few days it's just driving me nuts really right how long has the cough been there for um I suppose about 3 or four days now has it and have you got any other symptoms with that cough um I've got quite a 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 yeah they're both pretty much the same time gosh okay and the cough and sore throat is it worth any particular time of the day or night uh well the cough is probably worse first thing in the morning I notice it particularly when I get up uh sore throat is there all the time really is it are you able to swallow with that sore throat yes yeah I can you can you can drink okay and the cough can you describe it for me well it's just a sort of a fairly meaty cough you know I'm coughing up all sorts of muck really right okay um what color is the Muk that you're coughing up uh some green really is it is it large amounts or a fair amount is it is there any blood in it no I haven't seen any blood okay and how bad on a scale of not to 10 is that cough for you 10 being the worst possible oh I suppose it's about six or seven really right and is there any area in your throat or um anywhere in your chest that's painful well I mean my throat and neck are sore when I cough but other than that no they just it's just the sore throat okay does it travel anywhere else the sore throat any sort of radiation of pain no no there okay and has any other persons been affected by this have they been sort of coughing around youve been in contact with anyone uh well my girlfriend she's had a she had a cough uh last week has she okay and has she been well in herself or well she was she was ill for a few days has she okay she's better okay what makes a cough and sorcerer better for you is there any relieving factors uh well the cough nothing really um you know I've tried over the counter sort of stuff from the chemist and that didn't work didn't the throat if I have a warm drink that helps okay okay anything make it worse a test cough uh no not really nothing at all okay what do you think it is I I don't know I just think I need some antibiotics to get rid of it okay I I just want to ask you more specific questions now you said there's no blood in the flame um but is there any fever any feeling shivery uh first day I was ill I was a bit bit bit shaky like that but uh now I'm not okay and what about breathlessness so you've got any breathing problem or chest tightness no no nothing at all okay and when you go to bed at night are you able to lie on your same amount of pillows yes yeah that's are the same okay and what about are you feeling because I know you're coughing up lots of green Flem 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 none at all good any recent travel abroad no I've Haven been abroad months okay okay I just want to go through some of your key sort of body systems Paul just def fine about your overall health um can you tell me about have you do suffer with headaches at all uh sometimes I get headaches do you okay how how often do you get headaches once every month something like that is it and have you seen your doctor for that no I just just take some pills 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 you wear glasses no no okay vision's good yeah okay do you ever suffer with nasal congestion or uh sinus problems the only time I do is with cats really they set me off right are you allergic to cats I think I must be oh shame okay um what about your um tastes any change in taste no okay no do you get mouth ulcers at all sometimes I do do busy at work or something I get mouth ERS okay and you have a sore throat now but do you get recurrent sore throats or no you don't years good good and any sort of problems with your chest in terms of heart problems breathing problems no no nothing like that okay and your bowels working all right 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 heterosexual or okay yep okay and contraception do you um use barrier methods my girlfriend's on the pill okay and it's a long-term relationship is it okay okay and what about your bones any joint problems uh well your sort of aches and pains if I've been busy at work but than that no not really okay good okay and how's your mood how do you feel in yourself uh fed up at the moment nor really good but I just want to get rid of this cough the cough okay but no sleeping problems and feeling low moods in terms of good excellent a little bit about your um surgical in the past have you ever had any operations I had an operation or must be 20 years ago some sort of operation on my back a right do you recall was a a pie something pyo pylon idal sinus okay okay and has it been all right since then no problem all and no other operations no okay I'm just going to list of just to probe your mind a bit in terms of medical history have you or any of your first degree relatives so Mom Dad siblings ever suffered with any jaundice where you've seen yourself go yellow no okay any anemia at all iron deficiency good okay have you ever had a heart heart attack or any member of your family no okay um what about TB anybody with TB or you've been not as far as I know good any thyroid problems no okay any rheumatic fever or rumor Thor arthritis good okay any heart problems no okay any high blood pressure well I've got high blood pressure oh you have okay and when was that diagnosed that was diagnosed uh what 2 years ago now was it and is it well controlled well I go yeah I think so I go to the doctor regularly and have my blood pressure checks it seems okay perfect when was it last checked it was last checked about 2 weeks ago and everything was great yeah I think so perfect it was okay okay and what about diabetes do you have any diabetes or you yes yes or you do yes I'm diabetic right and do you know what type uh it's the one with the tablets okay so you take tablets do okay um when were you diagnosed with t um diabetes that was about 3 years ago now okay and when was your last checkup for your diabetes uh I had that at the same time I had my blood pressure saw the nurse perfect and they were happy yeah okay perfect any asthma at all no okay any Strokes you had any mini sort of numb there family members oh my dad my dad he died uh two years ago with the stroke okay how old was he he was 72 72 okay and any cancers in the family or you've been no okay good okay brilliant I just want to move move you along a bit further um do you take any prescribed medicines I know you've got diabetes and high blood pressure I I do I take um I take Ramy P okay um and I take performing and there's another one that begins with G for the diabetes G gy excellent okay and do you know a dosage of the Ramil uh I think it's 5 Mig 5 Mig and you take it regularly oh yeah yeah take it every evening and no side effects with it um I did have an awful cough to start with but that's that stopped now it's settled good okay and do you know um the metformin you take it did you a dosage and how often I take it three times a day but I don't know what dose that is okay we can check that out we can follow that up okay and what about um allergies are you allergic to anything uh well the only thing I think I'm allergic to is cats but no one's ever told me that okay so that's the environment do you know if you got any drug allergies no no I don't think so and any foods like nut allergy or anything like that no okay perfect good okay I need to ask you this do you take any recreational drugs at all no don't have anything to do with them excellent good any over the counter you said you've been to well I had some had some cough medicine okay uh benlin I think it was didn't really help and I I do take s of paracetamol occasionally but not not often and have you had paraset more recently uh I had it a few days ago for the sore throat which it helped a bit it helped a little bit okay and do you take any Herbal Remedies at all nothing at all excellent that's brilliant okay um well a little bit about your social background if you don't mind me asking what's your occupation uh I'm a builder right okay and what have you been lately exposed to dust or any sort of new substances no no so very standard new build at the moment okay and you're happy with work yeah I'm plenty of work at the moment so that's good great excellent and what about you said you've got a girlfriend do you live with her I do right okay and you're happy everything's good at home no stresses no no excellent okay and do you live in a house or a flat or uh it's a two bed house it's a two-bedroom house are you house owner are you uh yes you own your own house excellent good can I ask you do you smoke at all uh yeah I do smoke do you okay um can I ask what you smoke I just smoke cigarettes low tar cigarettes low tar and how many cigarettes do you go through in a day uh well it's about three packs about two packs every 3 days is it okay and what at what age did you start smoking uh it would have been about 30 age 30 okay have you thought about giving up well not really at the moment you don't want to consider that at the moment no no okay well when you're due uh we're here anytime 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 want to ask you what your alcohol intake do you drink I I do drink yeah okay uh what do you normally drink uh wine okay and how much wine do you drink uh not a lot really couple of glasses a week in the week yeah not a lot at all really okay good and your diet you eat well yeah no we eat really well uh my girlfriend's you know really into healthy eating so we grow our own vegetables at home Wonder things yeah wonderful excellent great and do you exercise uh not really because I'm just on site so much I'm busy all day I'm I'm very active during the day but I don't really exercise outside right I suppose if you could find that time it will be relaxing I suppose to help you know good for your diabetes as well n if we could I just want to sum up Paul if you don't mind um please correct me if I've got any of it wrong you've had this cough and sore throat for the last 3 days it's sort of nothing makes it really better or do you have taken do your paracetamol that's helped a little bit you've not had any blood in that flame no fever no unexplained weight loss breathing's okay as well you've got type 2 diabetes CU you take tablets for that and it's well controlled and so is your blood pressure your dad died sadly of a stroke um uh you uh live with your girlfriend and you're quite happy work is good um and you just really want us to sort out your sore throat and cough yes please okay okay is there anything else you want to add to that before we move on no no that's it I think 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 that's fine good thank you well that concludes our demonstration of the history taking 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 the practitioner ensuring that the environment was safe and accessible for the patient I was also mindful to avoid interruptions thus 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 pool I I thought that was uh quite appropriate and I felt that you you respected my uh right to be called Mr Mr Collins or Paul accordingly um and I was happy to be called Paul great I also felt it was imperative that I gained informed consent and so I told the patient at the outset what was to be expected and seek consent from him I also thought that it was important that I used an open-ended question at the outset so that the patient could tell his story in his own words how did you find that um I I thought that was good uh and I certainly had the opportunity to talk about what was concerning me which was obviously the cough um so yeah I got that out of the way quite quickly I think great all good the other thing is although I'm wanting the patient to tell their own story I also am mindful of the red flags thus ruling out life-threatening causes I Tred to be systematic but I also also wanted to respond to the patient cues 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 clarify it from their perspective I was mindful as well not to use jargons but how did you feel I cuz sometimes we get lost as practitioners and we we see medical jargons as normal terminology I think on on the whole it was very good um and for the most part it was fairly free of medical jargon although I know at one point you did ask about social history which which I think had the potential to confuse somebody of course I didn't think of it that that but that's so right absolutely great I mean the questions once you once you'd said you were going to ask about the social history I think the questions were absolutely fine it's just that just that headlining really of that particular area of the history taking up perhaps that's and that's important for me to note as a 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 online for you that will help you to explore further the KE key issues surrounding history taking thank you very much e