Summary
summary anamnesis
- Module
- Medicine
- Institution
- Cardiff University (CF)
A quick guide to history taking.
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HISTORY TAKING• Correctly identify the patient (name and date of birth).
• Introduce yourself and chose a quiet, private place.
• Gain consent.
• Pick up non-verbal cues from the patient. Are they in distress? Mood? How does their
demeanour change during consultation. This is particularly important in those that
cannot express verbally.
• Actively listening to patient throughout history taking is essential. Clarify anything
you do not understand and tell them your interpretation of what they said and
confirm if that is indeed true.
• Once it has been established what has happened to the patient find out FIFE: Feelings
related to illness, Ideas about what has happened to them, Functioning in terms of
impact on life and Expectation from the doctor.
Gathering information
Presenting complaint
• Ask- “what brings you in today?” - let patient explain in their own words and clarify
what they mean by any terms they use e.g., allergy, fits. Ask “can you explain a little
bit more about -”
• Ask about onset of symptoms, progression of symptoms, and associated symptoms.
• PAIN- if patients complain of pain ask SOCRATES
Site Somatic pain- well localised e.g., sprained
ankle.
Visceral pain- diffused e.g., angina pectoris.
Onset Speed of onset and associated
circumstances
Characteristics Adjectives e.g., sharp/dull,
burning/stabbing, crushing. Let the patient
describe it themselves. Do not suggest the
characteristic yourself
Radiation Does the pain radiate/ spread anywhere? If
so, where?
Associated symptoms Anything else that occurs with the pain?
E.g., visual aura with migraine. Nausea,
vomiting.
Timing (duration, cause, pattern) Since onset? Continuous or episodic? If
episodic, duration and frequency? If
continuous, any changes in severity?
Exacerbating and relieving factors What worsens or relieves the pain? Specific
postures? Medications?
Severity Subjective. Depends on the patient’s
tolerance to pain. On severity of 1-10, 1
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