Clinical history taking (with patient example)

a nurse is reviewing the medication history of a client who reports having difficulty sleeping This is a topic that many people are looking for. is a channel providing useful information about learning, life, digital marketing and online courses …. it will help you have an overview and solid multi-faceted knowledge . Today, would like to introduce to you Clinical history taking (with patient example). Following along are instructions in the video below:
My name is gemma hurley. Im a senior lecturer at kingston university. Georgess university of london.
Im also a nurse practitioner. Where health history forms a 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 im 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.
Im. 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 its paul collins and youre 46 years old and is this your address thats right perfect great okay. Excellent. So how can i help you today.
Well. Ive 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.
Ive got cost sore throat. Thats thats 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.
Its just a sort of fairly me tea coffee down cocking up all sorts amok really right okay. And what color is the muck that youre coughing up green is it is it large amounts or feral is that is there any bird in it no im seeing you glad okay and how bad on a scale of not 210 is that coffee you tending to worth possible. I suppose.
Its about six or seven. Really right and is there any area in your throat or anywhere in your chest. Thats painful well mom in my throat and nick.
I saw when i call right after them that no theyre just its 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 persons been affected by just have they been sort of coughing around youve 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. Shes 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 ive tried over the counters of stuff on the chemist and that didnt work it didnt 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 dont know i need some antibiotics right okay okay.
I just want to ask you more specific questions. Now you said. Theres 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 youve 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.

a nurse is reviewing the medication history of a client who reports having difficulty sleeping-0
a nurse is reviewing the medication history of a client who reports having difficulty sleeping-0

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 dont 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 dont i hope you dont 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 its 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 hows 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.
Im 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 youve 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 ill go yeah.
Think so the dots regulate blood pressure checked. So shes 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.

a nurse is reviewing the medication history of a client who reports having difficulty sleeping-1
a nurse is reviewing the medication history of a client who reports having difficulty sleeping-1

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 thats 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 im 72 72. Okay and any cancers in the family or youve 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 youve got diabetes and high blood pressure. I do i take i take a bleep rule.
Okay and i take metformin and theres another one begins with g for the diabetes. So good. Clickers or clickers are excellent.
Okay and youre not a dosage of the ramipril. I think its 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 thats 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 dont 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 ones have told me that okay so thats the environment do you know if youve 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 youve 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. Thats brilliant okay and well a little bit about your social background. If you dont mind me.
Asking whats 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 youre happy with work. Yeah.
Plenty work at the moment. Thats good great excellent. And what about it.
You said. Youve got a girlfriend you live with her auggie right okay. And youre happy.
Everythings good at home. No stresses. No excellent okay and you live in a house or a flat.
Oh. Thats too big house. Its 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.

a nurse is reviewing the medication history of a client who reports having difficulty sleeping-2
a nurse is reviewing the medication history of a client who reports having difficulty sleeping-2

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. Its not really all about you dont want to consider that at the moment.
Okay well. When you do and were here any time. Weve got lots of support strategies in place so whenever you feel you would like to talk about stopping smoking.
Were 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 youre dieting eat well ya. Know eat really well my girlfriends really into healthy eating so we grow our own vegetables at home one excellent great and you exercise not really because im just on site.
So much busy all day. I was very active during the day. I dont 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 dont mind and please correct me.
If ive got any of it wrong youve had this coughing. Sore throat for the last three days. Its sort of nothing makes it really better or do you have taken do a paracetamol thats helped a little bit youve not had any blood in that phlegm.
No fever no unexplained weight loss breathings okay as well youve got type 2 diabetes. You take tablets for that. And its well controlled.
And so is your blood. Pressure your dad died. Said live a stroke.
And you live with your girlfriend. And youre 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 whats 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 patients privacy and confidentiality as i called a patient in i was mindful not to use the patients 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 didnt think of it that that but thats so right absolutely well i mean. The questions once you want you take youre 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 thats important for me to note as the practitioner. Well that concludes.
The key steps in history. Taking process and we hope that weve 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 .

a nurse is reviewing the medication history of a client who reports having difficulty sleeping-3
a nurse is reviewing the medication history of a client who reports having difficulty sleeping-3

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