Communication

including history taking, documentation...

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While undertaking a complete and accurate clinical history from a patient, it is essential to understand each symptoms characteristic. By obtaining the full information regarding the symptoms will enable the practitioner in the formulation of the differential diagnosis. Bickley et al. (2017) outline seven key attributes which should be obtained from the patient concerning each presenting symptom.


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Practitioners will encounter a large proportion of patients presenting with pain as their main presenting complaint regardless of the speciality. To ensure that a proper history is obtained from the patient the mnemonic "SOCRATES" can be used as a prompt.

It can be used for various types of pain; cardiac, abdominal, muscular, headaches, and much more. The SOCRATES mnemonic can be broken down as detailed below:

Site; where exactly is the pain?

Onset; what were they doing when the pain started?

Character; what does the pain feel like?

Radiating; does the pain go anywhere else?

Associated symptoms; e.g. nausea/vomiting?

Time/duration; how long have they had the pain?

Exacerbating/relieving factors; does anything make the pain better or worse?

Severity; what is their pain score?


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According to Nixon (2013), obtaining a past medical history from the patient can be an important indicator in understanding their current presenting illness. It is essential to establish if the patient has any significant medical problems. Using an open question can lead to the patient omitting this information as they recognise its importance.

Therefore, instead of asking the patient "do you have any medical problems?"(open questioning), you can ask specifically "do you have epilepsy, diabetes...?"(closed questioning). 

A useful mnemonic in identifying some common medical conditions is JAM THREADS:


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