History Taking

You are a pharmacist working in a GP.

A 54-year old male has come to speak with you about a health concern.

Your task is to take a full clinical history from the patient.

You do not need to diagnose or manage the condition. Your task is simply to collect a thorough and structured history.

You have 8 minutes.

You are David Parker (DAY-vid PAR-ker).

Opening statement: “I’ve been having this discomfort in my chest recently, and I thought I should probably get it checked.”

Only provide information if the student asks appropriate questions:

• Name: David Parker

• Age: 54

• Symptoms: 

• Onset: “It started about three weeks ago.”

• Location: “It’s in the middle of my chest.”

• Character: “It feels tight, almost like pressure.”

• Radiation: “Sometimes it spreads a little to my left shoulder.”

• Severity: “Maybe a 5 or 6 out of 10.”

• Timing: “It usually comes on when I’m walking or going up stairs.”

• Duration: “It lasts a few minutes and goes away when I rest.”

• Aggravating factors: “Walking uphill or rushing somewhere makes it worse.”

• Relieving factors: “Resting for a couple of minutes usually makes it go away.”

• Associated symptoms: “I do get a bit short of breath and sometimes I feel a bit sweaty”

• No other symptoms

• No trauma

• Past medical history: 

• “I got diagnosed with high blood pressure 5 years ago.”

• Medication history:

• “I take ramipril 10 mg once a day.”

• “I take paracetamol sometimes for headaches.”

• Allergies: 

• “I might be allergic to shellfish, but I don’t like seafood so I’m not having it anyways.”

• Family history: 

• “My dad had a heart attack when he was about 60.”

• “My mum is alive and well.”

• Social history: 

• Occupation: “I’m an accountant. It's a bit stressful during busy periods.”

• Living situation: “I live with my wife.”

• Smoking: “Yes, about 10 cigarettes a day. I've smoked since I was 20 years old.”

• Alcohol: “Probably 3 or 4 beers most evenings.”

• Recreational drugs: “No, never.”

• Exercise: “Not much. Mostly sitting at a desk all day.”

• Diet:  “Probably not the healthiest — a lot of takeaway and processed food.”

• ICE (Ideas/Concerns/Expectations)

• Ideas: “I’m worried it could be something to do with my heart.”

• Concerns: “My dad had a heart attack, so that worries me.”

• Expectations: “I was hoping someone could check if it’s something serious.”