Hello my name is Gemma Hurley.

I’m a senior lecture at Kingston University George’s University of

London. I’m also a nurse practitioner where health history forms a key 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 priciples of history taking to do that I’m going to bring in a patient and
demonstrate the key steps involved in history taking.

P : Patients

N : Nurse

N : Come on in and have a seat

P : thankyou

N : Okay, hi my name is Gemma Hurley. I’m a nurse practitioner and you ?

P : paul Collins

N : okay mr.Collins. How would you like to meet accordion son ?

P:

N : 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 you health and also put your social circumstances is that okay
with you ?

P:

N : 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 you address ?

P : that’s right

N : perfect great okay excellent. So, how can help you today ?

P : well I’ve had a call for a few days just driving me nuts really ride

N : how long has the cough been there for ?

P : I suppose about three or four days now

N : has it and have you got any other symptoms with that cough ?

P : I’ve got cost sore throat that’s, that’s quite bad as

N : well right and a sore throat has it been there same amount of time ?

P : yes, both long time gosh

N : okay and the cough and sore throat is it worse any particular time for the day or night ?

P : well cops probably worse first thing in the morning I noticed it killing when I get up sore throats
there all the really

N : I said are you able to swallow with that sore throat ?

P : yes

N : you can you can drink, okay and the cough can you describe it for me ?
P : it’s just a sort of fairly me tea coffee down cocking up all sorts amok really

N : right okay and what color is the muck that you’re coughing up ?

P : green

N : is it, is it large amounts or ?

P : feral

N : is that, is there any bird in it ?

P : no, I’m seeing you glad

N : okay and how bad on a scale of not 210 is that coffee you tending to worth possible ?

P : I suppose it’s about six or seven really

N : right and is there any area in your throat or anywhere in your chest that’s painful ?

P : well mom in my throat and nick I saw when I call right after them that no they’re just it’s just the
sore throat

N : okay does it travel anywhere else the sore throat eddie sort of radiation of pain ?

P : no

N : okay, okay and has any other person’s been affected by just have they been sort of coughing
around you’ve been in contact with anyone ?

P : well my girlfriend she said she had a cough last week

N : I she okay, and has she been well in the south oh ?

P : she’s out she was over for a few days

N : okay okay . What makes a cough and sore throat better for you is there any relieving factors ?

P : well a cough nothing really you know l’ve tried over the counters of stuff on the chemist and that
didn’t work it didn’t tear the throat war drink that helps

N : okay okay. Anything make it worse at orders cough ?

P : no, not really

N : nothing at all okay. What do you think it is ?

P : I don’t know I need some antibiotics

N : right okay okay. I just want to ask you more specific questions now you said there’s no blood in
the phlegm and but is there any fever and you feeling sugary ?

P : ah first day I was little I was a bit shaking like that now not

N : okay and what about breathlessness so you’ve got any breathing problem or chest tightness ?

P : no

N : nothing at all okay, and when you go to bed at night be able to lie on your same amount of
pillows ?
P : yes

N : 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

P : no

N : nothing like that okay and have you had any unexplained weight loss at all

P : no not at all

N : any recent travel abroad ?

P : no, no abroad months

N : 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 ?

P : sometimes I get headaches

N : do you okay. How often do you get headaches ?

P : once the B month something like that

N: is it, and have you seen your doctor for that ?

P : no, I just take some painkillers and they go away

N : they go away okay. Have you ever had any head injuries

P : no

N : okay, good okay and what about your vision do wear glasses

P : no

N : okay, visions good ?

P : yaeh

N : okay, do you ever suffer with nasal congestion or sinus problems ?

P : the only time I do is with cats really and they set you off

N : right are you allergic to cat ?

P : I think I must be

N : oh shame okay, and what about your aunt tastes any change and tastes ?

P : no, no

N : okay, do you get mouth ulcers at all ?

P : sometimes I do busy at work or something

N : right okay, and you have a sore throat now but you that recurrent sore throat so ?

P : we don’t use
N : okay good and any sort of problems with your chest in terms of hearts problems breathing
problems ?

P : no

N : okay okay and your bowels working alright

P : I’m fine

N : good. Water 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 ?

P : yeah

N : okay. Are you a heterosexual ?

P : oh yes

N : okay and contraception to use barrier methods ?

P : on the pill

N : okay and it’s a long-term relationship is it ?

P:

N : okay and what about your bones any joint problems ?

P : well your breaks and pains is your work

N : okay good and how’s your mood how do you feel in yourself ?

P : fed up at the moment no I did but I just will get rid of course

N : 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 ?

P : I had an operations there must be 20 years ago some school operation on my back

N : all right, would you remember recall ?

P : a PI somethings higher than pilonidal sinus

N : pilodinal sinus okay, and has it been all right since then ?

P:

N : okay and no other operations ?

P:

N : okay I’m 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 ?

P : oh no

N : okay. Any anemia at all ?

P : no
N : I am officially good okay have you ever had a heart heart attack or any member of your family ?

P : not

N : okay and what about TB anybody would TB or you’ve been hunting ?

P : rossano

N : could any thyroid problems ?

P : no

N : okay, any through matic fever or rheumatoid arthritis

P : no

N : good okay any heart problems ?

P : no

N : any high blood pressure ?

P : have high blood pressure

N : oh you have, okay and when was that diagnosed ?

P : diagnosed what two years ago now

N : was it and is it well controlled ?

P : well I’ll go yeah think so the dots regulate blood pressure checked so she’s

N : okay. Perfect when was it last checked ?

P : it was last checked about two weeks ago

N : and everything was great ?

P : yeah I think so perfect was

N : okay and what about diabetes do you have any diabetes

P : oh yes yes

N : are you doing ?

P : your some diabetic

N : right and do you know what type

P : that’s one of the tablets

N : okay, so you take tablets

P:

N : okay and when were you diagnosed with type diabetes ?

P : that was about three years ago

N : okay and when was your last checkup for your diabetes ?
P : so I had that the same times I my blood pressure drugs she knows

N : perfect and they were happy

P : yeah

N : okay okay perfect any asthma at all ?

P : no

N : okay any strokes you had any many sort of numbness or family members