History Taking

Question 1

Step 1

Answer 1

1. Obtain baseline set of vitals (BP, P, R)

Question 2

Step 2

Answer 2

2. Obtain SAMPLE history

Conscious:

Signs and symptoms “can you tell me what’s wrong?”
Allergies “do you have any general allergies or allergies to medications?”
Medications “can you tell me what medications you are currently taking to include over the counter medication, vitamins and/supplements?”
Pertinent past history “do you have any significant past medical history of any chronic illnesses?”
Last intake and output “when was the last time you had anything to eat or drink?”
Events leading to the injury “can you tell me what you were doing before you dialed 911?”

Unconscious
“Given that my patient is unconscious, I cannot obtain a SAMPLE history at this time.”

Question 3

What comes after history taking?

Answer 3

Secondary assessment