History Taking Flashcards
History taking involves asking questions why do we do this?
In order to gain information to aid a diagnosis
History taking
What is SAMPLE
Signs and symptoms
Allergies
Medication
Past medical history
Last oral intake (when did he last eat)
Events leading to
Give me some examples of signs
Rashes
Injuries -including wounds, deformity, Swelling.
Skin pallor - flushed, pale, cyanosed
Evidence of oxygen therapy e.g.O2 cylinders in the home.
Sweating
Shivering/tremors
Pulse - fast/slow/strong/weak
Abnormal breathing
Example of symptoms
Hot/cold
Nauseous
Pain
Dizzy
Pins and needles
Fatigued
Anxious
Hallucinations
Blurred vision
How can we assess pain effectively?
Two tools we can use?
PQRST
SOCRATES
What does PQRST stand for?
Provoking/Palliative factors - what were they doing at the time? Does anything make it worse?
Quality - ask them to describe the pain e.g. is it sharp, dull, stabbing, throbbing etc.
Region/Radiation - where is the pain? Where does it start?
Where does it go?
Severity - use a scale of 0-10,
0 = no pain
10 = the worst pain.
What was the worst pain they’ve had previously to this?
Time - when did it first occur? How long does it last
What does SOCRATES stand for?
Site
Onset
Character
Radiation
Associated features - e.g nausea, vomiting
Timing
Exacerbating/relieving factors
Severity - compare with the worst pain ever felt
Allergies
It is important to find this out early why?
Finding out they are allergic to penicillin or Morphine can prevent inadvertently causing harm to a patient further down the line
Medication
What questions can I ask?
How long have they taken medication for?
Have they taken it today as prescribed?
Has there been a recent change, either in drug or dosage?
Has a new medication been added recently?
Past medical history
The key here is relevance.
Why do we ask this?
Gaining an accurate patient history can help us understand current illnesses and add context to their signs and symptoms
Last oral intake
Why is this important?
Last ate or drank could provide insight and context to symptoms.
It also highlights risk to the attending clinician if they were to need sedation/intubation/surgery.
Events leading to?
What can this information provide?
Vital clues as to the cause, progression and severity of the illness/injury.
What were they doing in the lead up to the illness/ injury?
What was happening in their immediate environment at the time of onset?
Could that be the trigger?
