History Taking

Question 1

SAMPLE

Answer 1

Signs and symptoms
Allergies
Medications
Past illnesses
Last oral intake
Events leading up present illness/injury

Question 2

Calgary Cambridge

Answer 2

Patient centred approach
Introduction which maintains patient dignity, privacy and comfort. Clarify concerns and expectations.
Presenting complaint - initially using open ended questions.

Question 3

Pain assessment tools

Answer 3

SOCRATES
OPQRST

Question 4

SOCRATES

Answer 4

Site
Onset
Character
Radiation
Associated symptoms
Timing
Exacerbates/relieves
Severity - 1-10

Question 5

OPQRST

Answer 5

Onset
Pain
Quality/quantity
Radiation
Severity/score/symptoms
Timing

Question 6

Continuing history

Answer 6

History of presenting complaint - how long has it been going on? has anything like this ever happened before?
Past medical history, including surgical
Drugs history - medication, allergies, smoking, alcohol.
Family history
Social history - who do people live with? additional support? coping with activities of daily living?
Occupational history - jobs with risk factors.

Systems enquiry

Question 7

Systems enquiry

Answer 7

Mental health
Neurological - headache, dizziness, limb weakness, confusion
EENT - eyes, ears, nose, throat, vision/hearing problems
Chest/respiratory - breathlessness, cough, wheeze, sputum, haemoptysis.
Cardiovascular - chest pain, palpitations, breathlessness, orthopnea, oedema.
Gastrointestinal - indigestion, vomiting, dysphagia, abdominal pain, diahorrea.
GUS - dysuria, haematuria, sexually active, contraception.
MSK - joint pain, stiffness, swelling, previous surgery
Integumentary - pruitis, skin rash, itchy, bruising, allergies.
Immunological - HIV, flu/covid vaccine, recurrent infections

Question 8

Summary

Answer 8

Situation
Background
Assessment
Recommendations

Plan
Documentation