History taking

What is the order for history taking?

PC (Presenting complaint)

HxPC (History of presenting complaint)

DDx (Differential diagnosis) - ideally, obs are being taken at same time

SAMPLE (Signs and symptoms [Including SOCRATES], Allergies, Medications, Past Medical History, Last meal, Events/Evaluate all said)

If not already covered in SAMPLE, should ensure you have:

• DHx (Medications and allergies)

• FHx (family history)

• SHx (Social history)

RoS (Review of Systems)

Now you should have an IMP (Impression)

Now move onto TxT

What is the presenting complaint (PC), and what questions could you ask as part of this?

Objective statement of what the patient thinks is wrong with them. Should be documented verbatim.

• What has happened today?

• What have you called us for?

• What is going on?

What is the presenting complaint (PC), and what questions could you ask as part of this?

Objective statement of what the patient thinks is wrong with them. Should be documented verbatim.

• What has happened today?

• What have you called us for?

• What is going on?

What are the Differential Diagnoses (DDx)?

What are all the things it could be?

Describe the SAMPLE process and questions you could ask for each element of it

S - Signs and symptoms

• Ask questions pertaining to the signs (what you see) and symptoms (what pat is experiencing) to rule out DDx. Use SOCRATES to evaluate

A - Allergies

• Do you have any allergies?

M - Medications

• What prescribed medication are you taking?

• Are you on any prescribed medication?

• Have you taken any recreational drugs?

• Do you have a prescription list?

• Do you mind if I access your medical records?

P - Past medical history

• Do you have any medical conditions, have you had any medical conditions?

L - Last meal

• When was your last meal and what was it? When was your last bowl movement and was it normal? Have you been passing urine okay and what has it looked like?

E - Evaluate/Events

• What led up to you experiencing this problem?

• What made you call?

• So just to confirm… XYZ

Describe SOCRATES and questions you could ask in each section

S - Site

• Can you point to the pain/feeling?

O - Onset

• When did it start?

• Was it gradual or sudden?

• What were you doing at the time?

C - Character

• What does it feel like?

R - Radiation

• Does it move?

• Does it go anywhere else?

A - Association

• Does it make you feel anything else?

T - Timescale

• How long has it been going on for?

• Is it there all the time? Or does it come and go?

E - Exacerbating factors

• Does anything make it worse?

• Does anything maker it better?

S - Severity

• How bad is it on a scale of one to ten? One being a slight annoyance and 10 being the worst pain you could ever imagine?

Describe the Review of Systems (RoS) and questions you could ask

Review of bodily systems based on presenting complaint and your history taking, relating to your impression and differential diagnosis.

• e.g. if sounds like breathing and or cardiac problem, ask questions pertaining to the cardiovascular and respiratory system.

  • Does it hurt when you reach up?

  • Do you have any swelling on your feet or ankles? When did that start?

  • On one lung or both lung?