Session 1: Taking a History

Question 1

Informed Consent

Answer 1

A voluntary decision is made whereby the patient is completely educated and aware of the process that is about to occur. They are aware of the purpose, benefits and risks associated with the said exercise (eg. technique or history taking) that is about to occur. The patient must CLEARLY agree whilst also know they are able to withdraw their consent at any time.

Question 2

Phases of Informed Consent Collection

Answer 2

1: Clinical history
2: Examination
3: Management

Question 3

Process of Informed Consent

Answer 3

• nature and diagnosis of complaint
• proposed treatment and management
• benefits of treatment and management
• disclosure of possible risks
• who will be involved in management
• other treatment and management options

Question 4

Part 1: Presenting Complaint (OSQIRTPAARN)

Answer 4

O - onset
S - Site
Q - quality (type of pain)
I - Intensity
R - Radiation/referral
T - Timing
P - Progression
A - Associated Symptoms
A - Aggravating Factors
R - Relieving Factors
N - No Effect

Question 5

Part 2: Complaint History

Answer 5

Previous Episodes
Past treatment for complaint (practitioners seen about injury)
Previous investigations

Question 6

Part 3: Medical History

Answer 6

Medications (prescribed, self-prescribed, supplements, herbs, vitamins)
Major illness
Injuries/accidents/traumas
Surgeries
Relevant family history

Question 7

Part 4: Systems History

Answer 7

Cardiovascular
Respiratory
Gastrointestinal
Reproductive
Genitourinary
Endocrine
Neurological
Dental/optical
Ear/nose/throat/eyes
Diet/tobacco/alcohol/rec. drug use/QOL
Historical factors: Psychological, dental&opthalmic

Question 8

Red Flags

Answer 8

A sign or a symptom that indicates the possible or probable presence of a serious medical condition that has the potential to cause disability or death unless managed.

Question 9

Symptom (Red Flag)

Answer 9

Subjective
Abnormal
Described by the person feeling them
Experienced by the patient
Cannot be seen (eg. numbness)

Question 10

Sign (Red Flag)

Answer 10

Objective
Abnormal
Discovered by practitioner
Indicators of a problem
Seen (eg. sweating)

Question 11

Examples of red flags

Answer 11

Persistent night pain
Chest pain
Unexplained weight loss
Changes in bladder function
Sudden weakness
Bilateral neurological symptoms