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HISTORY TAKING
Online Learning Module
Community First Responders
DO WE REALLY NEED A SYSTEMATIC APPROACH?
A Systematic Approach
If you have undertaken the previous module covering Clinical Assessment, you will understand the importance of a systematic approach. By approaching a situation in a systematic way we not only identify critical issues early, we can also work in an efficient manner. This will lead to the patient receiving the right care at the right time.
DR<C>ABCDE RECAP!
Now I Know My ABC...
In the last module we introduced a slightly different approach to Patient assessment using the D-E system. If you would like to look at that again please Navigate to the course catalogue on the academy and search for 'Clinical Assessment'.
WHAT IS SAMPLE?
S
A
Lets Have A Look At SAMPLE
M
SAMPLE is a tool we can use to obtain a patients history.
Signs and symptoms
Allergies
Medication
Past Medical History
Last Oral intake
Events Leading to..
P
L
E
S- SIGNS AND SYMPTOMS
S
A patient's/family's report of signs and symptoms they have observed/felt is important.
It is important to look at both signs and symptoms, why?
Symptoms are subjective and only apparent to the patient, each patient's experience of symptoms is unique to them.
Signs are more objective, and provide evidence that can be observed by others.
A FEW EXAMPLES....
What Are The Signs You Speak Of?
- Rashes
- Injuries - including wounds, deformity, swelling...
- Skin pallor - flushed, pale, cyanosed...
- Evidence of drug paraphernalia
- Evidence of oxygen therapy e.g. O2 cylinders in the home
- Sweating
- Shivering/tremors
- Fast/ slow/ strong/weak pulse
- Abnormal breathing
A FEW EXAMPLES OF SYMPTOMS
How Do You Feel?
- Hot/cold
- Nauseous
- Pain
- Dizzy
- Pins and needles
- Fatigued
- Anxious
- Hallucinations
- Blurred vision
HOW CAN WE ASSESS PAIN EFFECTIVELY?
We've done ABC what about PQRST?
Pain is very subjective, often linked to tolerance levels and past experience, but it can provide us with vital information leading to a diagnosis. PQRST is a tool used in pain assessment, it aids the patient to describe their pain.
Another tool you can use is SOCRATES
PQRST
- 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 you can sometimes contextulise this by asking whats the worst pain they've had prior to this episode?
- Time - when did it first occur? how long does it last?
REMEMBER PAIN IS SUBJECTIVE, DON'T ALLOW YOUR EXPERIENCE OF PAIN AFFECT YOUR ASSESSMENT. REMAIN OBJECTIVE.
ONE THING ONLY I KNOW, AND THAT IS THAT I KNOW NOTHING
- SOCRATES
SOCRATES
Site
Onset
Character
Radiation
Associated features - e.g nausea, vomiting
Timing
Exacerbating/relieving factors
Severity - compare with the worst pain ever felt
A- ALLERGIES
Although we tend to focus on true allergies, in terms of Anaphylaxis, Sensitivity to drugs/medication may also be relevant.
Its important to find this information out early.
For example, our patient my be conscious on arrival but their condition can change while on scene. Finding out they are allergic to Penicillin or Morphine can prevent inadvertently causing harm to a patient further down the line.
M -MEDICATION
Repeat prescription slips and 'message in a bottle' can be key in identifying any medications belonging to a patient. Along with finding out what medication they are currently taking, other questions are equally important, these may include:
- How long have they taken the 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?
Don't forget to ask about over the counter and herbal medicines they may be taking.
Message in a bottle
P- PAST MEDICAL HISTORY
The key here is relevance!
What happened to our patient at age 7 is not always relevant to what is happening now.
If our patient is suffering from chest pain is the fact that they broke their arm at age 7 relevant? Conversely if they had open heart surgery at age 7 and are suffering chest pain is that relevant?
Gaining an accurate patient history can help us understand current illnesses and add context to their signs and symptoms.
L - LAST ORAL INTAKE
Why is this important?
When they last ate or drank could provide insight and context to symptoms, especially if looked at in conjunction with the other areas of SAMPLE we have already explored.
It also highlights risk to the attending clinician if they were to need sedation/intubation/surgery.
E-EVENTS LEADING TO...
This information can 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?
SAMPLE DOESN'T APPEAR ON OUR PATIENT REPORT FORM(PRF) THOUGH!
SAMPLE is just one tool you can use, and although it doesn't explicitly appear on our PRFs it can still be recorded there.
Recording SAMPLE On My PRF?
A PRF may use another tool which we will look at in more detail now.
PRF AIDE MEMOIRE
The picture below shows another systematic approach to obtaining a patients history that you may see. Lets look at what the abbreviations mean and see how its just a different tool to do the same job.
PRF Incident Summary
HISTORY RECORDING EXAMPLE
PRF Completion Using SAMPLE
S - On arrival patient was stood in doorway, looked pale and was visibly sweating. Patient complained of central chest pain which radiates to their jaw, assisted patient to sit in semi recumbent position supported against the wall. New irregular pulse weak at the radial, new onset breathlessness.
A - No Known Allergies (NKA) but has a sensitivity to Erythromycin
M- - Patient is prescribed GTN, taken today at 09:30, 10:00, 11:00 with no lasting benefit. Patient also takes regular OTC multivitamins (Tescos own),and OTC paracetamol - 2 x 500mg taken at 11:25
P - Patient suffers with Angina which is usually well controlled with medication. Recent history of surgery to left knee to rebuild anterior cruciate ligament 23/11/2019 at Lincoln county.
L - Ate breakfast at 7:30am, last drink was water at 11:25 with medication
E - The pain started at 9am, after attempting a new workout programme, and has gradually worsened over the last 3hrs. At onset pain score was 3/10 now scores 10/10.
Patient is a non smoker
Father died aged 68 from a Heart attack, paternal uncle diagnosed with unstable Angina lives with Wife, 2 children and a pet dog in a modern 3 storey town house.
No clinical interventions delivered.
AIDE MEMOIRE EXPLAINED
The word abbreviation sure is long for what it means.
-Zach Galifianakis
PMHx – Past medical history of the patient including past illnesses, hospital admissions, operations, treatments
Allergies – any allergies the patient might have including side effects of meds
DHx – Drug history – what meds are they taking? prescription/over the counter/herbal
Alc – Alcohol History
Smo – Smoking History (& illicit drug history)
FHx – Family History of illnesses
SHx – Social History (who is with them, who do they live with, who are they related to)
PC – Presenting complain
HxPC – History of the presenting complaint and the effects on activities of living if appropriate.
SE – Systemic enquiry. i.e. do they have problems
with the following “Systems”:
• CVS – Cardiovascular system
• RS – Respiratory System
• GIT – Gastrointestinal System
• UGT – Urogenital System
• CNS – Central Nervous System
• MSK – Musculoskeletal System
• Endocrine system
HISTORY RECORDING EXAMPLE
PRF Completion Using Incident Summary
PC/HcPX - On arrival patient was stood in doorway, looked pale and was visibly sweating. Patient complained of central chest pain which radiates to their jaw, assisted patient to sit in semi recumbent position supported against the wall. The pain started at 9am, after attempting a new workout programme, and has gradually worsened over the last 3hrs. At onset pain score was 3/10 now scores 10/10.
SE - CVS - new irregular pulse weak at the radial, RS- new onset breathlessness.
PMHX - patient suffers with Angina which is usually well controlled with medication. Recent history of surgery to left knee to rebuild anterior cruciate ligament 23/11/2019 at Lincoln county.
Allergies - NKA but has a sensitivity to Erythromycin.
DHx - Patient is prescribed GTN, taken today at 09:30, 10:00, 11:00 with no lasting benefit. Patient also takes regular OTC multivitamins (Tescos own),and OTC paracetamol - 2 x 500mg taken at 11:25
Alc - occasional drinker, at social events, none consumed in previous 24hrs
Smo - non smoker
FHx - Father died aged 68 from a Heart attack, paternal uncle diagnosed with unstable Angina
SHx- lives with Wife, 2 children and a pet dog in a modern 3 storey town house.
No clinical interventions delivered.