EAC obtaining a concise patient history

Question 1

global overview of the patient consists of:

Answer 1

sick or BIG SICK
Obvious distress
use of accessory muscles
pallor
cyanosis
other obvious signs of compromise

Question 2

observations consist of:

Answer 2

pulse
respirations
blood pressure
temperature
BM
SpO2/EtCo2
2 lead/12 lead ECG as appropriate

Question 3

JACCO

Answer 3

Jaundice
Anaemia
Cyanosis
Clubbing
Oedema

Question 4

Jaundice

Answer 4

build up of Bilirubin (orange/yellow pigment), possible liver disease, gallstones

Question 5

Anaemia

Answer 5

conjunctive pallor

fewer red blood cells or Haemoglobin = less O2

Question 6

Cyanosis

Answer 6

Central and/or peripheral

circulatory or ventilator problems = reduced blood oxygenation

Question 7

Clubbing

Answer 7

associated with lung and heart disease

Question 8

Oedema

Answer 8

fluid retention

possible underlying heart condition

Question 9

History

Answer 9

PC
HxPC
PMHx
DHx
S/FHx
RoS
SAMPLE Hx

Question 10

examination

Answer 10

O/E
IMP
SAMPLE Hx
Allergies

Question 11

SAMPLE Hx

Answer 11

Signs & Symptoms
Allergies
Medication
Past illnesses
Last meal
Events leading up to/Environment

Question 12

Reporting

Answer 12

essential part of assessment and care is the accurate reporting of your findings and treatment on the PRF

what you DID and DIDN’T do

Question 13

PC

Answer 13

presenting complaint

establish the presenting complain

Question 14

HxPC

Answer 14

history of primary complaint

clarify each question to get a clear picture of the sequence of events, consider associated symptoms

Question 15

PMHx

Answer 15

previous medical history

use appropriate language and key questions e.g. “do you see your doctor or nurse for anything” or “have you ever been in hospital”

Question 16

DHx

Answer 16

drug history

record accurately - can use medications to confirm/check PMHx by asking patient to give reason for taking each drug

Question 17

S/FHx

Answer 17

social/family history

current support networks, occupation, formal care packages, family medical history e.g. diabetes, hypertension and heart disease, smoking, alcohol, recreational drug use

Question 18

RoS

Answer 18

review of systems

couple of key questions for each major system e.g. “have you had a heart attack/stroke/fit/faint or funny turn”
cardiac, respiratory, digestive, urinary etc.

Question 19

O/E

Answer 19

a physical examination

Question 20

IMP

Answer 20

your overall impression and that of the patient. they often know what’s wrong with them, ASK!

Question 21

SOCRATES

Answer 21

Site - Where is the pain? Or the maximal site of the pain.

Onset - When did the pain start, and was it sudden or gradual? Include also whether if it is progressive or regressive.

Character - What is the pain like? An ache? Stabbing?

Radiation - Does the pain radiate anywhere? (See also Radiation.)

Associations - Any other signs or symptoms associated with the pain?

Time course - Does the pain follow any pattern?

Exacerbating/Relieving factors - Does anything change the pain?

Severity - How bad is the pain?

Question 22

Allergies

Answer 22

establish exact nature of perceived allergy to distinguish between true allergy and sensitivity.