EAC obtaining a concise patient history Flashcards
global overview of the patient consists of:
sick or BIG SICK Obvious distress use of accessory muscles pallor cyanosis other obvious signs of compromise
observations consist of:
pulse respirations blood pressure temperature BM SpO2/EtCo2 2 lead/12 lead ECG as appropriate
JACCO
Jaundice Anaemia Cyanosis Clubbing Oedema
Jaundice
build up of Bilirubin (orange/yellow pigment), possible liver disease, gallstones
Anaemia
conjunctive pallor
fewer red blood cells or Haemoglobin = less O2
Cyanosis
Central and/or peripheral
circulatory or ventilator problems = reduced blood oxygenation
Clubbing
associated with lung and heart disease
Oedema
fluid retention
possible underlying heart condition
History
PC HxPC PMHx DHx S/FHx RoS SAMPLE Hx
examination
O/E
IMP
SAMPLE Hx
Allergies
SAMPLE Hx
Signs & Symptoms Allergies Medication Past illnesses Last meal Events leading up to/Environment
Reporting
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
PC
presenting complaint
establish the presenting complain
HxPC
history of primary complaint
clarify each question to get a clear picture of the sequence of events, consider associated symptoms
PMHx
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”
DHx
drug history
record accurately - can use medications to confirm/check PMHx by asking patient to give reason for taking each drug
S/FHx
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
RoS
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.
O/E
a physical examination
IMP
your overall impression and that of the patient. they often know what’s wrong with them, ASK!
SOCRATES
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?
Allergies
establish exact nature of perceived allergy to distinguish between true allergy and sensitivity.
