Unit 18: History Gathering Flashcards
What or who are sources of medical history?
The patient, family members, bystanders, the scene, other professionals, medic alert tags, medications and the patients wallet or purse.
Medical History Sources: The Patient
If the patient is alert and able, question them
Medical History Sources: Family members/bystanders
witnesses will have an outside perspective on the incident
Medical History Sources: The Scene
the mechanism of illness or the mechanism of trauma may be apparent at the scene
Medical History Sources: Other Professionals
The police or fire department may have arrived first and already gathered information
Medical History Sources: Medic alert tags
A patient may have a bracelet, anklet, tattoo etc with warnings about pre-existing medical conditions
Medical History Sources: medications
Medications prescribed to the patient may give a clue to the patients medical history
Medical History Sources: Wallet or purse
Their personal info may have clues to prE-existing medical conditions: CHECK WITH EITHER YOUR PARTNER OR THE POLICE
Obtaining Patient History: 1. Approaching the scene
Is the mechanism of injury or illness apparent? are there reasons for an altered state of consciousness(Alcohol, etc) What is their physical appearance? (Skin colour, visible blood, angulated fractures, what position are they in?)
Obtaining Patient History: 2. During the primary survey/ head to toe examination
Medical alerts may be present, medical implants, scars, and medications may provide more information
Obtaining Patient History: 3. Formal History gathering (After primary survey and critical interventions)
Take AMPLE and OPQRST after transport decision
- in Load and Go, ask in ambulance
- in Stay and Stabilize, ask as other team members collect vitals
What are the components of a general patient history?
Scene observations and patient overview
What are the components of a Focused History?
Consists of AMPLE and OPQRST
What does AMPLE stand for?
Allergies, Medications, Past Medical Care, Last Oral Intake, Events leading up to Incident
AMPLE: Allergies
Does the patient have allergies? Would they have contributed to the patients chief complaint?
AMPLE: Medications
What medications are they on? did they possibly contribute to the chief complaint? will they exacerbate your treatment plan?
AMPLE: Past Medical History
Gives cues to changes in how medication works on them, what medications they’ve taken. Recent procedures etc
*repeat back to the patient for the sake of clarity
AMPLE: Last Oral Intake
Find out what the last medication they took was, when they last ate, and when they last drank. Surgeons need to know if the patient has a full stomach, and it helps you determine if medications or noxious substances have contributed to their condition.
AMPLE: Events Leading Up to Chief Complaint
find out the mechanism of injury/ illness, what’s at the scene, who was with the patient. If details are vague, assume the worst.
What do you use OPQRST for?
OPQRST is used to assess the location and severity of pain the patient is experiencing, in the head, chest and abdomen.
OPQRST: Onset
What was the patient doing when the pain started? Did the pain come on gradually or suddenly?
OPQRST: Provocation
What makes the pain worse or better? Did they take medication when it started? did it help?
OPQRST: Quality
What does the pain feel like? How would the patient describe the pain in one word?
OPQRST: Radiation
where is the pain? doe sthe pain go anywhere?
OPQRST: Severity
on a scale of 0-10 how bad is the pain? 0 is non-existent, 10 is the worst pain in your life
OPQRST: Time
When did the pain start?
