Unit 18: History Gathering

Question 1

What or who are sources of medical history?

Answer 1

The patient, family members, bystanders, the scene, other professionals, medic alert tags, medications and the patients wallet or purse.

Question 2

Medical History Sources: The Patient

Answer 2

If the patient is alert and able, question them

Question 3

Medical History Sources: Family members/bystanders

Answer 3

witnesses will have an outside perspective on the incident

Question 4

Medical History Sources: The Scene

Answer 4

the mechanism of illness or the mechanism of trauma may be apparent at the scene

Question 5

Medical History Sources: Other Professionals

Answer 5

The police or fire department may have arrived first and already gathered information

Question 6

Medical History Sources: Medic alert tags

Answer 6

A patient may have a bracelet, anklet, tattoo etc with warnings about pre-existing medical conditions

Question 7

Medical History Sources: medications

Answer 7

Medications prescribed to the patient may give a clue to the patients medical history

Question 8

Medical History Sources: Wallet or purse

Answer 8

Their personal info may have clues to prE-existing medical conditions: CHECK WITH EITHER YOUR PARTNER OR THE POLICE

Question 9

Obtaining Patient History: 1. Approaching the scene

Answer 9

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?)

Question 10

Obtaining Patient History: 2. During the primary survey/ head to toe examination

Answer 10

Medical alerts may be present, medical implants, scars, and medications may provide more information

Question 11

Obtaining Patient History: 3. Formal History gathering (After primary survey and critical interventions)

Answer 11

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

Question 12

What are the components of a general patient history?

Answer 12

Scene observations and patient overview

Question 13

What are the components of a Focused History?

Answer 13

Consists of AMPLE and OPQRST

Question 14

What does AMPLE stand for?

Answer 14

Allergies, Medications, Past Medical Care, Last Oral Intake, Events leading up to Incident

Question 15

AMPLE: Allergies

Answer 15

Does the patient have allergies? Would they have contributed to the patients chief complaint?

Question 16

AMPLE: Medications

Answer 16

What medications are they on? did they possibly contribute to the chief complaint? will they exacerbate your treatment plan?

Question 17

AMPLE: Past Medical History

Answer 17

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

Question 18

AMPLE: Last Oral Intake

Answer 18

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.

Question 19

AMPLE: Events Leading Up to Chief Complaint

Answer 19

find out the mechanism of injury/ illness, what’s at the scene, who was with the patient. If details are vague, assume the worst.

Question 20

What do you use OPQRST for?

Answer 20

OPQRST is used to assess the location and severity of pain the patient is experiencing, in the head, chest and abdomen.

Question 21

OPQRST: Onset

Answer 21

What was the patient doing when the pain started? Did the pain come on gradually or suddenly?

Question 22

OPQRST: Provocation

Answer 22

What makes the pain worse or better? Did they take medication when it started? did it help?

Question 23

OPQRST: Quality

Answer 23

What does the pain feel like? How would the patient describe the pain in one word?

Question 24

OPQRST: Radiation

Answer 24

where is the pain? doe sthe pain go anywhere?

Question 25

OPQRST: Severity

Answer 25

on a scale of 0-10 how bad is the pain? 0 is non-existent, 10 is the worst pain in your life

Question 26

OPQRST: Time

Answer 26

When did the pain start?