Patient Assessment Techniques

Study Notes

SAMPLE History

A method to gather medical history from patients, their families, and bystanders.
Components include Allergies, Medications, Pertinent Past History, Last Oral Intake, and Events leading up to the injury or illness.
Important to document findings on the Prehospital Care Report (PCR).

Signs

Observable and measurable patient data, such as vital signs.

Symptoms

Subjective experiences reported by the patient, like pain or numbness.
Can be assessed using the OPQRST method.

OPQRST

Acronym for assessing symptoms:
- Onset: When did it start?
- Provocation or Palliation: What makes it worse or better?
- Quality of Pain: How can the pain be described?
- Region and Radiation: Exact location of the pain and if it radiates.
- Severity: Rate the pain on a scale of 1 to 10.
- Time: Duration and progression of symptoms.

Onset

Questions to determine activities at the time symptoms began.

Provocation or Palliation

Inquiry about factors that exacerbate or relieve symptoms.

Quality of Pain

Asking for descriptions of pain (sharp, dull, constant, intermittent).

Region and Radiation

Questioning the specific location of pain and whether it spreads elsewhere; significant for conditions like myocardial infarction.

Severity

Rating pain intensity on a scale from 1 to 10.

Time

Understanding duration and the progression of symptoms over time.

Allergies

Includes reactions to medications, food, or environmental factors.
Check for medical alert tags for critical information.

Medications

Queries about current medications, recent intake, and any herbal or recreational drugs.
Ensure the patient knows it's for treatment purposes and not law enforcement.

Pertinent Past History

Inquiry about any previous illnesses, hospitalizations, or surgical procedures to understand the patient's health background.

Last Oral Intake

Asking about the last food or drink consumed to evaluate conditions like hypoglycemia, especially in diabetics.

Events Leading Up to the Injury or Illness

Seeking details about circumstances surrounding the incident to identify underlying causes.

Description

Explore the methods of gathering patient medical history and understanding their signs and symptoms. This quiz focuses on the importance of documenting findings and utilizing the OPQRST assessment method effectively. Enhance your prehospital care skills through this comprehensive assessment of essential patient information.