CLS105 Week 4 Lecture

Assessment and the Medical Interview

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Learning Objectives
• demonstrate (evidence based) patient assessment skills
required to perform primary and secondary surveys, and
patient interviews

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History Taking
Aim: to ensure the patient receives the right treatment for the
right condition

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Importance of history taking
• 90% of diagnosis made on history
• Figure rises when supported by physical examination
• Higher still with addition of lab investigations

• Challenge: scenes may be chaotic, noisy & full of distractions

Crucial to take a structured approach – consultation models

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Setting the scene…
Choose most appropriate model for situation – assess urgency!
Remember importance of communication skills
Importance of dialogue
Invite the patients story
Build shared understanding

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Taking the history: What do you need to know?

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Categories of information
•Presenting complaint
•History of presenting complaint
•Allergies
•Past medical history
•Drug history
•Social history
•Family history

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Presenting Complaint (PC)
• May be verbal or non-verbal
• Presenting complaint is not always as it seems
• Don’t put blinkers on

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SAMPLE
•Signs & Symptoms
•Allergies
•Medications
•Past Medical History
•Last oral intake
•Events leading up to illness / injury

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Signs & Symptoms of Presenting Complaint
OPQRST: SOCRATES:
•Onset •Site
•Provocation / Palliation •Onset
•Quality •Character
•Radiation / Referral •Radiation
•Severity •Associated symptoms
•Time •Timing
•Exacerbates / Alleviates
•Severity

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Allergies - why do we need to check?
• Adverse drug events can cause illness or death of patients
• Administration of drugs to which an allergy is known is a
preventable cause of patient harm

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Allergic Reactions - symptoms
• Rash (urticaria)
• Nausea, vomiting and diarrhoea
• Airway swelling
• Bronchoconstriction
• Hypotension
• Shock, coma and death

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Medication
• Prescribed
• OTC
• Herbal
• Illegal / Illicit
• Allergies / Sensitivities

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Medication – why do we need to know?

• Helps avoid drug interactions & subsequent harm to patients

• Provides important clues about patient’s medical history
• Provides clues about risk factors for other conditions
• May provide clues as to cause of presenting complaint

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Past Medical History
• Medical history (inc childhood illnesses)
• Surgical history
• Obstetric / gynaecological history
• Trauma
• Any heart disease, epilepsy, CVA, hypertension, diabetes,
asthma/COPD, DVT/PE
• Risk factors
• Immunisations

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Last oral intake
• Surgery may be required
• May be relevant to the diagnosis

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Events leading up to the illness / injury
History of presenting complaint:
•Events occurring prior to ambulance arrival may determine your
treatment
•Events occurring prior to ambulance arrival may help to form a
diagnosis

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Extended history taking
•Can be helpful to get more complete picture

•Only to be used in non-time critical patients!

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Family history
• Health of siblings
• Cause and age of death – parents & siblings
• History of CHD, HTN, respiratory diseases, diabetes, cancer
• Hereditary conditions
• Contagious disease

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Social history
Lifestyle factors:
• Smoking, alcohol, diet
• Domestic environment - Abuse? Domestic violence?
• Social interaction & support
• Hobbies
• Independence - activities of daily living (ADLs)
• Occupation - retired or working?
• Sexual history (if appropriate)

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Decisions & Documentation
• History + physical exam + vital signs = working diagnosis
• Working diagnosis & differential diagnosis needed to
formulate a treatment plan
• All decisions on treatment & transport need to be discussed
with the patient
• Importance of documentation!

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