Monday, June 16, 2025

Taking and Giving A Patient History

Earlier this year (wow, time is flying by) the importance of maintaining personal medical records was addressed.  Every individual needs a hard copy of his personal medical records before there's a crisis.  These records will be kept by each individual and they will need to be taken to the caregiver each time for recording notes.  In a collapse, there probably isn't going to be an office employee doing all this for you.

I have to admit, I truly hate going to see the doctor.  I hate the time wasted, I hate sitting in a waiting room of sick people infested with diseases just dying to get me, and I hate being questioned by a doctor, most of whom in my experience have been class A jerks.  Of course, not all doctors are like this, but an awful lot are.  Maybe I've just been lucky.

Anyway, when someone is sick or injured, there are a lot of questions that need to be asked and answered in order to provide the best outcome.  Try not to view all these questions as an invasion of privacy or unwarranted curiosity on their part.  Seemingly insignificant events can be of utmost importance.  And a doctor can also figure out pretty quickly if you are lying.  Lies are often used to cover up stupid mistakes, right?  So if a guy gets super mad and punches the wall and as a result breaks a bone or two in the hand, he may not want to tell the doctor that he was so stupid.  And so he tells him that he fell.  Problem is, bones break in one way when a person punches the wall, and in an entirely different way when a person falls.  The doctor already suspects the guy is lying based on which bones appear to be broken in his initial examination; he knows the guy is lying when the x-rays come in.

Unfortunately, without nifty diagnostic tests and x-rays, doctors are going to have to be a lot more discerning and ask more questions.  And they have to be told the truth.  Doctor-patient confidentiality will still be a thing.  They're going to have to know if you've been unfaithful to your spouse or if you've been abusing substances.

There are a lot of mnemonics care providers use to remember to gather all the information possible from a patient.  Many of these will be covered in another post and pertain more to what the caregiver observes.  This post is devoted to the information that the patient or family member shares.  Just as the nurse or doctor should not skimp on or skip taking a history, neither should the patient skimp on the information provided.


SAMPLE is the mnemonic most commonly used for taking a patient history.  These are the questions a patient is going to be asked.
  • Symptoms and Signs.  What is bothering you?  What happened?  What has changed?  Is there a fever, pain, a rash, or swelling?  If there is diarrhea, is it totally watery, or just loose?  Bloody or mucous-y?   How long has this been going on?  What patient shares are the symptoms.  What the caregiver sees are signs.   
  • Allergies.  All allergies--seasonal, foods, medications, and insects--need to be reported.  When it comes to an allergy due to a medication, was it a life-threatening allergy, or simply a rash?    Rashes arise due to many antibiotics, but it doesn't necessarily mean the patient has a life-threatening or even potentially life-threatening allergy.  There are some life-threatening conditions that can only be treated by antibiotics.  If a patient has only experienced a rash in the past, that drug might still be used, though the patient will be much more carefully monitored.    However, if it was anaphylaxis, then that drug can't be used, even if there are no other options.  A primitive skin test where the skin is scratched and a paste or powder of the drug in question is applied to observe the patient's reaction may help determine whether to use that drug.
  • Medications.  The mnemonic PORCCH covers the medications a person uses:
    • Prescriptions
    • Over-the-counter
    • Recreational drugs
    • Contraceptives
    • Compliance (are drugs used as directed by the physician or the bottle?)
    • Herbal supplements and vitamins and minerals
  • Past medical history.  Has this happened before?  Has this been developing slowly over time, or is it a sudden onset?  Does the patient have a medical condition predisposing him to what he has now?  What illnesses have you had recently?  Any bug bites in the last month or so?  Last period?  Was it normal? Have pregnancies been normal, without problems? Any chance she could be pregnant? (I have always, always hated those last questions.  They seem so invasive.  But it's really important that the doctor knows.)
  • Last intake/output.  The last time eating usually pertains more to whether there is a need for surgery, but it is sometimes helpful to know.  Depending on the reason for seeking treatment, a doctor may definitely want to know the last time the patient urinated or defecated and whether everything was normal.  
  • Events.  What happened to lead up to this pain or complaint?  When did it start? Where did it start?  Where does it hurt?  Has anyone near you experienced anything similar?
Another mnemonic is commonly used for helping to describe pain:
  • O--Onset.  Was the onset gradual or sudden?
  • P--Provoke or Palliate.  Is there anything that makes the pain worse or better?
  • Q--Quality.  Is the pain constant, or does it come and go?  Is it throbbing?  Is it dull or sharp?
  • R--Radiate or Refer.  Does the pain move anywhere?
  • S--Severity.  Rate the pain on a scale of 1 to 10.
  • T--Time. When did it start?

The answers to any of these questions may prompt the care provider to ask more questions, questions which may seem even more invasive.  Try to keep in mind that the doctor is trying to provide the best care possible in what may be a very difficult situation with limited resources.  Lots of medications can have drug interactions with other meds or with food.  Some medications or herbs can make illnesses worse.  Lots of conditions have rather unspecific symptoms, but if someone else in your family is experiencing something similar even if it's not as bad, that can narrow things down.

Remember, the more information provided, the faster and more accurate the diagnosis and treatment, and the sooner the patient will begin to improve.

Links to related posts:
Maintaining personal medical records

For further reading:
https://emttrainingbase.com/taking-sample-history-opqrst-pain-assessment/
https://www.ems1.com/patient-assessment/articles/186807048-How-to-use-SAMPLE-history-as-an-effective-patient-assessment-tool/
https://www.sampleforms.com/sample-medical-history-form.html

© 2019, PrepSchoolDaily.blogspot.com  

3 august 2021

No comments:

Post a Comment

Basic White Sandwich Bread