Chapter 9. Taking a medical history
In medical illness, the history affords 70% of the information on which most diagnoses are made.
The history is thus much more important than the physical examination in establishing a diagnosis.
Assessment and correction of any problems in airway, breathing and circulation will take priority.
The aims of history-taking are to establish:
• What has happened (the history)
• What the patient feels to be wrong (the symptoms)
• The background to the current events (the past medical history)
• What medication the patient is taking
• A list of possible diagnoses (the differential diagnosis)
• Priorities for treatment
• Information that will not be available later (e.g. from the scene).
Structure of the history
However detailed or simple a medical history is being taken, a structured approach is essential. While at the scene a detailed history is not usually appropriate, a brief outline history is ample – and ‘AMPLE’ is a useful mnemonic to remember what constitutes an adequate history at the scene:
A – Allergies
In all emergencies other than cardiac arrest, it is important to try to establish any known allergies before drugs are administered.
M – Medicines
The presence of medications in the bloodstream may influence the response to injury or illness or to any other drugs which may be given. Knowledge of what medication the patient has been taking may indicate the severity and duration of any pre-existing illness.
P – Past medical history
The past medical history has a major bearing on responses to treatment and possible outcomes from illness or injury. It also offers vital clues as to what the current problem may be. Particular note should be made of any known cardiac disease, respiratory disease or such chronic conditions as diabetes or epilepsy.
L – Last food and drink
A full stomach is a major risk factor for regurgitation and consequent airway compromise. It is also helpful to obtain information about the patient’s nutritional status and general level of self-care.
E – Events leading up to the current problem
This is the core of the history. The other elements are important but this is the key to understanding what is happening to the patient now.
Not all of the information needs to be acquired at the scene; some can be acquired en route to the hospital.
Often, rather than attempting to laboriously establish the drug history in detail, all medications should be gathered together and taken to the hospital with the patient.
Sources of information
The scene
There may be vital clues at the scene and in the vast majority of cases, only Ambulance service personnel will have the chance of interpreting them and carrying the information to those who will subsequently be caring for the patient.
The patient
If the patient cannot cooperate, further information can be sought from bystanders or witnesses.
The witnesses
Witnesses may help with information about the mechanism of injury. Some witnesses or bystanders may know the patient and be able to give background information.
Medical information devices
Medic-Alert® bracelets or necklaces are always worth looking for. Horse riders may carry medical information in a recess inside their crash helmet. Many patients have lists of medication on their person and the elderly often carry containers with compartments for timed administration of tablets.
Information to be gleaned at the scene
• Is the patient and are the surroundings clean and tidy?
• Are there carers present?
• Is it an environment to which the patient could return?
• Are there bottles of medication which could be taken to the hospital?
• Are there empty pill bottles indicating a possible overdose?
• Is there evidence of alcohol or drug abuse?
• If the patient is unconscious, are there any clues at the scene that might help establish the duration or cause of the unconsciousness?
The art of questioning
• Obtaining information from frightened, ill or injured patients is made easier by a positive, confident and friendly approach
• Patients who are confused or deaf may be reassured more by a smile than by the words that are spoken
• Whenever possible, practitioners should position themselves at the same level as the patient, e.g. kneeling beside a patient who is lying on the floor
• Eye contact should be maintained if possible
• Always introduce yourself
• Avoid inappropriate familiarity. Older patients appreciate the correct use of their surname and title, at the very least on first introductions
• Maintain conversation with the patient
• Establish the patient’s name and age
• Questioning should begin with open questions such as: ‘Tell me what the matter is’. Open questions can then be followed by questions that focus on the complaint.
Symptoms such as pain can be explored with a set of specific queries:
‘What’s the pain like?’
‘How long have you had it?’
‘Have you ever had a pain like this before?’
‘What makes the pain worse?’
Classic descriptions of pain
Chest pain: ‘like an iron band round my chest’ is virtually specific to myocardial ischaemia.
Sudden pain: ‘like a severe blow in the back of the neck’ suggests subarachnoid haemorrhage.
Passing on the information
The key points of the history should be recorded with brevity and clarity. In many situations, a printed form assists recording of the history and findings at the scene.
The summary should include:
• The patient’s name (if known)
• The patient’s age (if known)
• The events surrounding the involvement of the emergency medical services
• Past history.
The receiving doctor or other professionals will need a brief handover initially but will generally have more time to receive information after they have completed the primary survey, which may only take a very few minutes.
It is essential that prehospital personnel are actively involved in the handover and do not leave until they have imparted all the information that they think is relevant to the case.
Good emergency departments will ensure a brief period of undivided attention to the incoming crew for the initial brief handover.
A copy of the prehospital record must accompany the inpatient notes to allow a complete picture of the injury or illness to be recorded.
For further information, see Ch. 9 in Emergency Care: A Textbook for Paramedics.
