* Learning To Perform a Medical Assessment – Part 1: Quick Assessment and the Medical History *
By: Haumana
19 February 2005

If you don’t have a good book on what to do if there is no doctor and you don’t have years of healthcare experience, you are behind the power curve in medical preparation for survival. However, don’t despair, because this article will get you started on learning how to evaluate sick and injured people. That’s very important, because if you can’t figure out what’s happening, the best stocked medical kit won’t be of much use and might actually cause more harm than good.

An Initial Assessment - “It’s Easy As ABC…”

If you could ask a sick or injured person just one question to determine as much information about their well-being as possible, what might that question be? I’d ask them, “How are you feeling?”

If they respond with, “I feel sicker than a boiled owl” or something along those lines you have just gathered a tremendous amount of information about their current physical state: A – Airway is open B – Breathing is occurring C – Circulation of blood is going on D – Disabilities, if present, have not yet affected the higher brain function

Wow! You’ve just learned how to do a rapid patient assessment and what the ABCD’s are and you’ve done it with one question. That is very good work and you will need to memorize the ABCD’s.

Let’s try to make the rest of performing a more detailed medical assessment almost as painless as your initial assessment was. The first thing to learn is that there is no one perfect way to do this. All that you are trying to do is get the patient or someone with the patient to tell you a story. If you want this to go well, both you and the person telling the story need to be as comfortable as the situation permits and you need to stay calm and keep them calm.

A medical story is called a MEDICAL HISTORY and the information in it is SUBJECTIVE—you can’t see it, touch it, hear it on your own, taste it, or smell it, because those are OBJECTIVE findings and we’ll cover those later.

One way to start this is to ask, “What sort of problems are you having today?” This puts it in a time frame and you can hopefully just sit back and listen.

“My knee hurts.” Okay, you aren’t going to get to just sit and listen, because your patient isn’t going to make this easy for you. You need to remember that you’re just trying to get a story, so just keep it simple and ask a few pointed questions.

WHERE Questions: “Which knee hurts?” “What part of the knee hurts?” “Does the pain go anywhere besides the knee?”

WHEN Questions: “Does it hurt all of the time?” “How long has it been hurting?” “Is this the first time that it has hurt?”

WHAT Questions: “What where you doing when you first noticed it hurting?” “What makes it hurt more?” “What have you done that helps ease the pain?”

HOW Questions: “How severe is the pain on a scale of zero = no pain and 10 = the absolute worst pain that you can imagine?” ABCD was an easy mnemonic): OPQRST. Okay, this one is out of the normal order that you intuitively ask questions, but it is a quick checklist that will insure that you’ve covered the main areas: O – Onset. When and how did it start? P – Provocative and Palliative. What makes it better and what makes it worse are what this covers. Q – Quality. If it involves pain or another sensation, is it sharp, dull, throbbing, burning, crushing, etc.? R – Region and Radiation. Where is the problem? Be specific as you can and try to get the patient to narrow the location. S – Severity. Is it incapacitating or is it mild? How does it affect their ability to work or play? T – Timing. Is it constant or intermittent? Is there a time pattern (this ties into the Provocative and Palliative section)?

For some of your patients, you use the mnemonic to guide your efforts to dig a history from them and for other patients it helps to keep you and them focused on the main problem, if they have a tendency to ramble on about all sorts of other things. You can see that the HISTORY of PRESENT ILLNESS is just a story and we’re going to get more of the patient’s story.

“Do you have any medical problems or have you had any injuries?” “Have you ever been a patient in the hospital or had any surgery?” “Are there any medications that you take?” Are there any medications that you can’t take?” With these and similar questions you naturally move into the part of the assessment called the PAST MEDICAL HISTORY.

“Does anyone in your family have problems with their knees or other joints?” Now you have started the part of the assessment called FAMILY HISTORY.

By asking, “What do you do for a living?” and “Do you exercise or play any sports?” you move into the SOCIAL HISTORY.

By now you should be getting the impression that performing the SUBJECTIVE part of a medical assessment usually won’t be too hard. It doesn’t get tough until you have some medical knowledge and then it can be complicated by your prejudices; avoid this as much as you can. Methodical usually is better than leaping to conclusions

There is one last area in the SUBJECTIVE part of the medical assessment and it is often the most challenging area; the REVIEW OF SYSTEMS (ROS). In this part of the assessment we ask questions about the various organ systems and/or body regions. Here is a list of the major systems and regions, but until you get some medical background, it can be difficult to decide what questions you should ask and which systems should be asked about. Take our person with knee pain as an example. If it is your six year-old daughter who fell off of her bicycle, a review of her sexual history probably won’t be part of the exam. However, if it is a 21 year-old with no history of an injury, knowing if they have had unprotected sex becomes a valid part of the ROS—some sexually transmitted diseases can cause joint problems. If you don’t recognize some of the terms, don’t worry, because this list is just to give you examples and most of the terms can be looked up at places like dictionary.com, until you can start learning and using medical terms.

• SYSTEMIC: Weight loss––fever––night sweats––trouble sleeping––loss of energy––arthritis––Other:
• NEUROLOGIC: Headache––convulsions––seizures––fainting––A.D.D.––stroke––Other:
• PSYCHIATRIC: Depression––anxiety––stress/excess worry––drug/alcohol issues––Other:
• EYES: Visual problem––Blurry Vision––Red Eyes––Glasses or contact lens––Other:
• NOSE: Nasal allergies––nose bleeds––Other:
• THROAT: Swallowing difficulty––frequent sore throats––speech problems––Other:
• MOUTH: Dental problems––tongue problems––canker sores––Other:
• NECK: Swollen glands––thyroid problems––Other:
• CHEST: Chest pain––asthma––shortness of breath––cough––TB––Other:
• HEART: Murmurs––palpitations––valve problems––mitral valve prolapse––angina/pain––Other:
• INTESTINAL: Colitis––ulcer gastritis––Barrett’s esophagus––polyps––constipation––Other:
• URINARY: Urinary problems––urinary frequency––burning––kidney stones––Other:
• GENITAL: Infection/discharge––warts––herpes––impotence––sexual difficulty––Other:
• UPPER EXTREMITY: Pain in arm–– Carpal Tunnel––shoulder pain––elbow pain––wrist pain––Other:
• LOWER EXTREMITY: Pain in legs––knee pain––hip pain––ankle pain––tingling––Other:
• SPINE: Low back pain––neck pain––mid back pain––scoliosis––herniated disc––sciatica––Other:

Okay, you may now go forth and perform the SUBJECTIVE portion of the medical assessment and, hopefully, in an organized manner and with less trepidation than before you read this article. Remember, in the MEDICAL HISTORY you’re only trying to get the patient or someone with them to tell you a story. The situation and your medical training and your experience will determine if the history is a limerick (“We’ve got a 45-minute old, 9mm pistol gunshot wound to the right thigh of an otherwise healthy male.”) or if it is a novel (“I feel tired all of the time and I hurt all over and this has been going on for the last three years….”).

Here’s the whole SUBJECTIVE part of the medical assessment in an easy to follow format (use the mnemonic SAMPLE-OPQRST as a memory aid): Rapid Initial Assessment: “How are you feeling?” A – Airway is open an the neck (cervical spine) is stabilized B – Breathing is present with normal depth, rate and pattern C – Circulation: Heart is present and functioning and there is no significant bleeding D – Disabilities: Can use the same number of extremities as they usually do and their mind is working (they are alert and can answer questions and follow commands) SAMPLE - S- Signs and symptoms of Present Illness/Injury:

• O – Onset
• P – Provocative and Palliative. What makes better/worse?
• Q – Quality. If it involves pain or another sensation, is it sharp, dull, throbbing, burning, crushing, etc.?
• R – Region and Radiation. Where is the problem?
• S – Severity. Is it incapacitating or is it mild?
• T – Timing. Is it constant or intermittent? Is there a time pattern?

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