Patient Assessment: History Taking and Examination

Where history taking fits

In short: treat threats to life first (primary survey). Take the history only once the casualty is stable, in the secondary survey.

Read first: nothing — this is the first topic of the Medical Care area. Next: Emergency Response and Radio Medical Advice.

• Primary survey first (DRSABC): any threat to life is treated before anything else. History taking belongs to the secondary survey, once the casualty is stable.
• The secondary survey combines three things: SAMPLE history, vital signs, and a head-to-toe / system examination.
• SAMPLE = Signs & symptoms · Allergies · Medications · Past medical history · Last oral intake · Events leading up.
• Rule of record keeping: what is not written was not done. Note times, findings and treatment as you go.

The history-taking flow

In short: open question, SOCRATES for the main symptom, every other symptom, systemic review, background — always in this order.

1. Open question — “What brings you here today?” Let the patient talk; summarise the presenting complaint in one line.
2. SOCRATES — characterise the main symptom (usually pain).
3. Exhaust every symptom — repeat for each other symptom the patient reports.
4. Systemic review — screen every body system for symptoms the patient did not mention.
5. Background — past medical and surgical history, current medications, allergies.

SOCRATES

In short: eight questions that describe any pain. Ask them in order and score the severity 0–10.

• Site — where exactly? Ask the patient to point with one finger.
• Onset — sudden or gradual? What were they doing?
• Character — sharp, dull, burning, crushing, colicky?
• Radiation — does it spread anywhere?
• Associations — nausea, vomiting, sweating, fever, breathlessness?
• Time course — constant or coming in waves? Getting better or worse?
• Exacerbating / relieving factors — movement, breathing, food, position, painkillers?
• Severity — score 0–10, and compare with earlier scores.

Systemic review

In short: short closed questions, one body system at a time, to catch symptoms the patient did not mention.

Ask short closed questions system by system:

• Cardiovascular — chest pain, palpitations, ankle swelling, breathlessness lying flat.
• Respiratory — cough, sputum (colour, blood), wheeze, shortness of breath.
• Gastrointestinal — appetite, nausea/vomiting, bowel habit, blood in stool, abdominal pain.
• Genitourinary — pain or burning on passing urine, frequency, blood in urine.
• Neurological — headache, dizziness, weakness, numbness, visual changes, fits.
• Gynaecological (female crew) — last menstrual period, possibility of pregnancy.

Background history

In short: past illnesses, operations, medications and allergies — and what reaction the allergy caused.

• Past medical history — chronic conditions (diabetes, asthma, epilepsy, heart disease).
• Past surgical history — previous operations and dates.
• Medications — including over-the-counter and supplements.
• Allergies — drug, food, latex; and what reaction occurred.

Examination principles

In short: WIPER before you start, then look → feel → percuss → listen, comparing left with right.

• WIPER before you start:
  • Wash your hands
  • Introduce yourself
  • Permission (consent) — and a chaperone where appropriate
  • Expose the area needed, respecting dignity
  • Reposition the patient (comfortable, usually half-sitting or lying)
• Order of each system: look → feel → percuss → listen.
• Compare sides — left against right is your built-in reference.
• Watch the face, not your hand — the expression tells you where it hurts.
• Finish by thanking the patient and explaining what happens next.

Airway and breathing

In short: pulse oximeter first (SpO₂ ≥ 95%), then airway, then look, feel, percuss and listen to the chest. Stridor is an emergency.

• Pulse oximeter — SpO₂ (normal ≥ 95%) and pulse rate.
• Airway — look in the mouth (swelling at the back of the throat?); feel that the trachea is central; listen to the voice (normal, hoarse, wheezy).
• Look — chest expansion equal and symmetrical? Paradoxical movement? Scars, bruising, tripod position or use of accessory muscles = respiratory distress.
• Feel — chest tenderness; equal expansion both sides.
• Percuss — more resonant = extra air (pneumothorax); dull = fluid or mass (effusion).
• Listen with the stethoscope:
  • Vesicular — normal breath sounds.
  • Crackles (coarse or fine) — fluid or secretions in the airways.
  • Expiratory wheeze — narrowed lower airways (asthma).
  • Stridor — upper-airway obstruction: emergency.
  • Pleural rub — inflamed pleura.
• Useful signs: cherry-red lips suggest carbon monoxide poisoning; a flapping tremor of the hands suggests CO₂ retention.

Abdomen

In short: map the abdomen into quadrants, palpate the painful area last, and look for tenderness, guarding and rebound tenderness.

• Position — stand on the side of your dominant hand; patient lying flat, relaxed.
• Start at the mouth — tongue, cracks at the corners of the lips.
• Look — distension, rashes, bruising, visible veins. If distended, think of the 5 F’s: Fat, Fluid, Fetus, Flatus, Faeces.
• Map the abdomen into 4 quadrants (RUQ, LUQ, RLQ, LLQ) or 9 regions, and record findings by location.
• Palpate:
  • Start away from the painful area and finish there.
  • Hand flat, fingers together; press with the finger pads, flexing at the knuckles. Light first, then deep.
  • Note tenderness (pain on pressing) and guarding (involuntary muscle tension = peritoneal irritation).
  • Rebound tenderness — pain on release rather than on pressure; in the right lower quadrant it suggests appendicitis.
  • Deep two-handed palpation above the umbilicus: a wide, expansile pulsation can suggest an aortic aneurysm.
• Percuss — tympanic (hollow) = gas; dull = fluid or solid organ.
• Listen — absent bowel sounds suggest ileus; hyperactive sounds suggest obstruction.

Vital signs and recording

In short: record a full set of observations, repeat them, and send them on the medical report form. The trend matters more than one value.

• Record pulse, respiratory rate, blood pressure, temperature, SpO₂, level of consciousness (AVPU), pupils and capillary refill (normal < 2 s).
• Repeat observations at regular intervals: the trend matters more than a single value.
• Use the ship’s medical report form so that history, findings and observations reach the Radio Medical Advice doctor in a structured order.