SAMPLE history

SAMPLE history

__NOTOC__SAMPLE history is an mnemonic acronym for first responders to remember key questions for patient assessment. The history is usually taken along with vital signs. This is used for alert patients, but often much of this information can also be obtained from the family of an unresponsive patient.

*S: Signs and Symptoms
*A: Allergies
*M: Medications
*P: Pertinent past history and Pregnancy
*L: Last oral intake (or Last ins and outs)
*E: Events leading up to (the emergency).

Symptoms (and possibly Signs)

Symptoms are what the patient reports, as in "my head hurts." The primary reason a patient is being seen is termed the Chief complaint. Signs are conditions the person rendering aid can "observe", such as seeing a hematoma (bruise) or laceration, or "measure", such as collecting vital signs with appropriate instruments. In a SOAP note, symptoms are typically included with the rest of the SAMPLE history is the "S"ubjective section, while signs are included in the "O"bjective section.

Allergies

When asking a patient about allergies it is important to make the distinction between medical allergies and non-medical allergies. Some allergies that may not seem medical in nature are important however, such as peanut allergies since many asthma inhalers contain peanut by-products.Fact|date=April 2008 Common abbreviations used when recording that a patient has no allergies include NKA (No Known Allergies) and NKDA (No Known DRUG Allergies).

Medications

It is important to obtain a list of medications that a patient is currently taking, since those medications can indicate existing medical conditions a patient may not have reported, as well as ensuring that a conflicting medication isn't prescribed. An example of conflicting medications are Sildenafil (Viagra) and Nitroglycerine that can cause dangerous vasodilation when taken together.

Pertinent Past History

A patient's medical history is a valuable tool in identifying or diagnosing a medical condition. For instance, if a patient has a history of cardiac issues, a provider should suspect cardiac involvement when the patient complains of difficulty breathing. Pregnancy is another concern in women of child-bearing age. First, this limits diagnostic and treatment options (no X-rays or certain medications). Secondly, in women with abdominal pain, a beta-hCG pregnancy test is given to rule out the potentially fatal misdiagnosis of ruptured ectopic pregnancy.

Last Oral Intake

Knowing the last time a patient ate or drank, and what it was can help identify a patients condition. For instance with a diabetic patient who is behaving erratically and states they haven't eaten in 8 hours, a provider should suspect hypoglycemia. Likewise, dehydration may be suspected if the patient reports poor fluid intake or dark urine output.

Events leading up to (the emergency)

Having a clear history of symptom onset or how an injury occurred helps in identifying possible life-threatening conditions. For example, the fact that a patient experienced a syncopal episode before a fall may be more important than a resultant bruise.

ee also

OPQRST

References


Wikimedia Foundation. 2010.

Игры ⚽ Нужна курсовая?

Look at other dictionaries:

  • Sample — may refer to:* SAMPLE History, a mnemonic acronym for questions first responders should ask * The USS Sample (FF 1048), a frigate in the U.S. NavyPeople with the surname Sample include: * Alexander King Sample, a Catholic bishop in Michigan *… …   Wikipedia

  • Sample-based synthesis — is a form of audio synthesis that can be contrasted to either subtractive synthesis or additive synthesis. The principal difference with sample based synthesis is that the seed waveforms are sampled sounds or instruments instead of fundamental… …   Wikipedia

  • History of the World, Part I — Theatrical release poster Directed by Mel Brooks Produce …   Wikipedia

  • sample — [n] example, model bit, bite, case, case history, constituent, cross section, element, exemplification, fragment, illustration, indication, individual, instance, morsel, part, pattern, piece, portion, representative, sampling, segment, sign,… …   New thesaurus

  • History of molecular biology — The history of molecular biology begins in the 1930s with the convergence of various, previously distinct biological disciplines: biochemistry, genetics, microbiology, and virology. With the hope of understanding life at its most fundamental… …   Wikipedia

  • Sample maximum and minimum — Box plots of the Michelson–Morley experiment, showing sample maximums and minimums. In statistics, the maximum and sample minimum, also called the largest observation, and smallest observation, are the values of the greatest and least elements of …   Wikipedia

  • History of virtual learning environments — A virtual learning environment (VLE) is a system that creates an environment designed to facilitate teachers in the management of educational courses for their students, especially a system using computer hardware and software, which involves… …   Wikipedia

  • History of the Hungarian language — The Funeral Sermon and Prayer . This text, dated to 1192, is the oldest longer Hungarian only document. Earlier, Hungarian sentences and words appeared in Latin context. Hungarian is an Ugric language. It has been spoken in the region of modern… …   Wikipedia

  • History of mass spectrometry — The history of mass spectrometry dates back more than one hundred years and has its roots in physical and chemical studies regarding the nature of matter. The study of gas discharges in the mid 19th century led to the discovery of anode and… …   Wikipedia

  • History of the Spanish language — The Spanish language developed from vulgar Latin, with loan words from Basque in the north and Arabic in the southern part of the Iberian Peninsula (see Iberian Romance languages). Typical features of Spanish diachronic phonology include lenition …   Wikipedia

Share the article and excerpts

Direct link
Do a right-click on the link above
and select “Copy Link”