Patient History and SAMPLE Assessment
Help Questions
NREMT: EMT Level › Patient History and SAMPLE Assessment
Which component of the SAMPLE history specifically addresses what the patient was doing when their symptoms began?
Events leading up to the current illness or injury
Signs and symptoms
Medications currently being taken by the patient
Allergies to medications or environmental factors
Explanation
The 'E' in SAMPLE stands for 'Events leading up to the illness/injury,' which specifically addresses what the patient was doing when symptoms began or what precipitated the current condition. Signs and symptoms (S) addresses current complaints, allergies (A) addresses known sensitivities, and medications (M) addresses current prescriptions or treatments.
When obtaining a SAMPLE history from a conscious adult patient, what is the most appropriate way to gather accurate medication information?
Ask the patient to list all medications from memory without assistance
Focus exclusively on cardiac and respiratory medications during assessment
Request to see actual medication containers or have family gather them
Only document prescription medications and ignore over-the-counter drugs
Explanation
Requesting to see actual medication containers provides the most accurate information, including correct spelling, dosages, and frequency. Many patients cannot accurately recall medication names or dosages from memory. All medications (prescription, over-the-counter, and supplements) should be documented, and all categories of medications are potentially relevant to patient care.
A patient reports having 'diabetes' in their past medical history. What additional SAMPLE history information is most important to obtain about this condition?
Which family members also have diabetes and their specific management approaches
The patient's most recent hemoglobin A1C results from their last doctor visit
Whether the patient follows a specific diet plan and their exercise routine details
The type of diabetes and how the patient normally manages their blood sugar levels
Explanation
Diabetes type and management method (insulin, oral medications, diet) directly affect emergency treatment decisions and help predict potential complications. While family history, lab results, and lifestyle factors may be relevant, understanding how the patient manages their diabetes provides the most immediately useful information for emergency care.
When documenting the 'P' component of a SAMPLE history, which information is most relevant for the EMT to obtain?
Detailed psychiatric history and all previous mental health treatments
Previous hospitalizations, surgeries, and significant medical conditions affecting current care
Comprehensive occupational history and workplace exposure documentation
Complete family medical history including grandparents' health conditions
Explanation
Past pertinent medical history (P) should focus on previous hospitalizations, surgeries, and medical conditions that could impact current assessment and treatment. While family history, psychiatric history, and occupational exposures may be relevant in specific situations, the most pertinent past medical history relates to conditions that directly affect current care decisions.
How should the EMT document this information in the SAMPLE history?
Document all three items as they represent the patient's complete medication profile
Omit the multivitamin since vitamins are considered nutritional supplements only
Record only the birth control pills as they are the only prescription medication
Focus only on the ibuprofen since it's related to her current complaint
Explanation
All medications, including prescription drugs, over-the-counter medications, and supplements should be documented in the SAMPLE history as they can all potentially interact with treatments or affect patient condition. Birth control pills, multivitamins, and ibuprofen all have potential medical significance and should be recorded completely.
A patient reports being allergic to 'sulfa drugs' but cannot remember what type of reaction occurred. What is the EMT's most appropriate response?
Assume it was a minor reaction and proceed with normal protocols
Document the allergy and treat it as potentially serious until proven otherwise
Disregard the allergy information since the reaction type is unknown
Contact the patient's pharmacy immediately to verify the allergy details
Explanation
When allergy severity is unknown, the safest approach is to document the allergy and treat it as potentially serious. This ensures patient safety and proper communication to receiving facilities. Assuming minor reactions or disregarding allergies could be dangerous, and contacting pharmacies is not practical in emergency situations.
How should the EMT handle obtaining SAMPLE history in this situation?
Insist that parents remain present since the patient is a minor requiring parental consent
Direct all history questions to the parents since they have legal authority over medical decisions
Respectfully ask parents to step aside briefly while gathering sensitive medical information
Skip the history component entirely to avoid creating family conflict during the emergency
Explanation
Adolescents may have sensitive medical information (pregnancy, drug use, sexual activity) they're reluctant to share in front of parents. Briefly speaking privately can yield more honest information while maintaining respect for family dynamics. Parents don't need to be present for history gathering, history shouldn't be skipped, and teenagers can provide their own medical history even if parents have decision-making authority.
When documenting allergies in a SAMPLE history, which approach provides the most complete and useful information?
Focus exclusively on allergies that caused severe reactions requiring hospitalization
Document only allergies that are relevant to the patient's current chief complaint
Record all allergies including medications, foods, environmental factors, and reaction types
List only medication allergies since environmental allergies don't affect emergency treatment
Explanation
Complete allergy documentation including medications, foods, environmental factors, and reaction types provides the most comprehensive information for treatment decisions. Environmental allergies can affect treatment (latex), food allergies may be relevant (certain medications), and even mild previous reactions could be severe in future exposures, so all allergies and reaction types should be documented.
When assessing the 'S' component of SAMPLE history, what is the primary difference between signs and symptoms that the EMT should understand?
Signs occur first chronologically, followed by symptoms in disease progression
Signs are always more serious than symptoms in determining patient priority
Signs require special equipment to detect, while symptoms are obvious to everyone
Signs are objective findings observed by the EMT, while symptoms are subjective complaints
Explanation
Signs are objective findings that can be observed or measured by the EMT (like vital signs, visible injuries, or skin color), while symptoms are subjective complaints reported by the patient (like pain, nausea, or dizziness). Neither is inherently more serious, they don't follow a chronological order, and signs don't require special equipment to detect.
When documenting 'last oral intake' in a patient's SAMPLE history, what specific information should the EMT record?
Only liquid intake, since solid food doesn't affect emergency treatments
Just whether the patient ate within the last four hours or not
Only the time of the last meal, as food type is not medically relevant
Both the time of last food/drink consumption and what was consumed
Explanation
Both timing and content of last oral intake are important. Time affects decisions about potential procedures or medications, while content may be relevant for certain conditions (alcohol, specific foods in diabetic emergencies, etc.). Both food and liquid intake are medically relevant, and specific timing rather than broad time ranges provides better clinical information.