ONTARIO
BASE HOSPITAL GROUP
Chapter 4
for 12 Lead Training
- ACS Assessment: History and ExamOntario Base Hospital Group
Education Subcommittee
2008
TIME IS
MUSCLE
ACS Assessment:
History and Exam
AUTHOR
REVIEWERS/CONTRIBUTORS
Greg Soto, BEd, BA, ACP
Neil Freckleton, AEMCA, ACP
Hamilton Base Hospital
Niagara Base Hospital
Jim Scott, AEMCA, PCP
Sault Area Hospital
Ed Ouston, AEMCA, ACP
Ottawa Base Hospital
Laura McCleary, AEMCA, ACP
SOCPC
Tim Dodd, AEMCA, ACP
Hamilton Base Hospital
2008 Ontario Base Hospital Group
Dr. Rick Verbeek, Medical Director
SOCPC
OBHG Education Subcommittee
Chapter 4 Objectives
 Explain
why getting a good medical
history is so important in the AMI patient
 List key elements to OPQRST &
SAMPLE mnemonics for clinical
investigation of possible ischemic
problem
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Importance of Clinical
Presentation
No diagnostic test for acute myocardial infarction
is perfect.
 All medical literature related to ACS recognition
suggest that the clinical presentation of the patient
is of great importance.

Clinical presentation consists of:
•Incident history
•Chief complaints
•PMHX
•Risk factors
•Vital signs
•Assessment findings
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Getting a Good History
 It
is HOW we ask the questions
 Mnemonics (OPQRST) are memory
aids
 Should not be asked literally to a
patient
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Investigating the C/C
O
P
Q
R
S
T
– Onset
– Provoke
– Quality
– Radiation
– Severity
– Time
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What to Ask
O
– Onset
 Actual
time this
episode started
P – Provoke
 Open-ended
Q – Quality
questions
R – Radiation
 Try to get an actual
S – Severity
time, i.e., 10:30 a.m.
 Very important for
T – Time
cardiac patients
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Onset
“When did this episode of chest
pressure start?”
“When did this asthma attack start?”
“When did the accident occur?”
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Onset
 Avoid
using closed or leading
questions...
“Did the pain start last night or this
morning?”
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What to Ask
– Onset
P – Provoke
Q – Quality
R – Radiation
S – Severity
T – Time
O
 What
makes it better
or worse?
 Note the position of
the patient
 What they were doing
when it happened?
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Rule # 1 of Questioning
While investigating a chief complaint,
the only words you may use are the
words the patient told you
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Rule # 1
If the patient tells you:
“I’m having a tightness in my chest.”
You would reply:
“When did this tightness start, Jack?”
Rather than:
“When did the pain start, Jack?”
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Provoke
“Jack, does anything you do make the
tightness worse?”
(Inspiration/Palpation/Movement/Position)
“Does anything you do make the
tightness less?”
(Inspiration/Palpation/Movement/Position)
“Jack, what were you doing when this
tightness first started?”
OBHG Education Subcommittee
What to Ask
– Onset
P – Provoke
O
Q
– Quality
– Radiation
S – Severity
T – Time
R
 What
does pain feel
like?
 Avoid closed and
leading questions
 Let the patient have
as many choices as
they like to describe
their “pain”
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Quality
“Jack, what does this “pain” feel
like?”
“What would I have to do to you to
make that kind of “pain?”
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Closed or Leading Questions
“Is the pain sharp or dull?”
“Does the pain kinda feel like a belt
around your chest?”
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What to Ask
– Onset
 P – Provoke
 Q – Quality
O
 Do
they have any
problems or pain
anywhere else?
 Watch for nonverbal
R – Radiation
clues
 S – Severity
 Where is the pain?
 T – Time
 Pain may not “go”
anywhere
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Radiation
Instead of:
“Does it hurt in the center or side of your
chest?”
Try:
“Where does it hurt?”
or
“Can you draw a circle around it?”
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What to Ask
– Onset
P – Provoke
Q – Quality
R – Radiation
S – Severity
T – Time
O
 Scale
of 1–10
 Make sure you find
out what the worst
pain was.
 Answers of >10
mean it hurts really
BAD!
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Severity
“On a scale of 1–10 with 10 being
the worst pain you’ve ever had,
and 1 being barely any pain at all,
how would you rate your pain
right now?”
“What was the worst pain you have
ever felt?”
OBHG Education Subcommittee
What to Ask
– Onset
P – Provoke
Q – Quality
R – Radiation
S – Severity
O
T
– Time
 The
duration of the
problem
 How long the current
episode has been
going on?
 If prolonged
duration, was there a
recent sudden
severity increase?
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Time
“How long has this recent episode
of chest pressure lasted, Jack?”
“How long did Jack’s seizure last?”
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Tag-ons
 Tag-ons
are extra questions tacked on
to the end of an ordinarily good
question
“Do you have diabetes, hypertension, or
cardiac disease?”
“Are you nauseated?” “Are you short of
breath?”
“Are you having chest pain?” “Is it sharp
or dull?”
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Tag-ons
The best way to avoid a tag-on is to ask
one question at a time and wait for the
answer
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SAMPLE History
S
A
M
P
L
E
– Signs/symptoms
– Allergies
– Medications
– Past History
– Last meal
– Events
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Allergies
“Jack, are you allergic to any
medications?”
“Jill, are you allergic to anything?”
“Do you have any allergies, Jill?”
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Medications
“Do you take any doctor-prescribed
medicines every day?”
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Past Medical History
Ask
one question at a time
Allow the patient time to answer
Explore what is pertinent
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Last Oral Intake
Very
important in diabetic
emergencies
Important information for patient
who may have to have surgery
Need to know when they ate last
(time) and approximate amount
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Events Leading up to C/C
What
were they doing when the
episode started?
Mechanism of injury?
Useful for neuro exam in head
injuries
Pain at rest or on exertion?
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Physical Exam
Head
to toe
Look for JVD
Assess lung and heart sounds
Palpate the chest wall
Palpate the abdomen
Palpate radial pulses at the
same time
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Physical Exam (cont.)
Blood
pressure in each arm
Positional changes for the patient
Apical versus radial pulses
Full auscultated blood pressure
Look for peripheral edema
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The 12 Lead ECG
 Best
“early” confirming diagnostic test
 Should be performed on any patient
with a “pulse and problem” between
nose and naval that is suspicious for
cardiac
 Should be acquired and triaged in less
than 10 minutes arrival on scene
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BASE HOSPITAL GROUP
QUESTIONS?
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BASE HOSPITAL GROUP
Well Done!
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