Learning outcomes
- Explain the purpose, timing and limits of a focused history and focused physical examination.
- Use SAMPLER to obtain signs and symptoms, allergies, medicines, past history, last oral intake, events and risk factors.
- Use OPQRST to analyse pain and other symptoms without leading the patient.
- Choose a focused examination for medical, trauma, paediatric, geriatric, obstetric, neurological and altered-consciousness presentations.
- Combine subjective history with objective findings, vital observations, glucose and response to treatment.
- Recognise when the focused assessment must be shortened because the patient needs immediate transport or resuscitation.
- Document and hand over findings accurately, including important positives, relevant negatives, uncertainty and changes on reassessment.
1. Definition of focused history and examination
A focused history is a targeted set of questions directed at the patient’s chief complaint, the likely body system involved, the mechanism of injury and the most dangerous alternative diagnoses. A focused physical examination is an examination of the body areas and functions most likely to explain the complaint, while still checking for immediately dangerous findings elsewhere.
Focused does not mean careless or superficial. It means prioritised. The EMT asks the questions and performs the examinations that can change the next decision: treat now, request advanced help, choose a destination, immobilise, isolate, monitor closely or transport without delay.
2. Position in the patient-assessment sequence
| Stage | Main question | What the EMT does |
|---|---|---|
| Scene size-up | Is it safe, and what happened? | Identify hazards, mechanism, patient number, PPE, resources and need for additional services. |
| Primary assessment | What can kill the patient now? | Form a general impression, assess responsiveness, airway, breathing, circulation, severe bleeding and immediate disability; treat as found. |
| Rapid trauma assessment | Are there hidden life threats from injury? | Perform a rapid head-to-toe survey when mechanism or condition indicates; expose only as necessary and prevent heat loss. |
| Focused history and exam | What is causing the complaint, and what needs to happen next? | Use SAMPLER, OPQRST, vital observations and a complaint-specific examination. |
| Reassessment | Is the patient improving or deteriorating? | Repeat key history, examination, observations, interventions and transport decision at appropriate intervals. |
| Handover | What does the receiving team need to know immediately? | Give a concise, structured summary of complaint, timeline, findings, care, response and outstanding concern. |
3. When to perform a focused assessment
- After the primary survey has identified no immediate threat requiring uninterrupted resuscitation.
- For a stable patient with a clear complaint such as chest pain, shortness of breath, abdominal pain, fever or an isolated injury.
- During transport when the scene is safe and assessment can occur without delaying a time-critical destination.
- After a treatment to determine whether the patient responded or developed an adverse effect.
- Whenever new symptoms appear, the mechanism is high risk or the patient’s condition changes.
Perform the assessment on scene or en route according to urgency, distance, staffing, safety, patient preference and local protocol. A critically ill patient receives a short, high-yield history while the team moves toward definitive care; a stable patient may receive a more complete focused assessment before departure.
4. Focused history versus focused physical examination
| Feature | Focused history | Focused physical examination |
|---|---|---|
| Source | Patient, relative, witness, caregiver, dispatch or record. | EMT observation, palpation, auscultation, measurement and monitoring. |
| Examples | “The pain began while walking and radiates to the left arm.” | Pale skin, unequal breath sounds, abdominal guarding or a weak distal pulse. |
| Strength | Explains timing, sensations, events, risks and baseline. | Confirms severity, identifies signs and detects conditions the patient cannot feel. |
| Limitation | Memory, language, fear, altered consciousness and misunderstanding can affect accuracy. | A single normal finding does not exclude a serious evolving illness. |
| Best practice | Ask open questions, then clarify with SAMPLER and OPQRST. | Compare sides, use a systematic sequence and repeat when the condition changes. |
5. The SAMPLER mnemonic
A — Allergies
M — Medications
P — Pertinent past medical history
L — Last oral intake
E — Events leading to the illness or injury
R — Risk factors or relevant additional information
SAMPLER extends the traditional SAMPLE history. Some curricula use the final R for “risk factors,” while others use “recent illness,” “relevant history” or “review of systems.” Learn the local school or service version, but understand the clinical purpose: ask what increases the probability of the dangerous conditions suggested by the complaint.
6. S — Signs and symptoms
Signs are findings the EMT or another observer can see, hear, feel or measure, such as pallor, sweating, wheeze, unequal pupils, fever or a weak pulse. Symptoms are what the patient experiences and reports, such as pain, nausea, dizziness, pressure, weakness or shortness of breath.
- Begin with: “Tell me what is troubling you most right now.”
- Ask the patient to describe the symptom in their own words before introducing medical terms.
- Clarify the location, onset, progression, severity, triggers, associated symptoms and effect on function.
- Ask what the patient was doing immediately before it began.
- Compare the patient’s report with observed findings and vital observations.
- Ask about important negatives that lower or raise concern, such as no trauma, no fever, no anticoagulants or no pregnancy possibility.
| Complaint | Signs to look for | Symptoms to clarify |
|---|---|---|
| Breathlessness | Work of breathing, posture, cyanosis, wheeze, stridor, speech and chest movement. | Onset, trigger, orthopnoea, chest pain, cough, sputum and previous episodes. |
| Chest discomfort | Pallor, sweating, distress, pulse irregularity and perfusion. | Pressure or sharp pain, radiation, exertional relation, nausea and syncope. |
| Abdominal pain | Guarding, distension, tenderness, bleeding, shock and pregnancy signs. | Location, migration, vomiting, stool, urine, menstrual history and last intake. |
| Altered consciousness | Response, pupils, breathing pattern, seizure signs, trauma and glucose. | Last known normal, headache, weakness, fever, medicines, toxins and baseline. |
7. A — Allergies
Ask about allergies to medicines, food, latex, insect stings, contrast, antiseptics and other exposures. For each suspected allergy, record the trigger and the actual reaction. A patient who says “I am allergic to penicillin” may mean rash, vomiting, swelling or previous anaphylaxis; those details change risk.
- “What happened when you were exposed?”
- “How quickly did the reaction begin?”
- “Did you have wheezing, swelling of the tongue, fainting or low blood pressure?”
- “Did you require adrenaline, oxygen, admission or intensive care?”
- “Have you tolerated a related medicine since then?”
8. M — Medications
Ask about prescribed medicines, over-the-counter products, inhalers, insulin, herbal remedies, supplements, recreational substances and medicines taken by mistake. Confirm the name, dose, route, timing of the last dose and reason for use whenever possible.
| Medication question | Example | Why it changes the focused assessment |
|---|---|---|
| What do you take? | “Show me the packet or treatment card.” | Identifies anticoagulants, insulin, sedatives and medicines that may explain symptoms. |
| How much and how often? | “How many tablets or units did you take?” | Assesses overdose, missed dose and treatment failure. |
| When was the last dose? | “When did you last use your inhaler or insulin?” | Links treatment timing to onset and response. |
| Any recent change? | New medicine, stopped medicine, refill unavailable or dose doubled? | Reveals adverse effects, withdrawal and non-adherence. |
| Any substance or herbal product? | Alcohol, cannabis, stimulants, pesticides or traditional preparations? | Identifies poisoning, interactions and altered consciousness causes. |
9. P — Pertinent past history
Pertinent past history means previous illness, injury, surgery or treatment that is relevant to today’s complaint. Ask broadly enough to identify danger, then focus on the systems involved.
- Previous episodes of the same complaint: diagnosis, severity, treatment and response.
- Heart disease, hypertension, stroke, diabetes, asthma, COPD, kidney disease or seizures.
- Previous operations, difficult airway, bleeding disorder, transfusion or implanted devices.
- Recent admission, infection, pregnancy, delivery, travel or immobilisation.
- Anticoagulant use, immunosuppression or known cancer.
- Baseline cognition, mobility, speech, vision, hearing and independence.
- Previous mental-health crisis, self-harm, violence, withdrawal or overdose where relevant.
10. L — Last oral intake
Ask when the patient last ate or drank, what was consumed and whether vomiting occurred. Include the last meal, fluids, alcohol, breastfeed or formula for infants, and any medicine or substance swallowed.
| Situation | Why last intake matters |
|---|---|
| Altered consciousness | Fasting, insulin, alcohol or poor intake may cause hypoglycaemia; vomiting increases aspiration risk. |
| Abdominal pain or vomiting | Food, contaminated water, alcohol and timing help assess infection, obstruction or poisoning. |
| Trauma | Relevant for aspiration risk and receiving-facility planning if anaesthesia may be needed. |
| Pregnancy or labour | Food, fluid loss and vomiting influence dehydration and emergency preparation. |
| Possible poisoning | Identifies co-ingestion and the time window for toxic effects. |
| Diabetes | Skipped meals with insulin or glucose-lowering medicine can precipitate hypoglycaemia. |
11. E — Events leading to the illness or injury
Events describe the sequence immediately before the problem. Ask what the patient was doing, where they were, who was present, what happened first, what happened next and what treatment was attempted.
- For trauma: mechanism, force, height, speed, position, protective equipment, ejection, entrapment and impact.
- For collapse: posture, activity, warning symptoms, witness description, seizure-like movements and recovery.
- For poisoning: substance, concentration, route, amount, time, container, co-exposures and decontamination.
- For respiratory distress: trigger, allergen, infection, exertion, smoke, medication access and previous attacks.
- For behavioural change: baseline, stressor, substance use, fever, head injury, self-harm risk and access to means.
12. R — Risk factors and relevant additional information
Risk factors are conditions or exposures that increase the chance of a serious diagnosis or poor outcome. They are not proof of a diagnosis. Ask about them according to the chief complaint.
| Complaint | Risk factors to ask about | Reason |
|---|---|---|
| Chest pain | Known heart disease, hypertension, diabetes, smoking, high cholesterol, family history, cocaine/stimulants and previous clots. | Changes concern for coronary, vascular and thromboembolic disease. |
| Breathlessness | Asthma/COPD, heart failure, infection, pregnancy, immobility, surgery, clot history and smoke exposure. | Guides respiratory, cardiac, infectious and embolic assessment. |
| Neurological deficit | Stroke/TIA, atrial fibrillation, anticoagulants, hypertension, diabetes, trauma and seizure history. | Identifies time-critical stroke, bleed or seizure causes. |
| Abdominal pain | Pregnancy, surgery, ulcers, liver disease, alcohol, anticoagulants, infection and last menstrual period. | Raises concern for bleeding, ectopic pregnancy, obstruction or sepsis. |
| Trauma | Age, frailty, anticoagulants, osteoporosis, intoxication, pregnancy and comorbidity. | Minor mechanisms may produce major hidden injury. |
| Fever or infection | Immunosuppression, recent admission, devices, travel, sick contacts, wounds and pregnancy. | Guides sepsis risk, isolation and destination. |
13. OPQRST symptom analysis
P — Provocation/Palliation: What makes it worse, better or change with position, exertion, breathing, food or treatment?
Q — Quality: What does it feel like in the patient’s own words?
R — Region/Radiation: Where is it, and does it move anywhere?
S — Severity: How severe is it now, at its worst and at baseline?
T — Time/Trend: How long has it lasted, is it constant or intermittent, and is it changing?
OPQRST is not limited to pain. It can structure questions about breathlessness, dizziness, nausea, headache, weakness, bleeding or palpitations. Ask the patient first, then clarify with neutral prompts.
| Letter | Core questions | Example for chest pain |
|---|---|---|
| O | When did it start? Sudden or gradual? At rest or during activity? | “It started suddenly while carrying a jerrycan.” |
| P | What worsens or relieves it? Position, exertion, breathing, food or medicine? | “Walking worsens it; rest helps slightly.” |
| Q | How does it feel: pressure, tightness, burning, stabbing, tearing or cramping? | “A heavy pressure, not a sharp pain.” |
| R | Where is it? Does it travel to arm, jaw, back or shoulder? | “It moves to the left arm and jaw.” |
| S | Use a 0–10 scale or a developmentally appropriate scale; compare with worst and usual. | “8/10 now; worst 9/10.” |
| T | Duration, frequency, pattern and change since onset. | “Present for 45 minutes and steadily worsening.” |
14. Using pain scales correctly
- Explain the scale before asking the number: 0 means no pain and 10 means the worst pain the patient can imagine or the agreed scale endpoint.
- Ask the patient’s own rating; do not substitute facial expression for a self-report when the patient can communicate.
- Use faces, behavioural or observational scales for young children, non-verbal patients or severe cognitive impairment according to local policy.
- Record location, quality, pattern and functional impact in addition to the number.
- Repeat after an intervention and document the time, intervention and response.
15. Focused physical examination: general principles
- Explain what you are going to do, obtain permission when possible and expose only the area required.
- Compare both sides when assessing pupils, strength, sensation, pulses, swelling, movement or breath sounds.
- Look before touching: posture, colour, work of breathing, distress, deformity, bleeding, swelling and unusual behaviour.
- Use inspection, palpation, auscultation and measurement in a logical sequence suited to the complaint.
- Do not perform painful or potentially harmful manoeuvres outside training, scope or protocol.
- Reassess after any intervention and stop if the patient deteriorates.
- Record positive findings and meaningful negatives, not a vague statement such as “normal examination.”
16. Focused examination of the head and face
| Look and assess | What it may reveal |
|---|---|
| Level of consciousness, speech and facial symmetry | Stroke, hypoglycaemia, intoxication, seizure, trauma or hypoxia. |
| Pupils: size, equality and reaction | Head injury, opioid effect, neurological deficit or raised intracranial pressure. |
| Scalp, skull and face | Bleeding, laceration, deformity, swelling, bruising or fluid from nose/ears. |
| Mouth and airway | Secretions, vomit, blood, burns, swelling, loose teeth, foreign body or cyanosis. |
| Eyes and vision | Vision loss, unequal gaze, chemical exposure, orbital injury or severe headache signs. |
17. Focused examination of the neck
- Inspect for tracheal position, swelling, wounds, bruising, distended neck veins and use of accessory muscles.
- Assess voice, swallowing, stridor and the ability to handle secretions.
- After trauma, maintain appropriate spinal precautions and assess for midline tenderness, deformity, numbness or weakness according to local protocol.
- Do not remove an embedded object or repeatedly move a potentially unstable neck.
- Look for airway burns, expanding haematoma or penetrating injury requiring immediate escalation.
18. Focused examination of the chest
| Component | Assessment | Important findings |
|---|---|---|
| Inspection | Rate, depth, effort, posture, symmetry, retractions, cyanosis and scars. | Respiratory fatigue, pneumothorax, asthma, pulmonary oedema or severe infection. |
| Palpation | Tenderness, chest expansion, crepitus, instability and tactile fremitus if trained. | Rib fracture, flail segment, subcutaneous emphysema or unequal expansion. |
| Auscultation | Compare breath sounds on both sides and note wheeze, crackles, stridor or silence. | Bronchospasm, fluid, airway obstruction or pneumothorax. |
| Circulation clues | Pulse quality, skin, capillary refill, chest discomfort, palpitations and perfusion. | Shock, arrhythmia, acute coronary syndrome or tamponade concern. |
Do not force a breathless patient flat for convenience. Assess in a position that protects breathing unless a specific emergency requires another position.
19. Focused examination of the abdomen and back
Inspect for distension, bruising, wounds, scars, movement and guarding. Ask where the pain began and where it is now. Palpate gently from the least painful area toward the painful area, watching the patient’s face and stopping when severe pain or instability appears. Do not repeatedly perform deep palpation, rebound testing or other manoeuvres outside your training and protocol.
- Look for rigidity, distension, visible pulsation, bruising, bleeding and signs of shock.
- Ask about vomiting, stool, urine, last menstrual period, pregnancy and previous abdominal operations.
- In trauma, inspect the back and flanks when safe, maintaining spinal precautions and preventing heat loss.
- Consider referred pain: chest, shoulder, back or pelvic symptoms may represent abdominal or thoracic disease.
20. Focused pelvic and genitourinary assessment
Only perform intimate assessment when clinically indicated, with consent, privacy, a chaperone or second staff member according to policy, and the least exposure necessary. Ask about pelvic pain, bleeding, discharge, urinary symptoms, pregnancy possibility, last menstrual period and assault. Do not perform internal examination unless specifically trained, authorised and required by protocol.
For trauma or shock, note external bleeding, bruising, pain, genital injury, urine output and pregnancy risk. For a patient who may have been sexually assaulted, preserve dignity and evidence, avoid unnecessary examination and follow the local safeguarding and forensic pathway.
21. Focused examination of the extremities
| Check | Questions or technique | Why it matters |
|---|---|---|
| Circulation | Colour, temperature, capillary refill, distal pulse and bleeding. | Detects shock, vascular injury or compromised limb perfusion. |
| Motor function | Can the patient move the limb, fingers or toes? Compare sides. | Identifies neurological or musculoskeletal deficit. |
| Sensation | Numbness, tingling, altered sensation or complete loss? | Suggests nerve, spinal or vascular compromise. |
| Appearance | Deformity, swelling, bruising, open wound, shortening or rotation. | Guides immobilisation, bleeding control and urgency. |
| Function and pain | What movement is possible, and what worsens pain? | Establishes baseline and response after splinting or treatment. |
22. Neurological focused examination
- Assess level of consciousness using a consistent method such as AVPU and, when indicated, the Glasgow Coma Scale under local protocol.
- Check orientation, speech, facial symmetry, pupils, gross motor strength, sensation and coordination when safe.
- Record the side and exact distribution of weakness or numbness rather than “neurology normal.”
- Ask for last known normal time and compare with the patient’s baseline.
- Look for seizure activity, meningism, headache, vomiting, head injury, fever, glucose abnormality and drug exposure.
23. Focused assessment of medical equipment and devices
Patients may arrive with an insulin pump, oxygen, tracheostomy, dialysis fistula, pacemaker, defibrillator, feeding tube, urinary catheter or implanted access. Ask what the device is, why it is used, whether it is functioning, when it was last checked and what changed today.
- Do not disconnect, clamp, flush, adjust or remove a device outside your training and protocol.
- Inspect tubing, connections, alarms, battery, skin and signs of infection or displacement.
- Protect dialysis fistulas from blood pressure cuffs, venepuncture and trauma when applicable.
- Bring medication lists, device cards and relevant equipment to the receiving team.
24. Responsive medical patient pathway
- Confirm the patient is stable enough for a focused assessment and continue monitoring.
- Ask the open chief-complaint question and allow the patient to speak without interruption.
- Analyse the main symptom with OPQRST.
- Complete SAMPLER, adapting risk-factor questions to the complaint.
- Obtain a full set of vital observations, including oxygen saturation and blood glucose when indicated.
- Perform a complaint-specific examination and compare objective findings with the history.
- Give immediate care within scope, reassess response and decide transport priority.
- Communicate the findings and outstanding risks to medical direction or the receiving facility.
25. Unresponsive or altered-consciousness patient pathway
- Perform scene safety and a primary survey; protect the airway and support breathing and circulation.
- Assess responsiveness, pupils, breathing pattern, skin, trauma signs and blood glucose according to protocol.
- Ask witnesses for last known normal, event description, seizure activity, trauma, medicines, diabetes, toxins, fever and baseline function.
- Look for medical-alert bracelets, medication packets, phone information and treatment cards without delaying care.
- Record the source of every fact and distinguish what was witnessed from what was assumed.
- Reassess frequently, monitor for deterioration and arrange urgent transport or advanced support.
26. Trauma-focused history and examination
| History | Focused examination | Critical concern |
|---|---|---|
| Mechanism, energy, position, restraint, ejection, entrapment and time. | Rapid head-to-toe inspection, bleeding control, pupils, chest, abdomen, pelvis, spine and limbs. | Occult haemorrhage, airway injury, spinal injury or traumatic brain injury. |
| Loss of consciousness, vomiting, seizure, anticoagulants and previous neurological disease. | Level of consciousness, speech, pupils, motor/sensory function and repeated neurological checks. | Intracranial bleeding or deteriorating brain injury. |
| Pain, numbness, weakness and ability to move before immobilisation. | Distal pulse, motor and sensation before and after splinting. | Neurovascular compromise or compartment syndrome. |
| Burn source, duration, enclosed space and chemical exposure. | Airway, breathing, burn depth/extent, circulation and associated trauma. | Inhalation injury, shock, chemical injury or rapidly swelling airway. |
Use the mechanism to anticipate injury, but let the patient’s actual findings guide priorities. A low-speed crash can still cause major injury in a frail older person or an unrestrained child.
27. Focused respiratory assessment
- Ask onset, trigger, baseline respiratory disease, inhaler or oxygen use, fever, cough, sputum, chest pain, allergy and previous intubation.
- Observe posture, speech length, respiratory effort, accessory muscle use, cyanosis, fatigue and mental status.
- Count respiratory rate for a full minute when rhythm is irregular and assess depth and pattern.
- Compare chest movement and breath sounds; identify wheeze, crackles, stridor or silence.
- Measure oxygen saturation according to protocol, interpret it with the clinical picture and reassess after oxygen or bronchodilator treatment.
- Escalate for exhaustion, reduced consciousness, silent chest, central cyanosis, severe hypoxia or inability to speak.
28. Focused cardiac and chest-pain assessment
Use OPQRST for pain and ask about exertion, breathlessness, sweating, nausea, palpitations, syncope, previous heart disease, hypertension, diabetes, smoking, cocaine or stimulant use, pregnancy and thromboembolic risk. Examine skin, perfusion, pulse rhythm, blood pressure, work of breathing, lungs and signs of heart failure.
| Ask or assess | Why it matters |
|---|---|
| Exact onset and last time pain-free | Time-sensitive cardiac and vascular conditions may require immediate referral. |
| Pressure, tightness, tearing or pleuritic quality | Different qualities suggest different dangerous causes but do not exclude one another. |
| Radiation to arm, jaw, back or shoulder | Supports concern for cardiac or vascular disease. |
| Syncope, palpitations or irregular pulse | Raises concern for arrhythmia or reduced cardiac output. |
| Blood pressure difference, unequal pulses or neurological symptoms | May signal major vascular disease and requires urgent escalation. |
29. Focused neurological and stroke assessment
- Establish the exact last known normal time and the time symptoms were first noticed.
- Ask about facial droop, arm weakness, speech difficulty, vision loss, balance problems, severe headache and seizure.
- Check glucose because hypoglycaemia can mimic neurological disease.
- Compare pupils, facial movement, speech, grip, limb drift, sensation and gait only if safe.
- Ask about atrial fibrillation, previous stroke/TIA, anticoagulants, hypertension, diabetes and recent trauma.
- Document baseline disability and the new deficit separately.
30. Focused abdominal assessment
Ask about location and migration of pain, onset, vomiting, diarrhoea, stool or blood, urine, fever, jaundice, previous operations, ulcers, alcohol, medicines, pregnancy possibility and last menstrual period. Inspect for distension, scars, bruising and guarding; palpate gently and look for shock. Consider chest, pelvic and urinary causes of abdominal symptoms.
31. Focused assessment of poisoning and overdose
| Information | Questions |
|---|---|
| Substance | What was taken or encountered? Can the container, packet or label be shown? |
| Amount | How much may be missing, and what is the maximum possible amount? |
| Route | Swallowed, inhaled, injected, absorbed through skin or splashed in eyes? |
| Time | When was exposure first possible, and was it repeated? |
| Co-exposures | Alcohol, other medicines, pesticides, household chemicals or unknown substances? |
| Patient factors | Age, weight, pregnancy, kidney/liver disease and prior tolerance? |
| Interventions | Vomiting, washing, milk, charcoal, antidote, oxygen or another home treatment? |
Do not induce vomiting or give food, drink or a home remedy unless instructed by an authorised poison or clinical service. Protect rescuers from secondary contamination and follow local decontamination and referral protocols.
32. Focused assessment of allergic reaction and anaphylaxis
- Ask what the patient was exposed to, by which route and when.
- Identify skin symptoms, facial/tongue swelling, throat tightness, wheeze, voice change, vomiting, dizziness or collapse.
- Ask about previous anaphylaxis, adrenaline auto-injector use and response.
- Examine airway, voice, breathing effort, wheeze/stridor, perfusion and mental status.
- Look for rapid progression; a normal skin examination does not exclude anaphylaxis.
- Follow current local emergency protocol for urgent treatment, monitoring and transport.
33. Paediatric focused assessment
Speak to the child at their developmental level, then obtain collateral history from the caregiver. Ask about weight, birth and medical history, immunisation, feeding, wet nappies, fever, breathing, activity and the exact dose/time of any medication or toxin. Observe interaction, consolability, cry, tone, work of breathing, perfusion and hydration.
34. Older adult, disability and communication needs
- Ask about baseline cognition, movement, communication, hearing, vision and independence before today’s change.
- Use the patient’s preferred communication method and allow extra time.
- Check medication organisation, carers, falls, swallowing and access to food or fluids.
- Inspect and protect hearing aids, glasses, dentures, wheelchairs and other assistive devices.
- Do not interpret a disability as the cause of a new deficit; compare with baseline.
35. Obstetric and reproductive focused assessment
Ask privately and respectfully about pregnancy possibility, gestational age, last menstrual period, gravida/parity, contractions, bleeding, fluid loss, fetal movement, severe headache, seizures, abdominal pain and previous complications. Examine for shock and external bleeding while preserving privacy; do not perform internal examination unless authorised and required.
- For a pregnant trauma patient, ask about mechanism, abdominal impact, restraint, pain, bleeding and fetal movement.
- For bleeding, estimate amount, colour, clots, dizziness, pregnancy stage and previous placenta or ectopic problems.
- For labour symptoms, ask timing and duration of contractions, waters, urge to push and delivery history.
- Escalate rapidly for shock, severe pain, heavy bleeding, seizures, altered consciousness or imminent delivery.
36. Psychiatric, behavioural and self-harm assessment
Maintain a calm, non-judgemental approach and continue to search for medical causes of behavioural change. Ask directly about safety and do not leave a high-risk patient alone.
| Domain | Focused question | Action if positive |
|---|---|---|
| Current thoughts | “Are you thinking about harming yourself or someone else?” | Ensure supervision, remove immediate means where safe and escalate. |
| Plan and access | “Have you thought about how, when or where you would do it? Do you have access to it?” | Urgent mental-health and safeguarding pathway. |
| Past behaviour | Previous attempt, self-harm, violence, admission or treatment? | Higher concern and need for collateral/support. |
| Medical contributors | Head injury, fever, glucose, drugs, alcohol, withdrawal, seizures or medication change? | Treat or investigate possible medical emergency. |
| Protective factors | Who can support you, and what has stopped you acting so far? | Include support in a safe handover; never use it to dismiss risk. |
37. Reassessment after focused care
- Repeat the patient’s main symptom and OPQRST elements that were abnormal.
- Repeat vital observations and glucose when clinically indicated or required by protocol.
- Re-examine the affected system: breath sounds after bronchodilator, distal pulse after splinting, neurological deficit after glucose or seizure, pain after analgesia.
- Check for treatment complications, new symptoms, fatigue or deterioration.
- Update the transport decision and destination if the patient’s risk changes.
- Document the time, intervention, objective change and patient-reported response.
38. Focused assessment and transport decisions
| Finding | Transport implication |
|---|---|
| Unstable vital observations or worsening mental status | Urgent transport, early notification, advanced support and minimal on-scene delay. |
| Time-critical symptom with a known onset | Document exact times and notify the destination early. |
| High-risk mechanism with apparently mild symptoms | Do not be reassured by a normal initial appearance; perform appropriate trauma assessment and transport according to protocol. |
| Good treatment response but significant underlying risk | Continue monitoring and follow local referral/transport guidance; improvement does not prove safety. |
| Uncertain history or unreliable source | Use collateral information, objective findings and a cautious disposition. |
39. Documentation standard for SAMPLER and OPQRST
A strong record shows the source, time, words, relevant positives, relevant negatives, interventions and changes. Write what is known and label uncertainty.
| Element | Example documentation |
|---|---|
| Source and reliability | “History from patient; alert and answering appropriately. Wife confirms onset.” |
| Signs and symptoms | “Sudden central pressure 8/10 with diaphoresis and nausea; no trauma reported.” |
| Allergy | “Penicillin: urticaria and facial swelling at age 20; no known latex allergy.” |
| Medication | “Metformin and amlodipine; patient missed morning doses; no medication list available.” |
| Past history | “Hypertension and diabetes; no known previous myocardial infarction.” |
| Last intake | “Tea and chapati at 06:30; no vomiting; alcohol denied.” |
| Events/risk | “Pain began while walking; smoker, diabetic, father died suddenly at 52.” |
| Focused exam | “Pale, clammy; bilateral breath sounds; irregular radial pulse; no focal weakness.” |
| Reassessment | “Pain 6/10 after intervention; BP and pulse repeated at 10:35; destination notified.” |
40. Handover using the focused assessment
Example: “This is a 64-year-old woman with sudden left-sided weakness noted at 08:40; last known normal 08:15. She has atrial fibrillation and takes warfarin; no seizure or trauma witnessed. Glucose is recorded on the chart. Speech is slurred and left arm drift is present. Airway is patent and breathing is adequate. We have kept her monitored, documented the exact times and request immediate stroke assessment on arrival.”
41. Worked EMS scenarios
Scenario 1: Chest pain during exertion
After the primary survey, the EMT asks OPQRST and SAMPLER while another crew member obtains observations. The patient describes pressure beginning while walking, radiating to the jaw, with sweating and nausea. Risk factors include diabetes, hypertension and smoking. The focused examination looks at perfusion, rhythm, breathing and signs of shock. The crew gives approved care, monitors continuously, notifies the destination and avoids delaying transport for a lengthy unrelated history.
Scenario 2: Asthma or severe respiratory distress
The patient is sitting forward and speaking in short phrases. The EMT asks about trigger, inhaler access, previous intubation, allergies, fever and last medication while assessing effort, air entry, wheeze, fatigue, mental status and oxygenation. A suddenly quiet chest with increasing drowsiness is treated as deterioration, not improvement.
Scenario 3: Fall in an older patient
The patient says, “I only slipped,” but the caregiver reports brief loss of consciousness. The EMT asks about height, head strike, anticoagulants, last known normal, preceding dizziness, chest symptoms and baseline mobility. The focused examination includes scalp, pupils, neck, spine, pelvis, limb neurovascular status and repeated consciousness checks.
Scenario 4: Abdominal pain in a woman of reproductive age
The EMT asks privately about pregnancy possibility, last menstrual period, bleeding, discharge, urinary symptoms, vomiting and previous surgery. The examination prioritises shock, pallor, severe tenderness and external bleeding while maintaining dignity and rapid referral for a possible obstetric or surgical emergency.
Scenario 5: Unresponsive person at a social gathering
Friends report alcohol, but the exact substance and amount are unknown. The EMT checks airway, breathing, circulation, glucose and trauma; asks last known normal, witnessed seizure, medications, other drugs, vomiting and head injury; preserves packets for the receiving team and treats the patient as an undifferentiated emergency.
Scenario 6: Suspected anaphylaxis
A patient develops wheeze, hives and throat tightness after a meal. The EMT asks exposure and onset, previous reactions and adrenaline access while assessing airway swelling, voice, breathing, perfusion and mental status. The rapid progression and airway symptoms take priority over completing every historical detail.
42. Common mistakes to avoid
- Starting SAMPLER before checking scene safety and immediate life threats.
- Treating the mnemonic as a rigid script when the patient needs urgent care.
- Asking the letters mechanically without understanding why each answer matters.
- Failing to ask the time of onset or last known normal in stroke, seizure, collapse or altered consciousness.
- Recording “allergic” without the substance and reaction.
- Writing “on medication” without name, dose, route and last dose.
- Ignoring last oral intake in diabetes, poisoning, vomiting, pregnancy and altered consciousness.
- Accepting an assumed diagnosis such as “drunk,” “panic” or “minor fall” without objective assessment.
- Performing a broad examination that delays transport when a time-critical condition is suspected.
- Using a normal initial vital sign to dismiss a serious evolving condition.
- Failing to compare motor, sensory, pulse, pupil or breath-sound findings side to side.
- Performing intimate examinations without consent, privacy, chaperone or clinical indication.
- Documenting only abnormal findings and forgetting relevant negatives or uncertainty.
- Failing to repeat the focused history and examination after treatment or deterioration.
43. Focused assessment checklist
- Have I completed scene size-up and the primary survey?
- Is the patient stable enough to continue a focused assessment?
- What is the chief complaint in the patient’s own words?
- Have I analysed the main symptom with OPQRST?
- Have I asked each SAMPLER element and adapted R to the complaint’s risk factors?
- Have I checked allergies, medicines, anticoagulants, insulin, pregnancy, toxins and safeguarding when relevant?
- Have I obtained vital observations and glucose when indicated?
- Which body areas require a focused examination?
- Have I compared both sides and checked circulation, motor and sensation after injury or splinting?
- What are the red flags and what action have I taken?
- What treatment was given, when, and what changed?
- When will I repeat the assessment, and what will I monitor?
- Can I hand over the history, findings, risks, treatment and outstanding concern clearly?
44. Examination summary table
| Patient presentation | History focus | Physical focus |
|---|---|---|
| Stable medical complaint | OPQRST, SAMPLER, risk factors and previous episodes. | Complaint-related system, vital observations and glucose when indicated. |
| Major trauma | Mechanism, energy, time, protection, loss of consciousness and anticoagulants. | Rapid head-to-toe, bleeding, airway, chest, abdomen, pelvis, spine and neurovascular checks. |
| Unresponsive patient | Last known normal, witness account, seizure, trauma, glucose, medicines and toxins. | Airway, breathing, circulation, pupils, glucose, trauma and neurological reassessment. |
| Child | Caregiver account, weight, birth, feeding, wet nappies, fever, medication/toxin dose. | Interaction, work of breathing, perfusion, hydration, tone and injury pattern. |
| Pregnancy-related complaint | Gestation, parity, bleeding, pain, contractions, fluid, fetal movement and complications. | Shock, bleeding, abdominal findings and safe positioning; preserve privacy. |
| Behavioural emergency | Safety, self-harm/violence risk, substances, medical contributors and baseline. | Airway, glucose, trauma, temperature, neurological status and environmental safety. |
45. Revision questions
- Define focused history and focused physical examination.
- Why must focused assessment never delay the primary survey or urgent transport?
- State the meaning of every letter in SAMPLER.
- How does SAMPLER differ from SAMPLE?
- What information belongs under signs and symptoms?
- Why should an allergy include the actual reaction?
- List six medication questions an EMT should ask.
- Give five examples of pertinent past medical history.
- Why is last oral intake important in diabetes, poisoning and altered consciousness?
- What is the purpose of the events-leading-to-illness section?
- Give risk factors for chest pain and breathlessness.
- State the letters of OPQRST and give an example question for each.
- How should pain severity be assessed and documented?
- Describe a focused chest examination.
- What should be assessed in the extremities after splinting?
- Outline the pathway for an unresponsive medical patient.
- What is the importance of last known normal in a suspected stroke?
- How does trauma mechanism guide the focused examination?
- List five questions for suspected poisoning.
- What special considerations apply when taking history from a child?
- How should a focused mental-health assessment address immediate safety?
- What should be repeated during reassessment?
- Write a focused handover for a patient with sudden unilateral weakness.
- List common mistakes that reduce the value of SAMPLER.
- Explain why a normal first vital sign does not end assessment.
46. Key take-home messages
- Focused assessment is prioritised, not incomplete.
- SAMPLER gathers the medical context; OPQRST analyses the presenting symptom.
- History, vital observations and physical examination must be interpreted together.
- Examine the body system related to the complaint while continuing to search for life threats.
- Shorten the assessment for unstable patients and continue it during transport or after treatment.
- Repeat abnormal findings and document trends, not just a single snapshot.
- Record who supplied the information, exact times, relevant negatives and uncertainty.
- Follow current Uganda clinical protocols, scope of practice and medical direction.
References and further reading
- SlideShare: Focused History and Physical Examination — Medical Patients.
- EMS.gov: National Emergency Medical Services Education Standards.
- EMS.gov: EMT patient-assessment refresher and SAMPLE history.
- EMS patient-care protocol: secondary assessment, SAMPLE, OPQRST and focused physical examination.
- NCBI Bookshelf: health history and focused assessment questions.