9.2 Secondary Assessment, History Integration (SAMPLE/OPQRST) & Lifespan Adaptation

9.2 Secondary Assessment, History Integration (SAMPLE/OPQRST) & Lifespan Adaptation

Structured Clinical History Taking (SAMPLE & OPQRST Frameworks)

Once the primary survey has ruled out or corrected immediate life threats, the primary care paramedic initiates the secondary assessment. Under the Canadian Paramedic Competence Framework (CPCF Area H2.2 and H2.3), clinical history taking is not a passive checklist; it is an active investigative process that contextualizes physical exam findings and guides differential diagnoses.

The SAMPLE History Matrix

The SAMPLE mnemonic provides a comprehensive baseline of patient health and acute illness context:

• S – Signs & Symptoms: Differentiating objective clinical signs observed by the clinician (e.g., diaphoresis, tachypnea, wheezing) from subjective symptoms described by the patient (e.g., retrosternal pressure, nausea, dizziness).
• A – Allergies: Identifying specific allergies to medications (e.g., penicillin, ASA), environmental substances, foods, and latex. Crucially, the paramedic must distinguish between true IgE-mediated anaphylaxis (bronchospasm, angioedema, urticaria, hypotension) and non-allergic adverse effects (e.g., gastrointestinal upset from codeine).
• M – Medications: Complete cataloging of prescription pharmaceuticals, over-the-counter drugs, herbal supplements, vitamins, and recreational substances. Focus on compliance, recent dosage modifications, and high-risk pharmacotherapies: anticoagulants/antiplatelets (e.g., warfarin, apixaban, clopidogrel), antihypertensives (beta-blockers masking shock tachycardia), and hypoglycemic agents (insulin, sulfonylureas).
• P – Past Pertinent Medical / Surgical History: Uncovering underlying cardiovascular disease, chronic obstructive pulmonary disease (COPD), diabetes mellitus, renal disease, and past surgical interventions (e.g., coronary artery bypass, aneurysm repair) that influence the current crisis.
• L – Last Oral Intake: Documenting the exact time, nature, and volume of food and fluid consumption. This is critical for assessing aspiration risk during sedation or intubation, scheduling emergency operative procedures, and managing diabetic insulin dynamics.
• E – Events Leading Up to the Incident: Establishing the precise chronology of events immediately preceding symptom onset or trauma. Did a motor vehicle collision occur because the driver suffered a syncopal episode or seizure? Was a mechanical fall preceded by lightheadedness, chest tightness, or stroke signs?

The OPQRST Pain and Symptom Exploration Model

When investigating pain, respiratory distress, or localized symptoms, paramedics employ the OPQRST framework:

• O – Onset: Sudden versus gradual. Was the patient resting, exercising, or emotionally stressed when symptoms began? Sudden onset ("like a light switch") often denotes catastrophic vascular events (e.g., subarachnoid hemorrhage, aortic dissection, pulmonary embolism), whereas gradual onset is typical of inflammatory or infectious processes.
• P – Provocation / Palliation: What actions, positions, or medications aggravate or alleviate the symptom? Does inspiration worsen the pain (pleuritic)? Does physical exertion exacerbate it while rest relieves it (angina)? Does leaning forward alleviate the discomfort (pericarditis)?
• Q – Quality: The patient's subjective description of the sensation in their own words. Is it "crushing, squeezing, heavy, or aching" (typical of visceral cardiac ischemia), "sharp, knifelike, or stabbing" (pleuritic or peritoneal), "tearing or ripping" (acute aortic dissection), or "burning" (esophageal or neuropathic)?
• R – Radiation / Region: The precise anatomical origin and referral trajectory. Visceral cardiac pain frequently radiates to the neck, jaw, shoulders, epigastrium, or down the left or right arm. Diaphragmatic irritation refers pain to the ipsilateral shoulder (Kehr's sign). Flank pain radiating to the groin suggests ureteral colic.
• S – Severity: Quantifying intensity using standardized scales: Numeric Rating Scale (0 to 10), Wong-Baker FACES for pediatric or cognitively impaired patients, or functional descriptors ("worst pain of my life").
• T – Timing: Temporal dynamics: constant, intermittent, fluctuating, waxing and waning (colicky). What is the total duration of the current episode, and have identical episodes occurred in the past?

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Detailed Head-to-Toe Physical Examination (DCAP-BLS/TIC)

The detailed secondary physical examination is a systematic head-to-toe evaluation designed to locate occult injuries and systemic illness indicators. Clinicians inspect and palpate using the DCAP-BLS/TIC mnemonic:

• DCAP: Deformities, Contusions, Abrasions, Punctures / Penetrations
• BLS: Burns, Lacerations, Swelling
• TIC: Tenderness, Instability, Crepitus

ANATOMICAL EXAMINATION SEQUENCE
[Head & Face]   --> Skull integrity, Battle's sign, Raccoon eyes, CSF/blood halo sign, PERRL
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[Cervical Neck] --> C-spine tenderness/step-off, tracheal alignment, JVD at 45°, stomas
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[Thorax/Lungs]  --> Clavicular/rib stability, symmetry, flail segments, 6-field auscultation
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[Abdomen]       --> Inspection (bruising/distension), gentle 4-quadrant palpation (guarding/rigidity)
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[Pelvis]        --> Single inward/downward gentle compression; binder application if unstable
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[Extremities]   --> DCAP-BLS, PMS (Pulse, Motor, Sensory) in all 4 limbs, fracture splinting
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[Posterior Body]--> Log-roll with in-line C-spine control; palpate full vertebral column

Critical Anatomical Review Markers

• Head & Craniofacial: Inspect scalp for lacerations and depressed skull fractures. Inspect periorbital tissues for "raccoon eyes" and mastoid processes for "Battle's sign" (basilar skull fracture signs; typically take several hours to emerge). Check ears and nose for clear cerebrospinal fluid (CSF) otorrhea/rhinorrhea or hemotympanum.
• Neck: Palpate posterior cervical spinous processes for focal point tenderness or anatomical step-offs. Inspect for subcutaneous emphysema. Evaluate jugular venous distension (JVD) with the patient positioned at 45 degrees. Verify midline tracheal alignment.
• Thorax: Auscultate across 4 to 6 lung fields (apices, bases, lateral axillary zones). Inspect for paradoxical chest wall movement (flail chest: two or more contiguous ribs fractured in two or more places). Palpate clavicles and sternum for instability.
• Abdomen: Inspect for distension, surgical scars, and ecchymosis (Cullen's sign: periumbilical bruising; Grey Turner's sign: flank bruising denoting retroperitoneal hemorrhage). Gently palpate four quadrants for voluntary guarding, involuntary rigidity, rebound tenderness, or pulsatile abdominal aortic masses.
• Pelvis: Gently compress the iliac crests bilaterally once. If instability, asymmetry, or crepitus is felt, cease examination immediately and apply a commercial pelvic binder centered over the greater trochanters.
• Extremities: Evaluate bilateral distal pulses, motor strength, and sensory perception (PMS / CMS). Document baseline neurovascular status before and after any splinting intervention.
• Posterior Body: With in-line spinal stabilization maintained, execute a coordinated log-roll to visualize the back, inspect the sacrum, and palpate the entire thoracic and lumbar spine for step-offs and localized tenderness.

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Lifespan Adaptations: Pediatric and Geriatric Nuances

Clinical assessment cannot be performed identically across age groups. Canadian paramedics must calibrate their communication, physical exam order, and clinical suspicion according to patient developmental age.

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Clinical Scenario: Atypical Geriatric Trauma & Collateral History

Prehospital Vignette: The Low-Energy Fall

Paramedics respond to a private residence for an 81-year-old female found on the bedroom floor by a visiting daughter. The patient reports she tripped over a slipper approximately 4 hours ago. She is alert (GCS 15), complaining only of moderate right hip discomfort and mild lower back soreness. Vital signs are HR 72 bpm (regular), BP 142/84 mmHg, RR 18 bpm, SpO2 96% on room air, and temperature 35.8°C.

Advanced History and Collateral Investigation:

1. SAMPLE & Medication Review: The paramedic reviews the patient's blister pack (Dosette) and identifies apixaban (Eliquis) 5 mg BID for atrial fibrillation, metoprolol 25 mg BID, and ramipril 5 mg daily.
2. Collateral History: The daughter notes that her mother seemed slightly unsteady yesterday, missing a meal. Because the patient was on the floor for 4 hours ("long lie"), the paramedic recognizes elevated risks of hypothermia, pressure injury, and rhabdomyolysis.
3. Focused Secondary Physical Exam:
   • Head/Neck: The patient denied striking her head. However, careful palpation of the scalp reveals a 3-cm soft tissue hematoma over the left occiput. The patient has no recollection of hitting her head.
   • Musculoskeletal: The right lower extremity exhibits classic shortening and external rotation, with severe groin pain upon gentle movement. Distal pedal pulse is palpable with intact motor and sensory function.
4. Clinical Synthesis: Despite normal vital signs and GCS 15, the patient's anticoagulated state (apixaban) combined with occult head trauma from a ground-level fall places her at severe risk for an evolving intracranial hemorrhage (subdural hematoma). The paramedic applies gentle in-line stabilization, splints the fractured hip using a vacuum splint, protects against hypothermia, and transports with continuous neurological re-evaluation.

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Exam Pitfalls & High-Yield Pearls

• The "Normal Confusion" Assumption: Assuming confusion in an elderly patient is simply "baseline dementia" without consulting caregivers, prior records, or home health charts is a catastrophic clinical pitfall. Acute confusion represents delirium, frequently triggered by sepsis (urinary tract infection, pneumonia), hypoglycemia, intracranial bleeding, or acute myocardial infarction.
• Medication Masking in Shock: Elderly trauma patients taking beta-blockers (e.g., metoprolol, bisoprolol) or calcium channel blockers cannot mount a compensatory tachycardia. A heart rate of 75 bpm in an older trauma patient with a systolic BP of 100 mmHg may represent profound, decompensated hemorrhagic shock.
• Pediatric Rib Compliance: In pediatric trauma, the absence of rib fractures does not rule out massive internal pulmonary contusion, pneumothorax, or lacerated solid organs (spleen/liver). The pediatric chest wall is highly compliant and easily transmits kinetic energy directly to underlying thoracic viscera without breaking ribs.
• Examining the Screaming Child: Never approach an alert toddler with a stethoscope or penlight aimed at their face. Sit at eye level, examine the child on the parent's lap, allow the child to play with the stethoscope bell, and evaluate breath sounds before initiating any invasive or uncomfortable checks.