PC Presenting Complaint

A brief factual summary of the patient’s condition. Include what they are complaining of and your findings.
Medical Examples Trauma Examples
Chest Pain ?ACS 3x stab wounds: 2x L upper chest, 1x L upper arm
DiB – exacerbation of COPD RTC – Driver, c-spine tenderness, L arm ?#
Cardiac Arrest R ankle ?# - post fall
HPC History of Presenting Complaint

Pertinent history of the events leading to the current presentation. Include positive and negative findings.

o Detailed summary of symptoms o Reports from witnesses

o Any priority symptoms – CP/SOB/DiB/LOC? o RTC & Trauma Information:
o Onset – what, when, how? o Was a seatbelt worn?
o Length of time symptoms experienced o Were airbags deployed?
o Changing – relieving/exacerbating factors o Trapped or ejected
o Impact on patient, and as appropriate relatives   o Any protective clothing worn?
o Patient and relative’s concerns   o Position of patient(s)
o Previous occurrences o Point of impact
o Pertinent medical history o Estimated speed of impact
o Consider whether story matches scene o Damage to vehicle

O/A On Arrival
Exactly what you find when you arrive on scene
o How access was gained o Other LAS on scene
o Patient positioning/what they were doing o Treatment prior to arrival
o Patient’s level of consciousness (AVPU) o Immediate interventions given
o Relatives/bystanders on scene o Patient movement
O/E On Examination
Exactly what is found during assessment, include pertinent negatives. Ensure clear structure and layout.
o Airway – clear & patent? o Pain:
o Breathing – RR, SpO2, effort, added sounds o Provocation – cause, relieving/exacerbating
o Circulation – HR, BP, colour, CP, AP, blood loss o Quality – description by patient
o Disability – GCS, FAST, PEARL, LOC o Radiation – go anywhere else? Red flag?
o Evaluate – Temp, BM, injs. o Scale – 1 – 10, consider pain management
o Are all observations normal? o Time – onset, and changes over time
o Document how treatment affects findings o Associated Symptoms
SHx Social History
A brief summary of the living state of the patient. Consider whether their environment contributed to their call.
o Who do they live with? o School (as appropriate)
o Type of accommodation o Social worker (as appropriate)
o Employment status o CPN (psychiatric)
o Main carer (as appropriate) o Safeguarding concerns
o Care package & company (as appropriate) o LA279/LA280 considered (as appropriate)
o Mobility aids (as appropriate) o Falls referral considered (as appropriate)
FHx Family History
A summary of conditions suffered by blood-relatives that are pertinent. Consider cause of relative’s deaths.
o Cardiac problems o Diabetes
o Respiratory problems o Cholesterol
o Cancers o Hypertension
ROS Review of Systems
A total top to toe assessment documenting findings, to demonstrate including and excluding possible conditions.
Head & Neurology Neck & Back
o Any obvious injuries – cause, size, bleeding? o Neck/Back pain – PQRSTA – analgesia?
o Loss of consciousness – causes (FISH SHAPED) o Central c-spine tenderness – immobilise?
o GCS – record any fluctuations, is this normal? o Consider any traumatic mechanism
o Pupils – PEARL? o Any stepping?
o Pain – PQRSTA – analgesia? o Any distracting injuries? – immobilise
o New onset confusion? – consider organic cause o Any alcohol/substance abuse? – immobilise
o Any history of trauma in last 7 days – red flags? o Any altered neurology – consider MTC
o Loss of co-ordination/dizzy – FAST test o Neck stiffness? – consider meningitis
o Word finding difficulties – FAST test o Lower back pain – assess kidneys and GU
o Headache – exclude sudden intense onset o Any potential cardiac cause? – ECG
o Behaviour changes – consider organic cause o Exclude AAA – “sharp ripping” pain
o Mini-mental test – 10 point (age appropriate)
o Visual disturbances
o Photosensitivity – exclude meningitis rash
o Bleeding from the ear – suspect basal skull #
o Battle signs – suspect serious head injury
Chest & Respiratory Abdomen/Genitourinary/Gastrointestinal
o Respiratory rate o Pain – PQRSTA – analgesia?
o Respiratory effort – review positioning – tripod? o Inspect/Auscultate/Palpate:
o Colour – cyanosis? flushed? o Distended? – think 6 x Fs
o Oxygen saturations – normal for patient? o Any scars? – surgical history?
o Stridor o Pulsating masses – bilateral BPs – AAA?
o SOB – at rest or exertion? o Bowel sounds x4? – loud? quiet? absent?
o DiB – say a sentence in one breath? o Rigidity – document location
o Accessory muscle use & Recession o Pain changes
o Pain – PQRSTA – analgesia? o Guarding
o Cardiac red flags? – ECG – consider ACS? o Rebound tenderness
o Inspect/Palpate/Auscultate: o Pulsating masses
o Equal chest rise o Females (particularly aged 12-55):
o Obvious wounds – consider chest seal o Pregnancy – ANY risk?
o Discolouration – consider PE o Last menstrual period (LMP)
o Crepitus/possible fracture? o Faint/dizzy (red flag) – consider ectopic
o Flail segments? o Sexually active?
o Equal air entry – any previous surgery? o Bleeding – PV/PR/urinary/vomiting – colour?
o Added sounds – wheeze/crackles o Urination – last time? pain? smell?
o Change in pitch of speech/cry o Faeces – last time? pain? consistency?
o History of a cough – productive & sputum colour o Vomiting – exclude blood – dehydration?
o Peripheral pulses o Trauma – bruising, consider NAI
Musculoskeletal/Limbs Pyschiatric (as appropriate)
o Pain – PQRSTA – analgesia? o Diagnosis – do the symptoms today fit?
o Movement – normal range in all 4 limbs? o Recent admissions?
o Sensation x4 – consider spinal trauma o Statement of harm to others?
o Circulation x4 – consider manual traction o Feelings – document quotes
o Any obvious fractures – splinting o Suicidal – calculate risk score (in JRCALC)
o Shortening or rotation to legs? – consider NOF o Trigger – anniversary, bereavement
o Ability to weight-bear o Coping – hygiene, cleanliness, cry for help?
o Co-ordination o Diet – evidence of food and fluid intake?
o Long bone integrity o Appearance – clothing, tattoos, scars?
o Swelling? – consider DVT – immobility? o Medicine compliance By Matt James
Rx/Plan Treatment and/or Plan

Summary of treatment or management plan – can be written together or separately.

General Treatment Conveyance
o Prior to AND post treatment o Hospital
o Observations improved? o Specific department – ED, HASU, MTC, HAC
o If treatment stopped, why? o Blue call?
o To what effect? – none, some, good o Interventions en route
o Any side effects experienced?
Non-conveyance
Include as required o Reason? – not required or refused?
o Airway management – OP/NP/ET/SGA/NCr o Capacity for refusal – LA5
o Breathing assistance – BVM/NTh/O2 o Referral – UCC, GP, District Nurses
o Circulatory intervention – CPR/Fluids/Drugs o Left in care – who? Responsible?
o Positioning – Legs raised/immobilised o Advice – ALL patients (see below)
o Pain relief – drugs/splints o Back of PRF and signature
o Drug administration
Referrals
Care Bundles o Falls – over 65, non-conveyed, no GP call
o ACS – ASP/GTN/MOR/NOO & blue call o Hypoglycaemia – NOT on oral diabetic meds
o Asthma – PERF/Inhaler/OXG/SLB/IPR/ADM
o COPD – 6 min nebs/OXG/SLB/IPR Additional services requested
o HEMS
Justify why an action was not completed: o Second crew
o Refusal – consider capacity/signature o Advanced Paramedic (APP)
o Allergies – clearly document o DSO
o Contra-indicated – why? o Team Leader
o Condition/Disability – what? o Clinical Support Desk (CSD)
o Lack of understanding
o Risk/benefit ratio – JRCALC cautions Forms completed
o LA3 – copy left on scene & asystole 30sec strip
o LA5 – capacity assessment
o Is the adult vulnerable/at risk? – LA280
o Is your child patient vulnerable? - LA279
o Are there other children at risk?
o LA52 – serious incident report
o LA277 – crew at risk
Advice Advice

Advice should be given to all non-conveyed patients and relatives, as well as specific advice for conditions.
All non-conveyed patients Specific advice should be given to
o Call back on 999 for any: o Headaches – FAST test, decreased LOC
o Shortness of breath o Head Injury – red flags & contact NOK
o Difficulty breathing o Diarrhoea & Vomiting – dehydration risk
o Loss of consciousness o Elderly fallers – reduced mobility to call back
o Chest pain o RTC Victims – neck/back red flags, pain relief
o Severe pain o Fainting – see GP in <48hrs, repeated call 999
o Chest pain* – character change, red flags – 999
Additionally advise when appropriate o Wounds – keep clean, advise infection risk
o Advise to contact own GP o Hypoglycaemia – monitor BM, 111, oral carbs
o Advise 111 for advice o Fever – PAR, fluids, meningitis red-flags
*Chest pain should always be conveyed – always provide if refusing transport
o Call NOK if not on scene to check on patient
o Inform Careline Any patient that experiences a change or worsening
o First aid advice in symptoms should be advised to call back on 999.