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CLINICAL INTERVIEW

The aim of the medical consultation via radio is to give advice on health management for each specific situation when a health problem arises on board.

The information available to the doctor to make an assessment of the condition is given by the patient and the health worker on board.

Therefore, to be able to find out and give precise information efficiently, a systematic collection of data about the different problems that justify the consultation is required, following different rules whether it is a disease or an accident, and systematically examining the patient afterwards. Together, this is the Clinical History.

This chapter explains how to collect data about the disease and how to examine the patient.

It is important to carry out a complete clinical interview, before the medical consultation via radio, whenever possible, avoiding questions which are irrelevant.

Every clinical history should start with the patient's personal details:

• National Identity Number (for Spanish crew member nationals).
• Name and surname.
• Place and date of birth.
• Employment on board.

The route or fishing area, distance to port and expected sailing days before docking should also be noted to facilitate the medical consultation via radio.

DISEASE

• How did the disease start?
• What was the first symptom?
• How long has the situation been going on for?
• How and where does it bother them?
• What happened after, how is it developing?
• Has this happened before?

The patient should answer three basic questions:

1. What is wrong with him? We should describe what is wrong with the patient, that is, what are the symptoms (pain, itching, nausea…) and what is noticed, signs (what we are able to check: cough, vomit, diarrhoea…). It is very important to indicate the main reason for consultation.
2. For how long? When did he start to feel it, the day and, if possible, even the hour.
3. What could the cause be? If there is any relation to a specific activity: food, drink, exercise…

The second stage of information collection is to accurately describe the referred symptoms. Pain, one of the most common symptoms, may be defined more precisely:

• Where does it hurt and where does it move? (Where does it radiate to?) (see Chapter 4.4 , PICTURES FROM THE LOCATION OF SYMPTOMS OR LESIONS).
• What is the pain like?
  
  
  • Continuous or intermittent.
  • Deep or on the surface.
  • Mild or severe.
  • Tight, sharp, burning...
  • Started suddenly or progressively
  
  
• When does it hurt?: Is it related to food, movement…
• With what is it relieved or worsened?: Medication, food, position…

Regarding vomit, urine or faeces we should note:

• Quantity and frequency.
• Appearance and texture.
• Colour and smell.
• Is blood present.
• Is pus present.

Identify the urine colour with one of the samples in the picture:

Lastly, enquire about:

Personal history. Major diseases suffered, Anterior surgery, hospital admissions, Anterior episodes of current disease, stomach diseases…

Known allergies to food, medication or others.

Alcohol consumption, drugs, smoking or regular medication. Medication taken for the current disease, when was it started, quantity and frequency.

ACCIDENT

When an accident has occurred it is important to point out:

• How and where on the ship did the accident happen, what day and at what time.
• Body part involved.
• Description of the type of injury: in case of burns, haemorrhage, fractures, contusions, cuts… the affected area, size and depth, movement impairment, loss of strength or sensibility should be described.

Moreover, all accompanying symptoms such as pain, loss of consciousness, difficult breathing… should be noted.