Pt assess history taking


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  • Many times, we will base our diagnosis of the patients illness on their past history. It gives us clues. Frequently, answers to our questions dictate physical exam. Pt hx contains many parts c/c, recent illness, past history
  • Remember to protect patient confidentiality, interview the patient alone if possible Don’t let someone else’s impression bias your opinion
  • You must trust the reliability of information gathered Does the patient trust you with confidentiality Watch for lies ie cp went away Patient gives different info to hospital Use layman terminology
  • Avoid using unfamiliar or demeaning terms such as granny or hon
  • Facilitation – encourage patient to elaborate – go on, I’m listening Reflection – repeating patients words encourage additional responses
  • Date and time – when did it start, time may be important in CVA or CP
  • Why did you call? What’s different today? Don’t get tunnel vision.
  • Onset – what were you doing when it started. Did a medical condition proceed trauma R – is it truly independent pain or rather tenderness on palpation etc. AS – symptoms commonly associated with C/C ie cp and SOB PN – are any of those symptoms absent
  • SAMPLE history Including recent surgeries
  • Based on C/C ask questions related to these body systems
  • General – Any weight changes, appetite Skin – Any new rashes HEENT – blurred vision Resp - orthopnea Cardiac - GI – last bowel movement, hemoptesis, hematemisis Urinary – hematuria, polyuria Female – last period, gravida para
  • Silence – pt suddenly becomes silent, WHY?, try a painful stimuli or arm drop Overly talk – put back on track, summarize, say so you have cp Anxiety – anxiety attack, paxil, may complain of cp sob Confusing – ask staff or family if normal behavior, LOC amount of O2 in brain, CVA
  • Pt assess history taking

    2. 2. PatientAssessment
    3. 3. The History
    4. 4. The ability to elicit a goodhistory lays the foundation for good patient care.
    5. 5. Source of History Patient Family Friends Police Others
    6. 6. Setting the Stage If a patient’s chart is available, review it before interviewing the patient. Use this information to gain clues about the patient.
    7. 7. Reliability Memory Trust Motivation
    8. 8. Patient Rapport
    9. 9. The First Impression Present yourself as a caring, competent, and confident health care professional.
    10. 10. When you introduce yourself to the patient,shaking hands or offering a comforting touch will help build trust.
    11. 11. Asking Questions Use a combination of open- ended and close-ended questions.
    12. 12. Language and Communication Use appropriate language. Use an appropriate level of questioning, but do not appear condescending. When encountering communication barriers, try to enlist someone to help. Actively listen.
    13. 13. Active Listening Facilitation Reflection Clarification Empathy Confrontation Interpretation Asking about feelings
    14. 14. Sensitive Topics A paramedic must learn to become comfortable dealing with sensitive topics. It is important to earn a patient’s trust.
    15. 15. The Comprehensive Patient History
    16. 16. Elements of thePatient History
    17. 17. Preliminary Data Date and time Age Sex Race Birthplace Occupation
    18. 18. The Chief Complaint This is the pain, discomfort, dysfunction that caused the patient to request help.
    19. 19. The Present Illness OPQRST-ASPN Onset of the  Associated problem Symptoms Provocative/  Pertinent Palliative factors Negatives Quality Region/Radiation Severity Time
    20. 20. Past History General state of health Childhood diseases Adult diseases Psychiatric illnesses Accidents or injuries Surgeries or hospitalizations
    21. 21. Current Health Status (1 of 3) Current medications Allergies Tobacco Alcohol, drugs, and related substances Diet Screening tests Immunizations
    22. 22. Current Health Status (2 of 3) Sleep patterns Exercise and leisure activities Environmental hazards Use of safety measures Family history Home situation and significant others Daily life
    23. 23. Current Health Status (3 of 3) Important exercises Religious beliefs The patient’s outlook
    24. 24. You should take your patient’smedications with you to the hospital, when practical.
    25. 25. Review of Systems A system-by-system series of questions designed to identify problems your patient has not already identified.
    26. 26. Systems General  Urinary Skin  Male/Female HEENT Respiratory Cardiac Gastro-Intestinal
    27. 27. Special Challenges (1 of 2) Silence  Depression Overly talkative  Sexually patients attractive or Multiple seductive symptoms patients Anxiety  Confusing behaviors or symptoms
    28. 28. Special Challenges (2 of 2) Patients  Limited needing intelligence reassurance  Language Anger and Barriers hostility  Hearing Intoxication problems Crying  Blindness  Talking with families or friends
    29. 29. If the patient cannot provide usefulinformation, gather it from family or bystanders.
    30. 30. Summary History taking techniques Active listening The comprehensive health history