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
The First Impression Present yourself as a caring, competent, and confident health care professional.
When you introduce yourself to the patient,shaking hands or offering a comforting touch will help build trust.
Asking Questions Use a combination of open- ended and close-ended questions.
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.
Active Listening Facilitation Reflection Clarification Empathy Confrontation Interpretation Asking about feelings
Sensitive Topics A paramedic must learn to become comfortable dealing with sensitive topics. It is important to earn a patient’s trust.