Obtaining Patients History

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Obtaining A Patient History : 

Obtaining A Patient History Department of EMS Professions Temple College

Topics to Discuss : 

Topics to Discuss The Value of History Taking Establishing the Patient Relationship Elements of the Comprehensive History Focusing the History Special Challenges

The Value of History Taking : 

The Value of History Taking Directs the focus of the Physical Exam Often the basis for the differential diagnosis Keys Trust Right Questions Interpreting the responses Knowing what to do next Care begins simultaneously

First Impressions : 

First Impressions Positive Impression Appearance Confidence Demeanor Body Language

Establishing the Patient Relationship : 

Establishing the Patient Relationship Polite Introductions Invited guest or unwanted pest? Be respectful of person, space, property & family Locate the patient(s) Introduce yourself - Handshake Determine patient’s desired name Avoid disrespectful terms & voice tone Consider age & culture

Establishing the Patient Relationship : 

Establishing the Patient Relationship Location & Position Quiet & Private location, if possible Can the patient be made more comfortable? Eye contact & Position at eye level Appropriate distance & position Safety Respect Personal Zone

Elements of the Comprehensive History : 

Elements of the Comprehensive History Prearrival & Caller Info First Impression & the Environment Identifying Data Chief Complaint(s) History of the Present Illness Current Health Status & Medical Care Significant Past History Family History Systems Review

Elements of the Comprehensive History : 

Elements of the Comprehensive History Prearrival & Caller Info Dispatch info Info from the caller (not patient) on arrival What is the “reported” chief complaint(s)?

Elements of the Comprehensive History : 

Elements of the Comprehensive History First Impression & the Environment Clues regarding History The Big Picture What is the setting? What is the Patient’s General Appearance? Are there medications or therapies present or in-use? Are medical documents or files available?

Elements of the Comprehensive History : 

Elements of the Comprehensive History Identifying Data Name Age & DOB Sex Race Physician’s Name

Elements of the Comprehensive History : 

Elements of the Comprehensive History The Chief Complaint The single most critical concern to the patient “What seems to be the problem today?” “What can I help you with today?” Which system (origin) do you believe to be affected by this CC? Do you clearly understand the patient’s complaint or complaints?

Elements of the Comprehensive History : 

Elements of the Comprehensive History The Chief Complaints Multiple Complaints “If I could make one thing better for you, which would you want it to be?” Are the multiple complaints likely to be related? Will you need to address multiple issues? Could some of these be chronic issues?

Elements of the Comprehensive History : 

Elements of the Comprehensive History Tips for effective history-taking Open-ended questions “What seems to be bothering you today?” Closed-ended questions “Is your chest pain sharp or dull?” Multiple Choice Questions

Elements of the Comprehensive History : 

Elements of the Comprehensive History Tips for effective history-taking LISTEN ACTIVELY!!! ACT as if you are listening Repeat patient’s statements Clarify if needed Take notes Display your concern Confront with caution

Elements of the Comprehensive History : 

Elements of the Comprehensive History History of the Present Illness Explore the CC in more detail Explore other complaints Are they associated? Do they involve completely different body systems? OPQRST - ASPN This is a GUIDE! Modify for complaints other than pain

Elements of the Comprehensive History : 

Elements of the Comprehensive History Current Health Status & Medical Care Current Medical Therapies & Medications Regular Physician Following Allergies Home Situation, Daily Life & Family Life (continued)

Elements of the Comprehensive History : 

Elements of the Comprehensive History Current Health Status & Medical Care (continued) Recent changes to Sleep & Diet Tobacco, Alcohol & Substance Abuse Type of Occupation Immunizations

Elements of the Comprehensive History : 

Elements of the Comprehensive History CAGE Questionnaire Felt the need to Cut-Down drinking Felt Annoyed by criticism re. drinking Guilty feels about drinking Eve drank first thing in the a.m. asEye-opener

Elements of the Comprehensive History : 

Elements of the Comprehensive History Significant Past History General State of Health per patient Significant adult or childhood illnesses or injuries Psychiatric illnesses Past hospitalizations, surgeries or long-term treatments

Elements of the Comprehensive History : 

Elements of the Comprehensive History Family History Relative Risk Factors Diabetes, HTN, or Renal Disease Heart Disease, early AMI, early SCD or Stroke Asthma or Allergies Cardiac dysrhythmias Cancer Osteoporosis Mental Illness

Elements of the Comprehensive History : 

Elements of the Comprehensive History Systems Review (focused by CC) Generalized symptoms Skin HEENT Respiratory Cardiovascular Central Peripheral Gastrointestinal Systems Review (focused by CC) Urinary Genitalia Musculoskeletal Neurologic Hematologic Endocrine Psychiatric

Focusing the History : 

Focusing the History Act on the Chief Complaint Direct immediate care as appropriate History taking may need to be temporarily halted Interpret the feedback and Act What do I think of these responses? Do they make sense? Am I missing something? Do I need clarification?

Focusing the History : 

Focusing the History Consider an Unsolved Mystery Focus on the body system associated with the CC Use knowledge of A&P and Pathophysiology Why is this patient experiencing these signs/symptoms? Create a picture of what occurred today to this patient Create a differential diagnosis, then work towards exclusions/inclusions

Special Challenges : 

Special Challenges Sensitive Topics The Right Location Does anyone present make the patient feel uncomfortable? Gaining Trust Choosing Appropriate Words Understand the patient’s feelings related to the sensitive nature Be Professional

Special Challenges : 

Special Challenges The Silent Patient Short periods of silence may be normal Allow time to collect thoughts Provide reassurance & encouragement Consider: You have frightened the patient You are dominating the discussion You have offended the patient There is a physical or mental disorder

Special Challenges : 

Special Challenges The Overly-Talkative Patient Allow patient to speak If necessary, politely interrupt and focus the discussion Focus on most critical issue Ask specific, closed-ended questions Summarize the patient’s story and move on Don’t display your impatience

Special Challenges : 

Special Challenges The Anxious or Frightened Patient Look for signs of anxiety or fear Try to alleviate concerns & develop trust No false reassurance “Everything is going to be fine” Identify the source of anxiety/fear Understand the patient’s feelings “I don’t know why you are so anxious’

Special Challenges : 

Special Challenges The Angry or Hostile Patient Common feelings with stress or fear Understand the source of these feelings Respond in a professional & caring manner Personal Safety is a primary concern!!! Distance Assistance Firm but caring verbal & body language

Special Challenges : 

Special Challenges The Intoxicated Patient Irrational Altered sense of right & wrong May become violent If patient is shouting, increased potential for violent behavior listen don’t respond back with shouting have assistance for safety

Special Challenges : 

Special Challenges The Depressed or Suicidal Patient Know the warning signs Explore the specific feelings of the patient Be direct and specific Question regarding thoughts of suicide or personal harm Talk openly and specifically about suicide plans

Special Challenges : 

Special Challenges The Patient with Confusing Behavior or History The entire history does not add up Assess mental status Consider possible dementia or delirium Identify cause if possible Consider specific causes based upon behavior Confabulation Multiple personalities

Special Challenges : 

Special Challenges The Patient with a Language Barrier Extremely difficult to assess Enlist friends or family to act as an interpreter Use pre-established questions in the patient’s language Language Lines

Special Challenges : 

Special Challenges Intelligence & Literacy Does the patient really understand your questioning? History may be inaccurate Enlist friends or family Can the patient actually read? Read statements aloud to the patient

Special Challenges : 

Special Challenges The Patient with Sensory Deficits Hearing Impaired Does the patient read lips? Face patient, close to good ear Talk slowly and distinctly Sign language? Will a hearing aid help? Where is it? Blindness Voice and touch are critical Establish relationship & trust early on

Common Pitfalls : 

Common Pitfalls Choosing to ask lots of questions to obtain a history WITHOUT also directing initial care or performing a physical exam Patient’s Impression Not doing anything for me Why are we wasting our time here? Stop asking all these silly questions

Common Pitfalls : 

Common Pitfalls Using a tone of voice that sends the wrong message “What is your ‘Problem’ TODAY Mrs. Jones? “Why did you call 911?” Patient’s Impression He thinks I call EMS for every little problem I must have called 911 and was not supposed to. I think I am bothering these nice people

Common Pitfalls : 

Common Pitfalls Lack of respect for cultural, religious or ethnic differences “Why do you people use these home herbal remedies?” “You have enough kids. You should consider birth control” Patient’s Impression This person thinks I am a fool She laughs at the traditions of my culture He does not respect my personal decisions

Common Pitfalls : 

Common Pitfalls Poor choice of words or using technical terms How many years has your husband been taking these ACE-inhibitors? Your wife is experiencing congestive heart failure Patient’s Impression What the heck is he talking about? My wife’s heart is failing?!?! Has her heart stopped yet? Son, could you speak English?

Summary : 

Summary Obtaining the history guides the physical exam History-taking is accomplished along with the physical exam and therapies For emergent patients, the history-taking is delayed or never actually obtained in the prehospital setting