Transcript Obtaining a Medical History

Obtaining a Medical History
Objectives
• Describe the factors that influence ability
to collect a medical history
• Describe the technique of history taking
open and closed ended questions
• Describe the structure and purpose of a
health history
• Describe how to obtain a health history
• List the components of a history of an
adult patient
• Demonstrate the importance of empathy
when obtaining a health history
• Demonstrate the importance of
confidentiality when obtaining a health
history
• Information is gathered on a patient-bypatient, case-by-case basis
• Several parts
• Specific purpose
• Together they give structure
• Does not dictate sequence
Source of history
• Patient
• Family
• Friends
• Police
• Others
• Reliability
• variable
• Memory
• Trust
• Motivation
Made at the end of the evaluation, not the
beginning
Contents of History
• Date
• Always important
• Time may also be a consideration
Identifying data
• Age
• Sex
• Race
Chief Complaint
• Main part of the health history
• The one or more symptoms for which the
patient is seeking medical care
History of the present illness
• Detailed evaluation of the chief complaint
• Provides a full, clear, chronological
account of the symptoms
• Past medical history
pertinent information to the current
condition
Current health status
• Present state of health
• Environmental conditions
• Individual factors
Current medications
Allergies
Tobacco use
Alcohol, drugs, and related substances
Diet
Screening tests
Immunizations
Sleep patterns
Exercise and leisure activities
Environmental hazards
Use of safety measures
Family history
Home situation and significant other
Daily life
Important experiences
Religious beleifs
• Patient’s outlook
Techniques of History Taking
Setting the stage
Environment
• Proper environment enhances
communication
• Be cautious of power relationships
• Personal space
Your demeanor and appearance
• As you are watching your patient, your patient
will be watching you
• Messages of body language
• Clean, neat professional appearance
Note taking
• Difficult to remember all details
• Most patients are comfortable with note taking
• Do not divert your attention from the
patient to take notes
Learning about the present illness
• Refer to the patient by name
• Avoid the use of unfamiliar or demeaning
terms such as “granny or “hon”
• Follow the patient’s lead
facilitation-any activity which makes
tasks for others easy.
• Posture, actions, or words should
encourage additional responses
• Typically does not bias the story of
interrupt the patient’s train of thought
• Clarification
used to clarify ambiguous statements
or words
• Making eye contact or saying “go on” or
“I’m listening” may help
Reflection
• Repeating encourages additional
responses
• Does not bias the story of interrupt train of
thought
Confrontation
• Some issues or responses may require
you to confront patients about their
feelings
Interpretation
• Goes beyond confrontation
History of Present Illness
• OPQRST
• SAMPLE
• Family history
• Social history
• Housing environment
• Economic status
• occupation
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High risk behavior
Travel history
Current health status
Diet
VS and LOC
• AVPU
• Obtunded
Insensitivity to unpleasant or painful stimuli
by reduced level of consciousness by an
anesthetic or analgesic
Posture
Movement
• Purposeful
• Non-purposeful
• Appropriateness
Dress, grooming, and personal hygiene
• Fastidiousness
difficult to please
• Neglect
• Facial expression
• Affect
interaction with stimuli
Speech
• Aphasia
Difficulty speaking
• Dysphonia
Inability to speak
• Dysarthria
Slurred speech
Skin color
• Pallor
pale
Posture, gait, and motor activity
• Ataxia
lack of coordination of muscle
movement