Transcript bledsoe_pcpp3_ch04_lecture - McLaren

Paramedic Care: Principles & Practice
Fourth Edition
Volume 3: Patient Assessment
CHAPTER
4
History Taking
Standard
• Assessment
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Competency
• Integrate scene and patient assessment
findings with knowledge of
epidemiology and pathophysiology to
form a field impression.
• This includes developing a list of
differential diagnoses through clinical
reasoning to modify the assessment
and formulate a treatment plan.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Introduction
• Base field diagnosis on patient history.
• Obtain history of patient's chief
complaint, recent illnesses, significant
past medical history.
• Foundation for providing good care.
• Gain patient's trust; ask right
questions; listen intently to answers;
respond accordingly.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Introduction
• The situation determines length and
completeness of interview.
• Interview is focal point of your
relationship with your patients.
• Understanding their problems and
differential field diagnosis.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Listen intently to your patient and respond accordingly. (© Daniel Limmer)
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Preliminary Data
• For documentation:
– Record date and time of physical exam.
– Determine patient's age, sex, race,
birthplace, occupation.
– Reconfirm information with patient.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Chief Complaint
• Pain, discomfort, dysfunction that
caused patient to request help.
• General question that allows patient to
respond freely.
• Primary problem is principal medical
cause of complaint
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Paramedic Care: Principles & Practice, 4th Ed.
Present Problem
• OPQRST–ASPN
– Onset
– Provocation/ P alliation
– Quality
– Region/ R adiation
– Severity
– Time
– Associated S ymptoms
– Pertinent N egatives
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Present Problem
• Onset
– Did problem develop suddenly or
gradually?
– What was patient doing when symptoms
started?
– In medical emergencies, investigate
patient's activities.
– In trauma cases, ensure medical
problem did not cause incident.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Present Problem
• Provocation/Palliation
– What provokes symptom (makes it
worse)?
– Does anything palliate symptom (make it
better)?
– Positioning may be a factor.
– If patient took medication shortly before
you arrived, its effect—or lack of effect—
may help determine problem.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Present Problem
• Quality
– How does patient perceive the pain or
discomfort?
– Ask him to explain how symptom feels.
– Listen carefully to answer.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Present Problem
• Region/Radiation
– Identify exact location and area of pain,
discomfort, or dysfunction.
– Identify specific location, or boundary,
of pain if it is regional.
– Is pain truly pain or tenderness?
– Does pain move or radiate?
– Referred pain: felt in part of body away
from source of disease or problem
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Present Problem
• Severity
– Intensity of pain or discomfort felt.
– Notice amount of discomfort patient's
condition causes.
• Time
– When did symptoms begin?
– Constant or intermittent?
– How long does it last?
– How long has it affected patient?
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Present Problem
• Associated Symptoms
– Symptoms commonly associated with
chief complaint.
• Pertinent Negatives
– Are any likely associated symptoms
absent?
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Past Medical History
• May provide insights into patient's chief
complaint and your field diagnosis.
• How does patient perceive his general
state of health?
• What childhood diseases did patient
have?
• Preexisting medical problem may
contribute to patient's current problem
or influence his care.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Past Medical History
• Is patient taking any medications?
– Over-the-counter medications,
prescriptions, home remedies, vitamins,
minerals.
• If practical, bring patient's medications
to hospital.
• Does patient have any known allergies?
• What type of reaction did patient have?
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Past Medical History
• Does patient have history of mental
illness?
• Has patient ever had serious accident
or injury requiring hospitalization?
• Has patient had other hospitalizations
or surgeries not already mentioned?
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Family/Social History
• Medical history of immediate family
members important.
• Find out whether he has support
network, and whom it includes.
• Find out what kind of life patient leads.
• Does your patient use tobacco?
• Alcohol and drugs often contributing
factors in, if not primary cause of,
patient's medical problems.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Family/Social History
• CAGE Questionnaire
– Cut down
– Annoyed
– Guilty
– Eye-opener
• Ask about blackouts, accidents,
injuries that happened while drinking.
• Ask about drug use.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Family/Social History
• Ask about patient's normal daily intake
of food and drink.
• Ask about screening tests.
• Ask about immunizations for diseases.
• Ask patient what time he normally goes
to bed and arises.
• Does patient exercise regularly or lead
sedentary existence?
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Family/Social History
• Ask about hazards in home, school, at
workplace.
• Use of safety measures: determine
extent of damage caused by particular
mechanism of injury.
• Ask about upbringing and home life
growing up.
• Ask about religious beliefs.
• Determine patient's outlook.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Review of Body Systems
• Patient's chief complaint, condition,
clinical status determine how much of
the review of body systems you use.
• Patient's weight; recent changes.
• Weakness, fatigue, fever, chills, night
sweats?
• Check skin, hair, nails.
• Check head, eyes, ears, nose, throat
(HEENT).
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Review of Body Systems
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•
•
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Chest and lungs
Heart and blood vessels
Lymph nodes
Gastrointestinal system
Genitourinary system
Male genitalia
Female genitalia
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Review of Body Systems
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•
•
•
•
Musculoskeletal system
Neurologic system
Hematologic system
Endocrine system
Psychiatric history
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Clinical Reasoning
• Conduct history and physical exam.
• Arrive at field diagnosis, or impression.
• Apply your clinical experience and
decision making to develop and
implement management plan.
• Knowledge of anatomy and physiology
and of pathophysiology of patient's
disease or injury.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Clinical Reasoning
• Focus on many specific data.
• Organize information you obtain and
form concepts from it.
• Elicit chief complaint and formulate
differential field diagnosis.
• Identify and deal with medical
ambiguity.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Clinical Reasoning
• Differentiate between relevant and
irrelevant data.
• Recognize patterns: analyze and
compare similar and contrasting
situations.
• Explain your decisions and construct
logical arguments.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Summary
• Assess patient to determine primary
problem.
• Chief complaint will lead you in right
direction; symptom of actual problem.
• Obtain comprehensive history and
physical exam.
• Think critically; remain open-minded
while progressing through assessment.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Summary
• Ask open-ended questions; avoid
leading questions.
• Develop script for interactions with
patients.
• SAMPLE or OPQRST-ASPN will help you
assess patient thoroughly.
• Document answers to your questions as
you receive them.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.