Transcript The History - mcstmf

MEDICAL HISTORY
Prof. Mohammad Abduljabbar
Bledsoe et al., Essentials of Paramedic Care: Division 1I
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Components of a
Patient History
Establishing rapport
Chief complaint
History of the present illness
Past medical history
Current health status
– Family history
– Psychosocial history
Review of systems
Bledsoe et al., Essentials of Paramedic Care: Division 1I
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
The Interview
Differential field diagnosis
Helps establish a bond
Bledsoe et al., Essentials of Paramedic Care: Division 1I
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Patient Rapport
Bledsoe et al., Essentials of Paramedic Care: Division 1I
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Patient Rapport –
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.
Bledsoe et al., Essentials of Paramedic Care: Division 1I
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Patient Rapport –
The First Impression
Present yourself as a caring,
competent, and confident health care
professional.
Bledsoe et al., Essentials of Paramedic Care: Division 1I
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Patient Rapport –
Building Trust
When you introduce yourself to the
patient, shaking hands or offering a
comforting touch will help build trust.
Bledsoe et al., Essentials of Paramedic Care: Division 1I
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Patient Rapport –
Asking Questions
Use a combination of open-ended and
closed-ended questions.
Bledsoe et al., Essentials of Paramedic Care: Division 1I
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Patient Rapport –
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.
Bledsoe et al., Essentials of Paramedic Care: Division 1I
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Patient Rapport –
Active Listening
Facilitation
Reflection
Clarification
Empathy
Confrontation
Interpretation
Asking about feelings
Bledsoe et al., Essentials of Paramedic Care: Division 1I
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Patient Rapport –
Sensitive Topics
A paramedic must learn to become
comfortable dealing with sensitive
topics.
It is important to earn a patient’s trust.
Bledsoe et al., Essentials of Paramedic Care: Division 1I
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
The Comprehensive
Patient History
Bledsoe et al., Essentials of Paramedic Care: Division 1I
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Preliminary Data
Date and time
Age
Sex
Race
Birthplace
Occupation
Bledsoe et al., Essentials of Paramedic Care: Division 1I
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
The Chief Complaint
This is the pain, discomfort,
dysfunction that caused the patient to
request help.
Bledsoe et al., Essentials of Paramedic Care: Division 1I
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
The Present Illness
OPQRST-ASPN
Onset of the
problem
Provocative/
Palliative factors
Quality
Region/Radiation
Severity
Time
Associated
Symptoms
Pertinent
Negatives
Bledsoe et al., Essentials of Paramedic Care: Division 1I
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Past History
General state of health
Childhood diseases
Adult diseases
Psychiatric illnesses
Accidents or injuries
Surgeries or hospitalizations
Bledsoe et al., Essentials of Paramedic Care: Division 1I
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Current Health Status (1 of 3)
Current medications
Allergies
Tobacco
Alcohol, drugs, and related substances
Diet
Screening tests
Immunizations
Bledsoe et al., Essentials of Paramedic Care: Division 1I
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
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
Bledsoe et al., Essentials of Paramedic Care: Division 1I
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Current Health Status (3 of 3)
Important exercises
Religious beliefs
The patient’s outlook
Bledsoe et al., Essentials of Paramedic Care: Division 1I
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
You should take your patient’s
medications with you to the hospital,
when practical.
Bledsoe et al., Essentials of Paramedic Care: Division 1I
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Review of Systems
A system-by-system series of
questions designed to identify
problems your patient has not already
identified:
–
–
–
–
–
–
–
–
Skin
Head
Eyes
Ears
Nose
Mouth/Throat
Respiratory
Cardiovascular
– Gastrointestinal
– Genitourinary
– Musculoskeletal
– Neurologic
– Psychologic
– Endocrine
– Hematologic
Bledsoe et al., Essentials of Paramedic Care: Division 1I
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Psychosocial History
Chronic health conditions
Job
– Work schedule
– Stress
Family dynamics
Support
Safety issues
– Car seat usage
– Smoke and CO alarms
Bledsoe et al., Essentials of Paramedic Care: Division 1I
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Special Challenges (1 of 2)
Silence
Overly talkative
patients
Multiple
symptoms
Anxiety
Depression
Sexually
attractive or
seductive
patients
Confusing
behaviors or
symptoms
Bledsoe et al., Essentials of Paramedic Care: Division 1I
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Special Challenges (2 of 2)
Patients needing
reassurance
Anger and
hostility
Intoxication
Crying
Limited
intelligence
Language barriers
Hearing problems
Blindness
Talking with
families or friends
Bledsoe et al., Essentials of Paramedic Care: Division 1I
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
If the patient cannot provide useful
information, gather it from family
or bystanders.
Bledsoe et al., Essentials of Paramedic Care: Division 1I
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ
Summary
History-Taking Techniques
Active Listening
The Comprehensive Health History
Bledsoe et al., Essentials of Paramedic Care: Division 1I
© 2006 by Pearson Education, Inc. Upper Saddle River, NJ