Chapter 10 History Taking

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Objectives

Describe purpose of effective history taking in prehospital care List components of patient history Outline patient interviewing techniques

Identify strategies to manage challenges in obtaining a patient history

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Scenario
You are dispatched to a call for abdominal pain. Your patient is a 41-year-old female who is having severe right lower quadrant abdominal pain.

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Discussion

What is the patients chief complaint? How could your patient history help to determine the nature of her pain? Why is it necessary to determine her medications and allergies?

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History Taking

Information gathered during patient interview Account of:

Medical and social occurrences in a patients life Environmental factors that may affect patients condition Source of referral Law enforcement, family, friend, bystander

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Techniques of History Taking

Set the stage:

Provide a safe environment Your demeanor and appearance Avoid the patients personal space Inquire about patients feelings Note taking

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Components of Patient History

Date and time Identifying data Source of referral Source of history

Chief complaint Present illness Past history Current health status

Review of body systems

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Present Illness

Greeting patient

By name Shake hands Avoid unfamiliar or demeaning terms

Patient comfort

Comfort levels Feelings Signs of uneasiness

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Opening Questions

Ask why patient is seeking medical care Use general, open-ended questions

Follow patients lead

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Therapeutic Communication

Facilitation Reflection

Empathy Confrontation

Clarification

Interpretation

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Chief Complaint

Symptoms that caused patient to seek care Often:

Pain Abnormal function Change in normal state Unusual observation made by patient (e.g., heart palpitations)

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Chief Complaint

Chief complaint may be misleading Problem may be more serious than the chief complaint

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History of Present Illness (HPI)

Identifies the chief complaint Provides full, clear, chronological account of symptoms A thorough HPI:

Asks questions related to chief complaint Interprets patient's response to questions

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OPQRST

Onset of problem Provocation/Palliative Quality Region/Radiation/Referral Severity Time

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Significant Past Medical History

General state of health

Childhood illnesses Adult illnesses Accidents and injuries Surgeries or hospitalizations

Psychiatric illnesses

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Current Health Status

Allergies

Medication allergies Food allergies Environmental allergies

Look for medical identification devices

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Medications

Medications taken regularly and why Medication compliance

Nonprescription medications
Herbal remedies Drugs for recreational purposes
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Last Oral Intake

May affect airway if patient loses consciousness To determine timing of surgery To rule out other problems

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Family History

Health of immediate family

High blood pressure, heart disease, contagious illnesses

Potential for hereditary diseases

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Last Menstrual Period

Women with abdominal pain If pertinent, also ask about:

Contraceptive use Venereal disease Urinary tract infections Ectopic pregnancy Vaginal discharge, bleeding

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Last Bowel Movement

Normal or abnormal for patient

Diarrhea Constipation Bloody bowel movements

Abnormal urinary function

Hematuria Urethral discharge Pain or burning with urination Frequent urination Inability to void
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Events Before the Emergency

Obtain information from patient and/or bystanders Correlate events with beginning or progression of illness or injury

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Direct Questions

Direct questions may be required

Should not be leading questions Ask one question at a time

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Sensitive Topics

Alcohol or drug use Physical abuse or violence

Sexual issues

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Sensitive Questions Guidelines

Respect patient privacy

Be direct and firm

Avoid confrontation

Be nonjudgmental
Use appropriate language

Document carefully

Use patients words when possible

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Special Challenges

Silence Overly talkative patients

Patients with multiple symptoms

Anxious patients

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Special Challenges

False reassurance

May be tempting Avoid early reassurance or overreassurance Unless it can be provided with confidence

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Special Challenges

Anger and hostility Intoxication Crying Depression Sexually attractive or seductive patients Confusing behavior or histories Limited intelligence Developmental disabilities

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Barriers to Communication

May result from:

Social or cultural differences Sight, speech, or hearing impairments

Attempt to find assistance to aid in communication

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Talking with Family and Friends

At scene of an emergency

Good source of information Helpful when patient cannot provide information due to illness or injury

If not available, may need to try to locate a third party to help supply missing data

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Conclusion
Obtaining a patient history provides structure to the patient assessment and often is essential to establish priorities in patient care.

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Questions?

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