Mosby's Ch12: History Taking Objectives

Front 1

Describe the purpose of effective history taking in prehospital patient care

Back 1

Provides an account of medical, social, and environmental factors that may have a bearing on patient condition; provides structure to patient assessment; and are essential to establishing priorities in patient care

Front 2

List components of the patient history as defined by the US DOT

Back 2

Date, time, identifying data (age, sex, race, birthplace, occupation), source of referral (by self or by others), source of history (patient, family, friends, police, others) reliability, chief complaint, history of present illness, past history, current health status

Front 3

Outline effective patient interviewing techniques to facilitate history taking

Back 3

Establish a professional demeanor, ensure patient safety and comfort, greet patient by name and shake hands, avoid entering personal space, inquire about feelings, be sensitive to feelings and experiences, watch for signs of uneasiness, use appropriate and understandable language, ask direct, open-ended questions, use therapeutic communication techniques

Front 4

Identify strategies to manage special challenges in history-taking (silence)

Back 4

Stay alert to nonverbal clues of distress or anxiety and give patient time to ready self to answer

Front 5

Identify strategies to manage special challenges in history-taking (overly talkative)

Back 5

Accept a less comprehensive history, give patient free reins for a few minutes, ask yes or no questions, summarize comments frequently, refocus often

Front 6

Identify strategies to manage special challenges in history-taking (patient with multiple symptoms)

Back 6

Anticipate longer interview times, help patient focus on most relevant

Front 7

Identify strategies to manage special challenges in history-taking (anxious patient)

Back 7

Be sensitive to nonverbal clues of anxiety, remain supportive and calm, maintain caring and professional attitude

Front 8

Identify strategies to manage special challenges in history-taking (false reassurance)

Back 8

Avoid false reassurance. Instead reassure patient that there is hope, that the paramedic is listening, that care is available, that patient will be treated with dignity and respect, that patient’s condition is understood

Front 9

Identify strategies to manage special challenges in history-taking (anger and hostility)

Back 9

Maintain calm manner, demonstrate confidence, set limits on behavior, attempt to calm patient

Front 10

Identify strategies to manage special challenges in history-taking (intoxication)

Back 10

Ensure personal and scene safety, establish limits for acceptable behavior, request law enforcement

Front 11

Identify strategies to manage special challenges in history-taking (crying)

Back 11

If crying is uncontrollable, hold hand and use direct eye contact to reassure

Front 12

Identify strategies to manage special challenges in history-taking (sexually attractive or seductive)

Back 12

Set limits on behavior, reinforce fact that relationship is to stay professional, care provider should be same sex as patient, use an additional caregiver as a chaperone

Front 13

Identify strategies to manage special challenges in history-taking (depression)

Back 13

Identify the seriousness of the depression and be sensitive to nonverbal clues of depression, remain supportive and calm, maintain caring and professional attitude

Front 14

Identify strategies to manage special challenges in history-taking (confusing behaviors or history)

Back 14

Identify behavioral pattern and lead patient with directed questions

Front 15

Identify strategies to manage special challenges in history-taking (developmental disabilities)

Back 15

Don’t overlook patient’s ability to answer questions; but if the disability is severe, ask family or friends

Front 16

Identify strategies to manage special challenges in history-taking (Communication barriers)

Back 16

Find assistance

Front 17

Identify strategies to manage special challenges in history-taking (talking with family and friends)

Back 17

Consider them a resource to fill in missing information

Front 18

Information gathered as part of the History of Present Illness

Back 18

OPQRST, pertinent positives and negatives

Front 19

Information gathered as part of the Past Medical History

Back 19

Childhood illness, adult illness, accidents and injuries, surgeries and hospitalizations, psychiatric illness, family history

Front 20

Information gathered as part of the Current Health Status

Back 20

Allergies, medications, food allergies, environmental allergies, and look for medical ID devices

Front 21

Information gathered as part of the Medications

Back 21

What is taken regularly and why, how compliant are they, what nonprescriptions are taken, use of recreational drugs

Front 22

Why is a patient’s last oral intake important to know

Back 22

May affect potential airway problems if patient loses consciousness, may determine appropriateness of surgeries, may help rule out other problems

Front 23

Determining the last menstrual period is important for all women presenting with abdominal pain. Which questions may you need to ask in follow-up

Back 23

Contraceptive use, history of venereal disease, urinary tract infection, history of ectopic pregnancy

Front 24

Information gathered as part of the last bowel movement

Back 24

Determine history of diarrhea, constipation, bloody bowel movements and whether they would be considered normal or abnormal

Front 25

Information gathered as part of the urinary function

Back 25

Occurrence of: hematuria, discharge, pain or burning associated, frequency, inability to void

Front 26

Information gathered as part of the environment

Back 26

Home conditions, occupation, travel, military record

Front 27

Information gathered as part of the personal habits

Back 27

Tobacco and alcohol use, diet, screening, immunizations, sleep patterns, exercise, leisure, safety practices, home situation, physical abuse, sexual history, daily life, important experiences, patient outlook

Front 28

Follow up questions to ask regarding alcohol use

Back 28

Cutting down, annoyance by criticism, guilty about use, eye-opener(mornig use) CAGE

Front 29

Tips to remember when questioning about abuse or violence

Back 29

Gather clues about situation, girect questions are best, have a nonjudgmental attitude, avoid judgmental statements, avoid “why” questions, be supportive

Front 30

Areas assessed in Review of Systems

Back 30

General impression, skin, HEENT (head, eyes, ears, nose, and throat) respiratory, cardiovascular, gastrointestinal, genitourinary, musculoskeletal, neurologic, hematologic, endocrine, psychiatric

Front 31

Identify and explain therapeutic communication techniques for opening questions

Back 31

Facilitation (words, actions, or psture should encourage patient to say more), reflection (repeat what patient said to encourage responses without bias or interruption), clarification (ask questions to to understand ambiguity), empathetic responses (interpret patient feelings), confrontation (tactfully confront patient about feelings), interpretation (make an inference from responses), ask about feelings

Front 32

Define: Dysuria

Back 32

Painful urination

Front 33

Define: hematuria

Back 33

Blood in urine