1	Chapter 10 History Taking
2	Objectives Describe purpose of effective history taking in pre-hospital care List components of patient history Outline patient interviewing techniques Identify strategies to manage challenges in obtaining a patient history
3	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.
4	Discussion What is the patient’s 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?
5	History Taking Information gathered during patient interview Account of: Medical and social occurrences in a patient’s life Environmental factors that may affect patient’s condition Source of referral Law enforcement, family, friend, bystander
6	Techniques of History Taking Set the stage: Provide a safe environment Your demeanor and appearance Avoid the patient’s personal space Inquire about patient’s feelings Note taking
7	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
8	Present Illness Greeting patient By name Shake hands Avoid unfamiliar or demeaning terms Patient comfort Comfort levels Feelings Signs of uneasiness
9	Opening Questions Ask why patient is seeking medical care Use general, open-ended questions Follow patient’s lead
10	Therapeutic Communication Facilitation Reflection Clarification Empathy Confrontation Interpretation
11	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)
12	Chief Complaint Chief complaint may be misleading Problem may be more serious than the chief complaint
13	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
14	OPQRST Onset of problem Provocation/Palliative Quality Region/Radiation/Relief Severity Time
15	Significant Past Medical History General state of health Childhood illnesses Adult illnesses Accidents and injuries Surgeries or hospitalizations Psychiatric illnesses
16	Current Health Status Allergies Medication allergies Food allergies Environmental allergies Look for medical identification devices
17	Medications Medications taken regularly and why Medication compliance Nonprescription medications Herbal remedies Drugs for recreational purposes
18	Last Oral Intake May affect airway if patient loses consciousness To determine timing of surgery To rule out other problems
19	Family History Health of immediate family High blood pressure, heart disease, contagious illnesses Potential for hereditary diseases
20	Last Menstrual Period Women with abdominal pain If pertinent, also ask about: Contraceptive use Venereal disease Urinary tract infections Ectopic pregnancy Vaginal discharge, bleeding
21	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
22	Events Before the Emergency Obtain information from patient and/or bystanders Correlate events with beginning or progression of illness or injury
23	Direct Questions Direct questions may be required Should not be leading questions Ask one question at a time
24	Sensitive Topics Alcohol or drug use Physical abuse or violence Sexual issues
25	Sensitive Questions Guidelines Respect patient privacy Be direct and firm Avoid confrontation Be nonjudgmental Use appropriate language Document carefully Use patient’s words when possible
26	Special Challenges Silence Overly talkative patients Patients with multiple symptoms Anxious patients
27	Special Challenges False reassurance May be tempting Avoid early reassurance or “overreassurance” Unless it can be provided with confidence
28	Special Challenges Anger and hostility Intoxication Crying Depression Sexually attractive or seductive patients Confusing behavior or histories Limited intelligence Developmental disabilities
29	Barriers to Communication May result from: Social or cultural differences Sight, speech, or hearing impairments Attempt to find assistance to aid in communication
30	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
31	Conclusion Obtaining a patient history provides structure to the patient assessment and often is essential to establish priorities in patient care.