Paramedic Care: Principles & Practice Volume 3: Patient Assessment CHAPTER Fourth Edition History Taking 4

©2013 Pearson Education, Inc. Paramedic Care: Principles & Practice, 4 th Ed. Standard Assessment

©2013 Pearson Education, Inc. Paramedic Care: Principles & Practice, 4 th 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, 4 th 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, 4 th 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, 4 th Ed. Listen intently to your patient and respond accordingly. (© Daniel Limmer)

©2013 Pearson Education, Inc. Paramedic Care: Principles & Practice, 4 th 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, 4 th 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

©2013 Pearson Education, Inc. Paramedic Care: Principles & Practice, 4 th 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, 4 th 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, 4 th 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, 4 th 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, 4 th 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, 4 th 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, 4 th 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, 4 th 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, 4 th 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, 4 th 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, 4 th 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, 4 th 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, 4 th 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, 4 th 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, 4 th 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, 4 th Ed. Review of Body Systems 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, 4 th Ed. Review of Body Systems Musculoskeletal system Neurologic system Hematologic system Endocrine system Psychiatric history

©2013 Pearson Education, Inc. Paramedic Care: Principles & Practice, 4 th 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, 4 th 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, 4 th 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, 4 th 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, 4 th 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.