Prof. Mohammad Abduljabbar Prof. Mohammad Abduljabbar MEDICAL HISTORY

 Establishing rapport  Chief complaint  History of the present illness  Past medical history  Current health status  Family history  Psychosocial history  Review of systems Components of a Patient History

 Differential field diagnosis  Helps establish a bond The Interview J

Patient Rapport

 If a patient’s chart is available, review it before interviewing the patient.  Use this information to gain clues about the patient. Patient Rapport

 Present yourself as a caring, competent, and confident health care professional. The First Impression

 When you introduce yourself to the patient, shaking hands or offering a comforting touch will help build trust. Building Trust

 Use a combination of open-ended and closed-ended questions. Asking Questions Asking Questions

 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. Communication

 Facilitation  Reflection  Clarification  Empathy  Confrontation  Interpretation  Asking about feelings Active Listening Active Listening

 A paramedic must learn to become comfortable dealing with sensitive topics.  It is important to earn a patient’s trust. Sensitive Topics Sensitive Topics

 Date and time  Age  Sex  Race  Birthplace  Occupation Preliminary Data

 This is the pain, discomfort, dysfunction that caused the patient to request help. The Chief Complaint

The Present Illness  Onset of the problem  Provocative and palliative factors  Quality  Region/Radiation  Severity  Time  Associated symptoms  Pertinent negatives

 General state of health  Childhood diseases  Adult diseases  Psychiatric illnesses  Accidents or injuries  Surgeries or hospitalizations Past History

 Current medications  Allergies  Tobacco  Alcohol, drugs, and related substances  Diet  Screening tests  Immunizations Current Health Status

 Sleep patterns  Exercise and leisure activities  Environmental hazards  Use of safety measures  Family history  Home situation and significant others  Daily life Current Health Status

 Important exercises  Religious beliefs  The patient’s outlook Current Health Status

You should take your patient’s medications with you to the hospital, when practical.

Review of Systems –Skin –Head –Eyes –Ears –Nose –Mouth/Throat –Respiratory –Cardiovascular –Gastrointestinal –Genitourinary –Musculoskeletal –Neurologic –Psychological –Endocrine –Hematologic

 Chronic health conditions  Job  Work schedule  Stress  Family dynamics  Support  Safety issues  Car seat usage  Smoke and CO alarms Psychosocial History

Special Challenges  Silence  Overly talkative patients  Multiple symptoms  Anxiety  Depression  Sexually attractive or seductive patients  Confusing behaviors or symptoms

Special Challenges  Patients needing reassurance  Anger and hostility  Intoxication  Crying  Limited intelligence  Language barriers  Hearing problems  Blindness  Talking with families or friends

If the patient cannot provide useful information, gather it from family or bystanders.

 History-Taking Techniques  Active Listening  The Comprehensive Health History Summary