Obtaining a Medical History. Objectives Describe the factors that influence ability to collect a...
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![Page 1: Obtaining a Medical History. Objectives Describe the factors that influence ability to collect a medical history Describe the technique of history taking.](https://reader035.fdocuments.us/reader035/viewer/2022070305/551516d655034673228b4c59/html5/thumbnails/1.jpg)
Obtaining a Medical History
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Objectives
• Describe the factors that influence ability to collect a medical history
• Describe the technique of history taking
open and closed ended questions
• Describe the structure and purpose of a health history
• Describe how to obtain a health history
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• List the components of a history of an adult patient
• Demonstrate the importance of empathy when obtaining a health history
• Demonstrate the importance of confidentiality when obtaining a health history
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• Information is gathered on a patient-by-patient, case-by-case basis
• Several parts
• Specific purpose
• Together they give structure
• Does not dictate sequence
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Source of history• Patient• Family• Friends• Police• Others• Reliability• variable
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• Memory
• Trust
• Motivation
Made at the end of the evaluation, not the beginning
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Contents of History• Date• Always important• Time may also be a considerationIdentifying data• Age• Sex• Race
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Chief Complaint
• Main part of the health history
• The one or more symptoms for which the patient is seeking medical care
History of the present illness
• Detailed evaluation of the chief complaint
• Provides a full, clear, chronological account of the symptoms
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• Past medical history
pertinent information to the current condition
Current health status
• Present state of health
• Environmental conditions
• Individual factors
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Current medicationsAllergiesTobacco useAlcohol, drugs, and related substancesDietScreening testsImmunizationsSleep patterns
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Exercise and leisure activitiesEnvironmental hazardsUse of safety measuresFamily historyHome situation and significant otherDaily lifeImportant experiences Religious beleifs
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• Patient’s outlookTechniques of History TakingSetting the stageEnvironment• Proper environment enhances
communication• Be cautious of power relationships• Personal space
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Your demeanor and appearance• As you are watching your patient, your patient
will be watching you• Messages of body language• Clean, neat professional appearance
Note taking• Difficult to remember all details• Most patients are comfortable with note taking
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• Do not divert your attention from the patient to take notes
Learning about the present illness• Refer to the patient by name• Avoid the use of unfamiliar or demeaning
terms such as “granny or “hon”• Follow the patient’s lead
facilitation-any activity which makes tasks for others easy.
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• Posture, actions, or words should encourage additional responses
• Typically does not bias the story of interrupt the patient’s train of thought
• Clarification
used to clarify ambiguous statements or words
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• Making eye contact or saying “go on” or “I’m listening” may help
Reflection
• Repeating encourages additional responses
• Does not bias the story of interrupt train of thought
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Confrontation
• Some issues or responses may require you to confront patients about their feelings
Interpretation
• Goes beyond confrontation
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History of Present Illness• OPQRST• SAMPLE• Family history• Social history• Housing environment• Economic status• occupation
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• High risk behavior
• Travel history
• Current health status
• Diet
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VS and LOC
• AVPU
• Obtunded
Insensitivity to unpleasant or painful stimuli by reduced level of consciousness by an anesthetic or analgesic
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Posture
Movement
• Purposeful
• Non-purposeful
• Appropriateness
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Dress, grooming, and personal hygiene
• Fastidiousness
difficult to please
• Neglect
• Facial expression
• Affect
interaction with stimuli
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Speech
• Aphasia
Difficulty speaking
• Dysphonia
Inability to speak
• Dysarthria
Slurred speech
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Skin color
• Pallor
pale
Posture, gait, and motor activity
• Ataxia
lack of coordination of muscle movement