Obtaining a Medical History

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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 consideration
• Identifying 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 medications
• Allergies
• Tobacco use
• Alcohol, drugs, and related substances
• Diet
• Screening tests
• Immunizations
• Sleep patterns

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• Exercise and leisure activities
• Environmental hazards
• Use of safety measures
• Family history
• Home situation and significant other
• Daily life
• Important experiences
• Religious beleifs

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• Patients outlook
• Techniques of History Taking
• Setting the stage
• Environment
• 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 patients 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 patients train of thought
• Clarification
• used to clarify ambiguous statements or words

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• Making eye contact or saying go on or Im
  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