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History Taking | Part Two

History Taking – Part Two

HPI = History of Present Illness = detail evaluation of the Chief Complaint with a full, clear, chronological account of the symptoms. OPQRST

PMHx = Past Medical History = record of any significant past injuries, hospitalizations, operations, diseases with regards to current conditions:

  • Preexisting medical problems/surgeries
  • Medications
  • Allergies
  • Medical care
  • Family History
  • Social History

Current Health Status: patient’s present state of health before the incident for which emergency care has been called.

Standardized Approach to History

  • Signs and Symptoms
  • Allergies
  • Medications
  • Pertinent past history
  • Last oral intake
  • Events leading up to the present situation

Sensitive Topics : be calm and professional, non-judgmental, remind them you are there to help.

Special Challenges:

  • Silent Patient: look for body language, give them time
  • Talkative: let them talk, steer them to the point
  • Multiple symptoms: ABCs first with both medical and trauma, find out what is bothering them the most.
  • Anxious: speaking too quickly or too slowly, watch body language. Do not over-reassure
  • Angry/Hostile: patient may displace anger to EMTs. Do not respond with anger, do not remain if you are in danger
  • Intoxicated: Don’t be judgmental, don’t challenge them or disrespect them
  • Crying: could be fear or pain, response could seem out of proportion to situation. Remain objective and empathetic
  • Depressed: use empathy, don’t tell them everything will be alright
  • Sexually Attractive/Seductive: act professional in all cases, patients are not dating material. Have partner chaperone if necessary
  • Confusing behavior/history: be patient, try to get consistent story, be professional and try to narrow down to the cause
  • Patient with limited intelligence: Speak clearly, and in normal tones to patient first. Get help from family/friends as necessary or possible
  • Language Barrier: get a translator or interpreter if possible
  • Hearing impaired: sign language translator, read lips, write notes avoid jargon
  • Sight Impairment: Announce yourself, explain why you are there, tell them whatyou are doing
  • Family and Friends: important resource for collateral data

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