Obtaining a Medical History

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

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

Information is gathered on a patient-by- patient, case-by-case basis Several parts Specific purpose Together they give structure Does not dictate sequence

Source of history Patient Family Friends Police Others Reliability variable

Memory Trust Motivation Made at the end of the evaluation, not the beginning

Contents of History Date Always important Time may also be a consideration Identifying data Age Sex Race

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

Past medical history pertinent information to the current condition Current health status Present state of health Environmental conditions Individual factors

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

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

Patients outlook Techniques of History Taking Setting the stage Environment Proper environment enhances communication Be cautious of power relationships Personal space

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

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.

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

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

Confrontation Some issues or responses may require you to confront patients about their feelings Interpretation Goes beyond confrontation

History of Present Illness OPQRST SAMPLE Family history Social history Housing environment Economic status occupation

High risk behavior Travel history Current health status Diet

VS and LOC AVPU Obtunded Insensitivity to unpleasant or painful stimuli by reduced level of consciousness by an anesthetic or analgesic

Posture Movement Purposeful Non-purposeful Appropriateness

Dress, grooming, and personal hygiene Fastidiousness difficult to please Neglect Facial expression Affect interaction with stimuli

Speech Aphasia Difficulty speaking Dysphonia Inability to speak Dysarthria Slurred speech

Skin color Pallor pale Posture, gait, and motor activity Ataxia lack of coordination of muscle movement