2024 Medical History Taking PDF

Medical History Taking Nathan Ross [email protected] (Information adapted from Sarah Wood)  Medical History taking includes The Importance lists of elements that you need to achieve. of Communication But … needs to be dynamic a...

Medical History Taking Nathan Ross [email protected] (Information adapted from Sarah Wood)  Medical History taking includes The Importance lists of elements that you need to achieve. of Communication But … needs to be dynamic and not just a list of questions. Key to getting the answers you NEED not just the answers you expect to hear. 16/09/2024 2  Describe the principles of medical history taking and understand the importance of a comprehensive patient history. List and demonstrate the elements of Session pain assessment. Objectives Apply communication knowledge to medical history taking,common frameworks and terminology in medical history taking. Discuss building rapport and gaining trust. 16/09/2024 3  Introduction and greetings Would you walk up to a stranger and just start talking without introducing yourself or at least saying hello? How to start 16/09/2024 4  Your name Your role That you are from the ambulance service Hello My Name Ask the name of the person or people is… you are talking to and what name(s) they would like you to use Mrs Elizabeth Smith could be Mrs Smith, Elizabeth, Betty, Betsy, Beth, Liz, Lizzie, Liza, Lillibet, etc,….or something completely different! 16/09/2024 5  Name - Patient name as it appears on official documents AND the name they prefer to be known by (this can vary greatly) Age – including date of birth Biographical information Gender – never assume Address – if not at own home address (check) 16/09/2024 6  The Primary Survey always comes first along with consent Primary survey gives you an initial impression and allows you to make a Primary Survey “Big Sick” vs “Little sick” assessment - in other words identifying the time critical patient from the urgent patient 16/09/2024 7  All communication and history taking must be done with consent Ask the patient for information do not demand it - voluntarily given Ask their permission to ask a carer or family member or to look at care Consent notes - do not just assume that it is ok to do so Remember that Consent and Capacity are dynamic processes 16/09/2024 8  History taking is not just to get information from the patient It is to facilitate information exchange An information You need to engage with the exchange patient, build rapport and trust, and listen to what the patient is saying Listening and hearing what they say is a skill 16/09/2024 9  Presenting Complaint (PC) History of Presenting Complaint (HxPC / HPC) Allergies Medications / Drug History (DHx) What do you Past Medical History (PMHx/ PMH) need to know Social History (SHx) Family History (FHx) Signs and Symptoms of what they are experiencing including a Review of Systems (RoS) 16/09/2024 10  Why have they called for help? Brief sentence needed for paperwork Presenting Complaint May be multiple or complex reasons (PC) given May need to guide patient back to the question 16/09/2024 11  How has the problem presented over what timeframe? The PC may not be related to the actual problem and the HxPC may highlight this History of Presenting You need to build a clear picture of what Complaint has happened (HxPC / HPC) Remember there may have been some information already given when you asked about the PC In any trauma this needs to include the Mechanism of Injury 16/09/2024 12  SAMPLE A quick way of getting the basic information SAMPLE Useful as a check list to make sure you have got the relevant information 16/09/2024 13  S – Signs and Symptoms (PC / HxPC) A – Allergies M – Medications / Drug Hx P – Past Medical History (PMHx) L – Last oral intake E – Events leading up to … (HxPC) SAMPLE(R) You can also add an R at the end R – Risk factors – social history (SHx) and family history (FHx) NOT necessarily asked in this order! 16/09/2024 14 Signs and Symptoms S AMPLER S AMPLER 16/09/2024 15  Some patients have very complicated stories about what has happened Getting to the Some patients find it very difficult to bottom of the describe signs and symptoms signs and symptoms Using a more structured approach can help get all the details needed. But remember that this should not be a “list” of questions but a more dynamic approach 16/09/2024 16  A couple of tools to help you – very good for assessing pain but can help direct other assessment questions as well OPQRST SOCRATES Pain and O – Onset S – Site P – Provocation O – Onset discomfort Q – Quality C – Character assessment R – Region/Radiation R – Radiation S – Severity A – Associated T – Timing Symptoms T – Time U - Understanding E – Exacerbating /relieving factors S - Severity 16/09/2024 17  In the patient who is not able to answer the questions on pain or discomfort (children, learning disabilities or other inhibiting factors) the Wong Baker faces can be used OPQRST vs SOCRATES 16/09/2024 18 Allergies S A MPLER 16/09/2024 19  Do they have any allergies? Be careful to record any – sometimes they can be significant Be aware that many people have sensitivities which do not result in a Allergies severe allergic reaction but they still need to be noted VERY relevant and should be asked before giving any medications 16/09/2024 20 Medications / Drug History (DHx) SA M PLER M SA PLER 16/09/2024 21  What medications do they take? – This needs to include: Prescribed Over the Counter (OTC) Medications Herbal remedies /Drug History (Drug Hx) Recreational drugs Any recent changes in medications? Are they compliant? 16/09/2024 22 Past Medical History (PMHx / PMH) SA M PLER S AM P LER 16/09/2024 23  RELEVANT past medical history Have they been in hospital or seriously ill in the past. Any surgery? Past Medical Have they had anything similar to History (PMHx / this before / had any issues in the PMH) same region of the body before Do they have any other illnesses? Have they visited a GP recently and what for? Make sure you question carefully 16/09/2024 24  JAM THREADS CSM J – Jaundice A – Anaemia/blood disorders M – Myocardial Infarction T – Thyroid problems / TB H – Hyper/hypo tension, Heart disease Past Medical R – Rheumatic Fever (damages heart valves) History (PMHx / E – Epilepsy or fits PMH) A – Asthma/COPD D – Diabetes and type (insulin dependent) S – Stroke / TIA C – Cancer S – Surgery M – Mental Health 16/09/2024 25 Last Oral Intake S AM P L ER 16/09/2024 26  This can be very important or seem relatively insignificant in the ongoing care of the patient Need to ask – may be related to symptoms or may be needed if the Last Oral Intake patient needs emergency operations in hospital Be sensible about when and how you ask it 16/09/2024 27 Events leading up to … SA M PLER S AM P L E R 16/09/2024 28  PC and HxPC should already have identified this You can use this section to confirm or expand on what you already know … Events Leading up to… “so you said that this came on as you walked up the stairs. What were you doing just before that? Did you notice anything different earlier in the day / before you went upstairs?” 16/09/2024 29 Risk Factors SA M PLER S AM P L E R 16/09/2024 30  Any significant family medical history– close family (parents, grandparents, aunts/uncles or siblings) Cardiac Risk Factors Diabetes Family History High Blood Pressure (FHx) Stroke Certain Cancers Genetic Disorders Any other significant illness 16/09/2024 31  Personal Social Hx Smoker / ex smoker / non smoker (how many a day / for how long and how long stopped?) Drink habits /alcohol dependent and drug habits Risk Factors Sexual History (if relevant) Social History Exercise (SHx) Nutrition Environmental Factors Neglect / self neglect Emotional / Stress factors Employment status and type of work 16/09/2024 32  Top things that will help you Build rapport and trust - engage Listen to what the patient says right from the moment you arrive Listen to what family, friends and The Skill bystanders have to say Use ALL your senses Verify, qualify and quantify NEVER assume 16/09/2024 33  Have you covered everything? Is there any other information to add to your differential diagnosis May not need all elements for every examination and may need to concentrate more on certain areas Need to understand your pathophysiology Review of to help direct you to more in depth Systems questioning (RoS) WARNING There is a lot in RoS. You are not expected to know this instantly. This will be built on throughout your degree as you explore different systems of the body, examination techniques and clinical pathways. 16/09/2024 34  General Health – How do you feel compared to normal? – Loss of appetite / weight gain or loss – Fatigue – more tired than normal Respiratory System – (RS or Resp) Review of Systems – DIB / SOB, cough, sputum (colour?), wheeze, bradypnoea, tachypnoea, (RoS) haemoptysis Cardiovascular System (CVS) – chest pains, SOB, dizziness, palpitations, tachy/bradycardia, oedema 16/09/2024 35  Nervous System (CNS or Neuro) – Headaches, trauma, numbness, tingling, weakness, balance issues, tremors Review of Systems – sensory changes, changes in vision (blurred, double, loss of sight, speech (RoS) or hearing problems or problems swallowing. (Can have a separate section on EENT (Eyes, Ears, Nose and Throat)) 16/09/2024 36  MuscularSkeletal (MSK) – Bones, joints, muscles, soft tissue. – New joint pain, limb stiffness or aching. Loss of or decreased mobility - what is normal mobility (walks with sticks, walker, etc) Review of – Can have separate section for Systems Integumentary (skin) if relevant. Are there any rashes, bleeding or bruising, (RoS) etc Gastrointestinal (GI) – D & V, abdominal pain and location, Changes in bowel movement, or blood in stool or vomit – Melaena / haematemesis 16/09/2024 37  Genitourinary (GU) – Burning or discomfort when passing urine. Change in frequency of passing urine (anuria, dysuria, polyuria, nocturia. Haematuria. Review of Systems Endocrine (RoS) – excessive thirst, sweating, intolerance to heat or cold Some put GI/GU/Endocrine all together and have GUE and in some cases Endocrine is put under “other” along with observations about skin, etc. 16/09/2024 38  Reproductive (Only when appropriate!) Review of – Vaginal discharge, last menstrual Systems period, risk of pregnancy, unprotected sex? (RoS) – Testicular or vaginal pain? 16/09/2024 39  To understand: the principles of medical history taking the importance of a comprehensive patient history To apply: Session communication knowledge to medical Objectives history taking common frameworks and terminology in medical history taking To discuss: building rapport and gaining trust 16/09/2024 40  You will get to practice this skill in sim. It will take some time to get skilled at it so do not worry if at first you can not Looking forward remember all that you need to do. 16/09/2024 41  Describe the principles of medical history taking and understand the importance of a comprehensive patient history List and demonstrate the elements of Session pain assessment Objectives Apply communication knowledge to medical history taking and common frameworks and terminology in medical history taking Discuss building rapport and gaining trust 16/09/2024 42 Questions and Discussion Any questions or input into this subject? 9/16/2024 43  Douglas, G. Nicol, F. Robertson, C. (2005.) Macleod’s Clinical Examination. Elsevier Jenkins, S. (2013). History taking, assessment and documentation for paramedics. Journal of Paramedic Practice Vol 5 (6) 310 - 316 References Pilbery, R. & Lethbridge, K. (2019) Ambulance Care Essentials. 2nd Ed. Bridgwater: Class Professional Publishing Silverman, J., Kurtz, S., & Draper, J. (2016). Skills for communicating with patients. CRC Press. 16/09/2024 44  www.sgul.ac.uk St George's, University of London Cranmer Terrace London SW17 0RE