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 considerationIdentifying 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 medicationsAllergiesTobacco useAlcohol, drugs, and related substancesDietScreening testsImmunizationsSleep patterns

Exercise and leisure activitiesEnvironmental hazardsUse of safety measuresFamily historyHome situation and significant otherDaily lifeImportant experiences Religious beleifs

• Patient’s outlookTechniques of History TakingSetting the stageEnvironment• 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 patient’s 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 patient’s train of thought

• Clarification

used to clarify ambiguous statements or words

• 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

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