Upload
rosamond-leslie-oliver
View
231
Download
0
Embed Size (px)
DESCRIPTION
Differential field diagnosis Helps establish a bond The Interview J
Citation preview
Prof. Mohammad AbduljabbarProf. Mohammad Abduljabbar
MEDICAL HISTORYMEDICAL HISTORY
Establishing rapportEstablishing rapport Chief complaintChief complaint History of the present illnessHistory of the present illness Past medical historyPast medical history Current health statusCurrent health status
Family historyFamily history Psychosocial historyPsychosocial history
Review of systemsReview of systems
Components of a Components of a Patient HistoryPatient History
Differential field diagnosisDifferential field diagnosis
Helps establish a bondHelps establish a bond
The InterviewThe Interview
J
Patient RapportPatient Rapport
If a patient’s chart is available, review it before If a patient’s chart is available, review it before interviewing the patient.interviewing the patient.
Use this information to gain clues about the patient.Use this information to gain clues about the patient.
Patient RapportPatient Rapport
Present yourself as a caring, competent, and Present yourself as a caring, competent, and confident health care professional.confident health care professional.
The First ImpressionThe First Impression
When you introduce yourself to the patient, shaking When you introduce yourself to the patient, shaking hands or offering a comforting touch will help build hands or offering a comforting touch will help build trust.trust.
Building TrustBuilding Trust
Use a combination of open-ended and closed-ended Use a combination of open-ended and closed-ended questions.questions.
Asking QuestionsAsking Questions
Use appropriate language.Use appropriate language. Use an appropriate level of questioning, Use an appropriate level of questioning,
but do not appear condescending.but do not appear condescending. When encountering communication When encountering communication
barriers, try to enlist someone to help.barriers, try to enlist someone to help. Actively listen.Actively listen.
CommunicationCommunication
FacilitationFacilitation ReflectionReflection ClarificationClarification EmpathyEmpathy ConfrontationConfrontation InterpretationInterpretation Asking about feelingsAsking about feelings
Active ListeningActive Listening
A paramedic must learn to become comfortable A paramedic must learn to become comfortable dealing with sensitive topics.dealing with sensitive topics.
It is important to earn a patient’s trust.It is important to earn a patient’s trust.
Sensitive TopicsSensitive Topics
Date and timeDate and time AgeAge SexSex RaceRace BirthplaceBirthplace OccupationOccupation
Preliminary DataPreliminary Data
This is the pain, discomfort, dysfunction that caused This is the pain, discomfort, dysfunction that caused the patient to request help. the patient to request help.
The Chief ComplaintThe Chief Complaint
The Present Illness The Present Illness Onset of the Onset of the
problemproblem Provocative and Provocative and
palliative palliative factorsfactors
QualityQuality Region/Region/
RadiationRadiation
SeveritySeverity TimeTime Associated Associated
symptomssymptoms Pertinent Pertinent
negativesnegatives
General state of healthGeneral state of health Childhood diseasesChildhood diseases Adult diseasesAdult diseases Psychiatric illnessesPsychiatric illnesses Accidents or injuriesAccidents or injuries Surgeries or hospitalizationsSurgeries or hospitalizations
Past HistoryPast History
Current medicationsCurrent medications AllergiesAllergies TobaccoTobacco Alcohol, drugs, and related substancesAlcohol, drugs, and related substances DietDiet Screening testsScreening tests ImmunizationsImmunizations
Current Health Status Current Health Status
Sleep patternsSleep patterns Exercise and leisure activitiesExercise and leisure activities Environmental hazardsEnvironmental hazards Use of safety measuresUse of safety measures Family historyFamily history Home situation and significant othersHome situation and significant others Daily lifeDaily life
Current Health Status Current Health Status
Important exercisesImportant exercises Religious beliefsReligious beliefs The patient’s outlookThe patient’s outlook
Current Health Status Current Health Status
You should take your patient’s You should take your patient’s medications with you to the medications with you to the hospital, when practical. hospital, when practical.
Review of SystemsReview of Systems– Skin– Head– Eyes– Ears– Nose– Mouth/Throat– Respiratory– Cardiovascular
– Gastrointestinal– Genitourinary– Musculoskeletal– Neurologic– Psychological– Endocrine– Hematologic
Chronic health conditionsChronic health conditions JobJob
Work scheduleWork schedule StressStress
Family dynamicsFamily dynamics SupportSupport Safety issues Safety issues
Car seat usageCar seat usage Smoke and CO alarmsSmoke and CO alarms
Psychosocial HistoryPsychosocial History
Special Challenges Special Challenges SilenceSilence Overly Overly
talkative talkative patientspatients
Multiple Multiple symptomssymptoms
AnxietyAnxiety
DepressionDepression Sexually Sexually
attractive or attractive or seductive seductive patientspatients
Confusing Confusing behaviors or behaviors or symptomssymptoms
Special Challenges Special Challenges
Patients needing Patients needing reassurancereassurance
Anger and hostilityAnger and hostility IntoxicationIntoxication CryingCrying
Limited intelligenceLimited intelligence Language barriersLanguage barriers Hearing problemsHearing problems BlindnessBlindness Talking with Talking with
families or friendsfamilies or friends
If the patient cannot provide If the patient cannot provide useful information, gather it from useful information, gather it from
family family or bystanders.or bystanders.
History-Taking TechniquesHistory-Taking Techniques
Active ListeningActive Listening
The Comprehensive Health HistoryThe Comprehensive Health History
SummarySummary