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