Chapter 15- History Taking Flashcards
with a medical patient, ___________ may be the only way to determine what the problem is or what may be causing the problem
history taking
It is important to gather a thorough history from the following individuals:
The patient, the patient’s family member and friends or bystanders who may have any pertinent information
investigate the nature of illness by inquiring about
the chief complaint
Ask about the history of the present illness, and as follow up questions, such as:
Has anything like this ever happened before if the patient answers yes then ask what was done at that time and how did this episode Compare with the previous episodes?
If the patient is unconscious survey the scene for evidence of
Medication containers, medical devices or evidence of traumatic events
what two mnemonics should you use during history taking?
SAMPLE and OPQRST
Sometimes older patients take numerous medications, both prescription and over-the-counter in these situations. It is best to:
take the medications with you to the hospital and list them in your report
ask about specific conditions that may have led to the complications such as:
Heart problems, breathing problems, and blood, sugar or glucose problems
determine if the patient is taking any medication for these conditions and whether he or she is
Compliant with the drug regimen