History Taking Flashcards
What should you do if the patient is unresponsive?
Gather history of present illness from family or bystanders
Look for signs of trauma, medical alert tags, track marks, or environmental clues.
How do you determine the chief complaint in a responsive patient?
Ask the patient what happened and look for signs and symptoms indicating altered mental status
Signs may include stroke symptoms like hemiparalysis or evidence of a seizure.
What should you evaluate in a patient’s speech?
Determine if the patient is making sense and if speech is slurred
This can indicate the severity of their condition.
What should you do if a patient has had a seizure and is in a postictal state?
Look for obvious trauma or explanations for the seizure
You will not be able to obtain a history from the patient.
What is a SAMPLE history?
A method for obtaining a patient’s medical history, including Symptoms, Allergies, Medications, Past medical history, Last oral intake, and Events leading up to the situation
This is critical in emergencies.
Why is the time of last healthy appearance important?
It helps physicians decide if certain treatments can be safely initiated
Especially relevant in cases of stroke.
What should you collect regarding medications?
List all medications the patient has taken and determine allergies and last oral intake
This information is vital for treatment decisions.
What should you avoid saying to a patient who appears unconscious?
Avoid making unnecessary or inappropriate remarks
The patient may still be able to hear and understand.
How can you communicate with a patient who has had a stroke?
Look for indications of understanding, like glances or movements, and reassure the patient
Effective communication can help calm anxiety.
What should your SAMPLE history reveal for a patient with a seizure history?
How seizures typically occur and any differences in this episode
Also, inquire about medications for seizure disorders.
What serious conditions should be suspected if a patient with no seizure history has a seizure?
Brain tumor, intracranial bleeding, or serious infection
This requires immediate attention.
What medications should you inquire about for patients with a history of seizures?
Medications that lower blood glucose, such as insulin or oral hypoglycemic agents
These can impact the seizure episode.
What additional inquiries may be necessary for patient assessment?
Illicit drug use or exposure to poisons
These factors can contribute to altered mental status.
