Obtaining Patient History Flashcards
What is the value of history taking?
Directs focus on physical exam and is the basis for differential differences
Differential differences definition?
Probability of one disease vs another
What are the keys of history taking?
Trust, right questions, interpreting the responses, knowing what to do next, care beginning simultaneously
What are the two elements of a comprehensive history?
Identifying data and chief complaint
What is involved in identifying data?
Name, age and DOB. sex, race, physician’s name
What is involved in a chief complaint?
Single most critical concern to the patient
Important questions for history taking?
Open ended, close ended, multiple choice
What does OPQRST stand for?
Onset, provocation, quality, radiation/referred, severity and time/treatment
What is onset?
- More than ‘when did this start’
- Know everything about onset of symptoms
What were you doing when symptoms began?
Onset pain during exertion has different origins than pain at rest
Have S&S at onset now subsided
What is provocation?
- To provoke
- What makes the patient’s condition better/worse
What is quality?
- How patient describes comfort
- Crushing, stabbing, aching, throbbing (helps determine a possible cause)
What is radiation/referred?
- Radiating pain: moves from one point to another and may follow a system
- Referred pain: one area is damaged and a different area of the body hurts, due to body’s inability to localize pain
What is severity?
- Subjective evaluation by the patient about the intensity of their condition
- Scale of 1-10 to label pain
- Severity of pain doesn’t by itself identify the severity of the condition
What is time/treatment?
- Exact time of symptom onset may play a crucial roles in the care of the patient
