PCT 1 - Gathering History Flashcards
what do you ask to figure out the patients cheif complaint?
Why did you call us?
Find out the full clear chronological account of
the patients symptoms.
With chronic issues – “What changed today to
make you call the ambulance?”
to figure out the history of present illness, what type of questions do you ask?
Ask open ended questions
Open ended questions allow the patient to
describe, in their own words, how they are
feeling
Use mnemonics to assist you in obtaining the
relevant patient history
Medical Alert tags can help identify important
conditions
what are mnemonics?
Mnemonics are memory joggers. They assist
you in remembering key points.
Used on call forms
Used for consistency
Universally accepted in ambulance field
Most are known by hospital staff.
what do you do for LOC or LOA assessment?
Alert
Verbal
Pain
Unresponsive
examples of questioning/history gathering/assessment (KNOW ALL OF THESE)
OPQRST
AEIOU TIPS
SAMPLE
CLAPPS STICD
PERLA
what are the 5 B’s of trauma assessment?
Breathing
Bleeding
Brains
Burns
Bones
What are the 5 P’s of circulation?
The 5 “P’s”:
Pain
Pallor
Pulse
Paresthesia
Paralysis
what do you ask for pain assessment?
OPQRST
Onset – What were you doing when it started?
Palliates/Provokes – What aggravates the symptoms? What
makes it better? What makes it worse?
Quality – What does the pain feel like? Sharp? Dull? Burning?
Tearing?
Radiates/Region – Where is the pain? Where does it go? Is it in
more than one area?
Severity – What is the pain on a scale of 1-10? Compare to
previous injuries/events, if necessary.
Time – When did the pain start? Does it come and go?
what is sample?
Signs & Symptoms – Signs are what you can
see; Symptoms are what the patient feels
Allergies
Medications
Past Medical History
Last meal or oral intake
Events before the emergency
what do you ask and look for for signs/symptoms?
Observe the patient. Take note of the following:
Patients physical condition
Posture (is the patient sitting, lying down, clutching their chest,
pursing lips?)
Vital signs (resp distress, skin color etc.)
Ask the patient to describe how they feel – use open
ended questions to avoid “leading” the patient into
what they think you want to hear
what do you ask to figure out allergies?
Does the patient have an allergy to any medications?
Does the patient have an allergy to any foods?
Does the patient have any environmental allergies such as (bee stings, grass etc.)
If the patient is unconscious look for a medical alert
bracelet and ask family or friends if the patient has
any allergies.
what do you ask to figure out medications?
Ask patient or family member what
medication the patient is taking.
This include prescription medications, over
the counter medications, and holistic
medications.
If possible gather the medications in a bag and
take them to hospital with the patient.
what do you ask to figure out past medical history? what are a few specific important medical conditions to ask about?
Ask the patient and/or family member if the patient has
any past medical history and past family history of the
following (to name a few):
Heart disease Contagious diseases
High blood pressure Cancer
Respiratory issues Psychiatric diagnosis
Stroke Arthritis/Osteoporosis
Diabetes Renal Failure
what do you ask for last meal/oral intake? why is it important to ask this?
When was the patients last meal or fluid intake?
*This may be a good opportunity to ask about the
patient’s recent eating/drinking habits
For any abdo pain – ask what the patient last ate, and ask
whether others at the same thing and how they’re
feeling
For allergic reaction – ask whether the food consumed
was new for the patient
For surgery purposes, the hospital will want to know
when the patient’s last meal was
Helpful to maintain airway patency in a patient with LOC
Assist in the preparation for surgery and possible
complications of aspiration
Help you rule out food poisoning as this does not
usually appear until several hours after ingestion.
Help you determine or rule out possible food
allergies as a person who is sensitive to certain types
of food would develop an allergic reaction
immediately after eating.
what do you ask for events prior to emergency?
Ask the patient and bystanders about the events
and/or actions that occurred prior to the
emergency.
Examples:
Was the patient experiencing emotional stress or
physical exertion prior to the episode of chest
pain?
Did the loss of consciousness occur before or after
the fall?
why is pattern recognition important?
Remain alert to patterns.
Compare information to what is in your
knowledge base about various diseases.
The ability to recognize patterns increases with
experience.
Example:
Whenever patient sits up, their blood pressure
drops
what are factors affecting assessment and decision making?
Personal attitudes
Uncooperative patients
Patient compliance
Distracting injuries
Environmental and personal considerations
what do you do for presenting the patient? what is SOAP?
Establish trust and credibility.
SOAP
Subjective findings
Objective findings
Assessment
Plan
Develop effective presentation skills.
what are patient reports?
Less than one minute
Concise and clear
Avoid extensive use of medical jargon
Follow a basic format (SOAP or other)
Include pertinent findings and negatives
Conclude with specific actions, requests or
questions related to the plan
what are some special challenges you may have with patients?
Intoxication
Anger and hostility
Crying and/or depression
Mental Health Illnesses
Deaf patients
Language barriers
Cultural barriers
what is functional inquiry?
Functional inquiry
A system-by-system series of questions
designed to identify problems your patient has
not already identified
Mainly determined by patient chief complaint,
condition and clinical status
what are the different systems to review?
General
Skin
HEENT
Respiratory
Cardiac
Gastrointestinal
Urinary
Genitalia
Peripheral Vascular
Musculoskeletal
Neurologic
Hematologic
Endocrine
Psychiatric
ROS: General (what questions to ask/things to look for?)
Weight? Any recent changes?
Weakness?
Fatigue?
Fever?
Eating/drinking habits?
ROS: Skin (what questions to ask/things to look for?)
Has your patient noticed:
Rashes
Lumps
Sores
Itching
Dryness
Colour changes
Changes in nails or hair?
ROS: HEENT (what questions to ask/things to look for?)
Headaches?
Visual disturbances? Glasses/Contacts?
Glaucoma, cataracts?
Hearing problems? Tinnitus? Vertigo?
Nasal discharge, stuffiness, epistaxis? Sinus?
Sore throat? Swollen glands? Dysphagia?
ROS: Respiratory (what questions to ask/things to look for?)
Wheezing
Coughing
Hemoptysis
COPD
Orthopnea
Pneumonia
Dyspnea
ROS: Cardiovascular (what questions to ask/things to look for?)
Heart trouble?
Dysrhythmias
HTN
Chest Pain- irregular heartbeat
Palpitations
Edema
Dyspnea
ROS: Gastrointestinal (what questions to ask/things to look for?)
Aphagia, Dysphagia
Heartburn
Anorexia
Nausea
Vomiting
Hematemesis
Indigestion
Bowel Movements
Rectal bleeding
Diarrhea
Constipation
Abd pain
Gas
Jaundice
Gallbladder problems
ROS: Urinary (what questions to ask/things to look for?)
Frequency
Polyuria
Nocturia
Burning
Pain
Odor
ROS: Genetilia (what questions to ask/things to look for?)
Male: Hernia Discharge Sores Testicular pain, lumps STD Rash
Female: Menstruation, LMP, dysmenorrhea Menopause Discharge Sores, lumps Gravida, Para, Living, Abortions Birth Control
ROS: Peripheral Vascular (what questions to ask/things to look for?)
Calf pain
Leg cramps
Varicose veins
History of clots
Red/Warm lower leg
Circulatory compromise
ROS: Musculoskeletal (what questions to ask/things to look for?)
Myalgia
Joint pain
Arthritis
Gout
Backaches
Weakness
ROS: Neurological (what questions to ask/things to look for?)
Syncope (fainting)
Blackouts
Seizures
Aphasia
Vertigo
Weakness
Headaches
Paralysis
Paresthesia
ROS: Hematological (what questions to ask/things to look for?)
Anemia of any kind
Transfusions
Bruising
Bleeding
Known disorders
Blood thinner prescription (important for head
injuries)
ROS: Endocrine (what questions to ask/things to look for?)
Thyroid disorders
Heat intolerance
Cold intolerance
Excessive sweating
Diabetes
Polyuria
Polydipsia
ROS: Psychiatric (what questions to ask/things to look for?)
Nervousness
Tension
Stress
Anxiety
Depression
Suicide
Known disorders
Hallucinations
