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Patient Care Theory (1st TEST) > PCT 1 - Gathering History > Flashcards

PCT 1 - Gathering History Flashcards

1
Q

what do you ask to figure out the patients cheif complaint?

A

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?”

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2
Q

to figure out the history of present illness, what type of questions do you ask?

A

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

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3
Q

what are mnemonics?

A

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.

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4
Q

what do you do for LOC or LOA assessment?

A

Alert

Verbal

Pain

Unresponsive

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5
Q

examples of questioning/history gathering/assessment (KNOW ALL OF THESE)

A

OPQRST

AEIOU TIPS

SAMPLE

CLAPPS STICD

PERLA

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6
Q

what are the 5 B’s of trauma assessment?

A

Breathing

Bleeding

Brains

Burns

Bones

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7
Q

What are the 5 P’s of circulation?

A

The 5 “P’s”:

Pain

Pallor

Pulse

Paresthesia

Paralysis

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8
Q

what do you ask for pain assessment?

A

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?

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9
Q

what is sample?

A

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

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10
Q

what do you ask and look for for signs/symptoms?

A

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

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11
Q

what do you ask to figure out allergies?

A

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.

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12
Q

what do you ask to figure out medications?

A

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.

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13
Q

what do you ask to figure out past medical history? what are a few specific important medical conditions to ask about?

A

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

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14
Q

what do you ask for last meal/oral intake? why is it important to ask this?

A

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.

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15
Q

what do you ask for events prior to emergency?

A

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?

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16
Q

why is pattern recognition important?

A

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

17
Q

what are factors affecting assessment and decision making?

A

Personal attitudes

Uncooperative patients

Patient compliance

Distracting injuries

Environmental and personal considerations

18
Q

what do you do for presenting the patient? what is SOAP?

A

Establish trust and credibility.

SOAP

Subjective findings

Objective findings

Assessment

Plan

Develop effective presentation skills.

19
Q

what are patient reports?

A

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

20
Q

what are some special challenges you may have with patients?

A

Intoxication

Anger and hostility

Crying and/or depression

Mental Health Illnesses

Deaf patients

Language barriers

Cultural barriers

21
Q

what is functional inquiry?

A

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

22
Q

what are the different systems to review?

A

General

Skin

HEENT

Respiratory

Cardiac

Gastrointestinal

Urinary

Genitalia

Peripheral Vascular

Musculoskeletal

Neurologic

Hematologic

Endocrine

Psychiatric

23
Q

ROS: General (what questions to ask/things to look for?)

A

Weight? Any recent changes?

Weakness?

Fatigue?

Fever?

Eating/drinking habits?

24
Q

ROS: Skin (what questions to ask/things to look for?)

A

Has your patient noticed:

Rashes

Lumps

Sores

Itching

Dryness

Colour changes

Changes in nails or hair?

25
Q

ROS: HEENT (what questions to ask/things to look for?)

A

Headaches?

Visual disturbances? Glasses/Contacts?

Glaucoma, cataracts?

Hearing problems? Tinnitus? Vertigo?

Nasal discharge, stuffiness, epistaxis? Sinus?

Sore throat? Swollen glands? Dysphagia?

26
Q

ROS: Respiratory (what questions to ask/things to look for?)

A

Wheezing

Coughing

Hemoptysis

COPD

Orthopnea

Pneumonia

Dyspnea

27
Q

ROS: Cardiovascular (what questions to ask/things to look for?)

A

Heart trouble?

Dysrhythmias

HTN

Chest Pain- irregular heartbeat

Palpitations

Edema

Dyspnea

28
Q

ROS: Gastrointestinal (what questions to ask/things to look for?)

A

Aphagia, Dysphagia

Heartburn

Anorexia

Nausea

Vomiting

Hematemesis

Indigestion

Bowel Movements

Rectal bleeding

Diarrhea

Constipation

Abd pain

Gas

Jaundice

Gallbladder problems

29
Q

ROS: Urinary (what questions to ask/things to look for?)

A

Frequency

Polyuria

Nocturia

Burning

Pain

Odor

30
Q

ROS: Genetilia (what questions to ask/things to look for?)

A 
Male:
Hernia
Discharge
Sores
Testicular pain, lumps
STD
Rash
Female:
Menstruation, LMP,
dysmenorrhea
Menopause
Discharge
Sores, lumps
Gravida, Para, Living,
Abortions
Birth Control
31
Q

ROS: Peripheral Vascular (what questions to ask/things to look for?)

A

Calf pain

Leg cramps

Varicose veins

History of clots

Red/Warm lower leg

Circulatory compromise

32
Q

ROS: Musculoskeletal (what questions to ask/things to look for?)

A

Myalgia

Joint pain

Arthritis

Gout

Backaches

Weakness

33
Q

ROS: Neurological (what questions to ask/things to look for?)

A

Syncope (fainting)

Blackouts

Seizures

Aphasia

Vertigo

Weakness

Headaches

Paralysis

Paresthesia

34
Q

ROS: Hematological (what questions to ask/things to look for?)

A

Anemia of any kind

Transfusions

Bruising

Bleeding

Known disorders

Blood thinner prescription (important for head
injuries)

35
Q

ROS: Endocrine (what questions to ask/things to look for?)

A

Thyroid disorders

Heat intolerance

Cold intolerance

Excessive sweating

Diabetes

Polyuria

Polydipsia

36
Q

ROS: Psychiatric (what questions to ask/things to look for?)

A

Nervousness

Tension

Stress

Anxiety

Depression

Suicide

Known disorders

Hallucinations

Patient Care Theory (1st TEST) (3 decks)

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