Lecture 2- History Taking w/ Lou

Importance of Accurate Histories in Field Diagnosis

  • Many practitioners do not take thorough patient histories in the field.
  • Lack of comprehensive history can lead to incorrect field diagnosis.
  • Accurate diagnosis is necessary for effective patient treatment, particularly when administering medications.

Historical Approaches to Patient Assessment

  • Traditional methods taught include SAMPLE and OPQRST.
    • SAMPLE includes:
      • S: Signs and symptoms - what the patient reports.
      • A: Allergies - any known allergies.
      • M: Medications - current medications the patient is taking.
      • P: Past medical history - significant past health issues.
      • L: Last oral intake - when the patient last ate or drank.
      • E: Events leading to emergency - circumstances before the patient’s condition.
    • OPQRST for pain assessment includes:
      • O: Onset - when and how the pain started.
      • P: Provocation/Palliation - what makes it better or worse.
      • Q: Quality - how the patient describes the pain.
      • R: Radiation - any spread of the pain.
      • S: Severity - pain scale from 1-10.
      • T: Time - duration and periodicity of the symptoms.
  • These methods, while useful, are not exhaustive and must be expanded upon to gather a full understanding.

Adaptive Conversations in Patient Assessment

  • Taking patient history should not be a mechanical process but rather a conversation.
  • Engage patients by asking them open-ended questions to understand their complaints better.
  • Example Scenario: Family Conversations
    • Shared experiences where family members express symptoms (e.g., a pounding headache) should trigger more questions during assessment.

Comfort Level in Assessment

  • In a classroom setting, students expressed varying levels of confidence post-EMT training in assessing patients (ranging from a little to moderate confidence).
  • Recognize that it's normal to feel apprehensive when first engaging with patients regarding medical history and issues.

Historical Context of Patient Assessment

  • Personal experiences shared regarding feelings of discomfort while questioning patients in stressful situations.
  • Emphasis on growing comfortable with history taking through practice and effective communication.

Practice Demonstration

  • Interactive role-play where students practice taking histories from actors portraying patients.
    • The scenario involved a 67-year-old male presenting with shortness of breath and dizziness.
    • Effective questioning led to gathering meaningful information relevant to the assessment.

Questions to Consider During Assessment

  • Supplementary questions to establish a comprehensive view:
    • Any recent changes in medication?
    • Frequency of lightheadedness?
    • Any current diet?
    • How involved or aware is the patient regarding their past medical issues?

Observable Vitals and Assessment Outcomes

  • Establishment of vital signs during assessments:

    • Blood Pressure: 100/70 (which may be considered low)
    • Spo2: 94%
    • Pulse Rate: 75 bpm

  • Interpreting vital signs in connection to the symptoms presented, e.g., shortness of breath vs. normal vital signs.

Considerations for Differential Diagnosis

  • The need to categorize potential diagnoses:
    • Differential Diagnosis Definition: A list of possible conditions that could explain the patient's symptoms.
    • Example Diagnoses for Chest Pain:
      • Angina - defined by chest pain due to heart muscle not receiving enough oxygen.
      • Myocardial Infarction (MI) - could involve chest pain and tightness.
      • Pulmonary Embolism - may present symptoms like sudden shortness of breath.
      • GERD (Acid Reflux) - can mimic chest pain with associated heartburn.
      • Anxiety or panic attacks could produce similar symptoms.

The Importance of Validating History

  • The significance of always corroborating information received from patients with observations or from additional sources (friends, family).
  • Examples of potential discrepancies when taking over from another medical team; always verify with the patient themselves.
  • Acknowledge that patients might not recall medications due to memory problems, especially in geriatrics.

Open-ended Questions for Effective Assessment

  • Begin with the patient’s chief complaint using open-ended questions to prompt discussion:
    • Example Question: “What brings you in today?”
    • Prompt for additional symptoms without limited directives to ensure comprehensive understanding, e.g., “Is there anything else bothering you?”

Chief Complaints and Corresponding Primary Problems

  • Overview of specific primary problems and related complaints:
    • MI: Chief complaint of chest pain, with onset and radiating aspects.
    • Stroke: Chief complaint may include dizziness and slurred speech or weakness.
    • Asthma Attack: Chief complaint will be shortness of breath.

Assessing and Ruling Out Conditions

  • Methods to rule out conditions during patient assessment:
    • Direct questioning regarding medical history and previous occurrences.
    • Physical examination of tender areas (e.g., checking for appendicitis).
    • Asking if the patient has undergone prior medical procedures that would negate certain diagnoses.

Utilization of OPQRST in Various Situations

  • Use OPQRST as a scaffold, allowing some flexibility in application for different complaints.
    • Example Application of OPQRST to assess shortness of breath and specifically asking for:
      • Onset of symptoms.
      • Factors worsening or alleviating shortness of breath (provocation/palliation).
      • Quality of breathing experience.
      • Note associated symptoms and pertinent negatives that could affect diagnosis.