Past Medical History and Current Health Status
Certain information about the patient’s past medical history and current heath status should be obtained with every patient contact. However, there are many aspects of one’s medical history, most of which are not necessary to obtain during a medical emergency. The key is to focus on significant historical information or those aspects necessary to determine the nature and potential severity of the patient’s illness or injury. All patients should be questioned about chronic illnesses, medications taken, allergies, and tobacco, alcohol, or other drug use.
Some medical conditions are specific to related body systems (Table 15-6). Most patients should be specifically asked about heart problems, hypertension, breathing problems, and diabetes.
Figure 15-2 Example of several different pain assessment scales in one reference.
Table 15-5 Other Useful Mnemonics for Obtaining the History of Present Illness
|
System |
Elements |
|
Any concern of pain |
OPQRST AS/PN as described previously |
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Altered mental status |
AEIOU-TIPS |
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A – alcohol |
|
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E – epilepsy/seizure |
|
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I – insulin (hyper- and hypoglycemia) |
|
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O – overdose |
|
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U – uremia/metabolic |
|
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T – trauma |
|
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I – infection |
|
|
P – psychiatric |
|
|
S – stroke |
|
|
Shortness of breath |
HAPI-SOCS |
|
H – history of pulmonary disease |
|
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A – activity at onset |
|
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P – pain on inspiration |
|
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I – infection symptoms (chills, night sweats, fever) |
|
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S – smoker (# packs per day x number of years = # pack years |
|
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O – orthopnea |
|
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C – cough? productive? |
|
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S – sputum (and color)? |
|
|
Psychiatric/Depression |
IN SAD CAGES |
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IN – interest (apathy, withdrawn, disinterested) |
|
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S – sleep disorder (insomnia, night walking) |
|
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A – appetite |
|
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D – depression/mood swings |
|
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C – concentration |
|
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A – activity |
|
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G – guilt |
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E – energy |
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S – suicidal ideation |
STREET SMART
Occasionally when Paramedics ask a patient if he has any medical problems, some patients will tell the Paramedic that there are not any, even though there is a history of a chronic disease. People sometimes feel that, since they are under care for an illness, it is no longer "a problem." The best approach is to ask if the patient has any medical problems and then ask if the patient has ever been under a health provider’s care for any reason.
Table 15-6 Past Medical Conditions Related to Specific Body Systems
|
System |
Past Medical History |
|
Neurological |
Stroke, seizure, head injury |
|
Cardiovascular |
Acute myocardial infarction, angina, coronary artery bypass graft (CABG), angioplasty/cardiac catheterization |
|
Respiratory |
Asthma, emphysema, smoking, hospitalization, intubation |
|
Gastrointestinal |
Surgery, abdominal aortic aneurysm, appendicitis, small bowel obstruction |
|
Genitourinary |
STD, pregnancy, abortions, kidney stones |
|
Musculoskeletal |
Fractures, surgery, multiple sclerosis, sports injuries |
|
Psychiatric |
Depression, suicide attempts, admission, medications, drug and alcohol use |
|
Endocrine |
Diabetes, thyroid disorder, surgery |
|
Hematologic |
Leukemia, infection, travel, transfusion |
|
Allergic |
Known allergies, allergy testing, anaphylaxis history |
Allergies
The Paramedic should determine if the patient has any allergies to medications. If an allergy is reported by the patient, the Paramedic should inquire what type of reaction the patient had to the medication. In some cases, a reported allergy is actually a common side effect or a familial "allergy" in which the patient’s relative is allergic, so the patient avoids a certain medicine. If related to the chief concern, such as a bee sting, the Paramedic should inquire about environmental allergies.
Medications
The Paramedic should ask the patient about any medication use and inquire about prescription, over the counter, and homeopathic or nutritional substances. The Paramedic should also determine if the patient is compliant with medication use and how long the patient has been taking each medicine. It is important to ask about recent changes in medications, such as dosage.
Tobacco, Alcohol, and Drug Use
The use of tobacco, alcohol, or other recreational drugs is a significant risk factor for many diseases.8-22 Knowledge of their use may raise the Paramedic’s index of suspicion for certain illnesses such as heart or vascular disease, COPD, and cirrhosis.
Clinical Reasoning
Based on the patient’s chief concern, history of present illness, and answers to direct questioning, the Paramedic can develop a general sense of the body systems that may be involved in the patient’s problem. Forming this impression will allow the Paramedic to decide which other questions she should ask and which physical exams she should perform to confirm the Paramedic’s conclusion.
Special Challenges to History Taking
The Paramedic can face difficulty in obtaining an accurate medical history in some situations. Application of several simple techniques can assist the Paramedic in obtaining a history in these situations.
Sensitive Topics
It is often imperative to question the patient about topics that may be embarrassing or socially sensitive in order to learn more about factors which may have contributed to the illness. These topics might include such issues as drug and alcohol use, physical abuse, and sexual history. Much of the difficulty in asking sensitive questions lies with our own biases, embarrassment, or perceptions with these topics. Some patients will readily answer these questions when asked in a professional manner. Questioning a patient about these topics becomes easier with experience. It is often helpful for each individual Paramedic to observe more seasoned providers obtaining this information and then develop an effective method which works.
Silence
For many of us, silence is uncomfortable. Nonetheless, it must be remembered that silence has many uses and possible meanings. Patients may use silence to collect their thoughts or remember details about their concerns. Silence may be the result of insensitivity by the Paramedic in asking questions, or the patient may be taking some time to decide whether or not to trust the Paramedic.
Whenever confronted with unexpected silence, the Paramedic should be alert for nonverbal clues of distress and try to determine if anything in his interview technique might be responsible for them.
Overly Talkative Patients
It is easy to become impatient with an overly talkative patient when time is of the essence. A few techniques may be helpful in this difficult situation.
Although not ideal, the Paramedic may have to lower expectations and accept a less comprehensive history. It may be helpful for the Paramedic to allow the patient free reign for the first few minutes and then directly question the patient about the most important details. If necessary, he should interrupt the patient as gently as possible and summarize the history as succinctly as possible. Phrases such as "I’d like to hear more about the chest pain you had before you called us" may help to refocus the patient on the chief concern.
Regardless of the situation, the Paramedic should not let impatience show. If necessary, he should explain to the patient that time is short and that the current discussion will be continued later.
Patients with Multiple Symptoms
Some patients seem to have every possible symptom. Although it’s possible that this patient might have multiple organic illnesses, it’s more likely that other confounding factors are present. The Paramedic should refocus the patient on one concern by asking the patient about the most important concern, for example, "You told me many concerns. Which is the most important concern, or the reason you called us to help you today?"
Anxious Patients
It is natural for a patient to be anxious during a medical emergency. For some patients, anxiety has significant implications in their reaction to their illness or even may have contributed to their illness. The Paramedic should be conscious of nonverbal clues to the patient’s anxiety and, when he senses anxiety, encourage the patient to talk about his or her feelings.
Reassurance
Providing reassurance to patients can be both beneficial and harmful depending on the way it is provided. In an emergency situation, many patients worry not only about their condition, but also how it affects others they care for or love. By providing reassurance, the Paramedic can help calm the patient down, allowing him to make appropriate medical decisions or be more cooperative with the assessment and treatment. Conversely, reassurance can provide false hope if provided improperly. Statements like, "Everything will be OK" and "You have nothing to worry about" are detrimental when patient receive the news that they have developed a severe condition. It is more appropriate to acknowledge that there are factors that are of concern, but state that it is better to focus on getting well first and take it a step at a time. Reassurance that the patient is in good hands or going to see a good physician can also help the Paramedic provide positive reassurance to the patient without creating a false expectation.
Anger and Hostility
It is not unusual for patients to exhibit anger toward healthcare personnel for a variety of reasons, including feeling unwell, suffering anxiety, or developing a feeling they have lost control over their lives. Paramedics should not take this behavior as anger against them personally. They can attempt to defuse the patient’s anger by identifying that, although they understand he is angry, you are there to help him. Paramedics should always remember that their safety and that of their crew are paramount, and thus they should retreat from any situation which becomes dangerous.23,24
The Intoxicated Patient
Acutely intoxicated patients who are belligerent, angry, or uncooperative can be some of the most difficult patients to interview. Paramedics should use a calm, direct voice and simple directions to encourage the patient to allow himself to be assessed and treated. The Paramedic should try to avoid talking to the patient in a confined area, as the patient may feel trapped and react with hostility. Intoxicated patients can be unpredictable; as a result, sudden violence is always a pos-sibility.25 Paramedics should always have an escape route planned and retreat from any situation which cannot be easily de-escalated.26 Patients who appear clinically intoxicated do not have the capacity to refuse care. Signs of clinical intoxication include slurred speech, disorganized thinking, inappropriate responses to your questions, combativeness, and staggering gait. A Paramedic may need to enlist the aid of local law enforcement to assist in bringing the patient to the emergency department for evaluation if the patient refuses to go.
Crying
Crying is an important clue to emotions.27-29 The Paramedic should be supportive and wait for the patient to recover. Quiet acceptance or a supportive comment may assist the patient in composing herself and continuing the interview. Handing the patient tissues is a gesture that is always appreciated.
Depression
Depression is a common medical problem and can have multiple manifestations. The Paramedic should always maintain a high index of suspicion for depression in patients complaining of multiple, vague symptoms. If the patient is depressed, one should be concerned for the possibility of self-harm and question the patient directly about suicidal thoughts.30 Any patient with the potential for self-harm must be transported to an emergency department for further evaluation.
Seductive Patients
Occasionally a provider may feel attracted to a patient. If the Paramedic becomes aware of such feelings, one should realize that these thoughts are normal responses. However, one must prevent these feelings from affecting her professional interaction with the patient. Some patients may make sexual advances toward the Paramedic. Paramedics need to make clear to these patients that the relationship with them is purely professional. It is unethical, and in some states illegal, for a Paramedic to have a personal and/or sexual relationship with a patient who is under his or her care.
Confusing Behaviors or Histories
Occasionally, despite best efforts, the patient’s history does not appear to make sense and the Paramedic may feel baffled or confused. While many of these situations involve an emotional component, the Paramedic should avoid dismissing the patient’s concerns and instead attempt to focus in on a single chief concern.
Limited Intelligence
Most patients with even moderately limited intelligence can usually give adequate histories. When patients suffer from severe mental impairment, however, most of the history will have to be derived from other sources, such as family, friends, or medical charts. The Paramedic should use simple language when interviewing the patient and listen closely as the patient describes tests or other elements of his medical history.
However, the Paramedic should be careful about making assumptions about the patient’s level of functioning. The best technique, just as with any other patient, is to establish a relationship first with the patient and then, if necessary, seek other sources for history.
Language Barriers
When confronted with a patient-provider language barrier, the Paramedic should make every effort to obtain a translator. The best translator is a neutral, objective observer who is fluent in both languages. Using a family member often leads to distorted meanings and may present a confidentiality problem.31,32 The Paramedic should look at the patient when talking, and not the translator. Also, he should ensure that the translator asks the patient the question and is not just answering the question for the patient.
CULTURAL /REGIONAL DIFFERENCES
In many regions and cultures, it is disrespectful for children to question their elders, especially in personal matters. Usually, however, the children are fluent in the two languages. If it is necessary to use children as translators, one should ask as few questions as possible and alert the staff at the hospital so that a more thorough and accurate history can be obtained.
Hearing Impaired Patients
Patients with hearing impairments may present as many issues as those with language barriers. The Paramedic should look at the patient directly while talking and speak slowly. Often the patient is able to read lips well enough to answer the Paramedic’s questions. He should avoid shouting or raising his voice unless the patient indicates it helps her hear the questions. If the patient has a "good ear," the Paramedic should make a point of speaking toward that ear. Communication through written notes, although time-consuming, may be the only solution to obtaining an adequate history.
Vision Impaired Patients
When talking to a patient with limited vision, the Paramedic should make sure to identify herself, alert the patient to her location, and explain what is being done. She should remember to always respond vocally to the patient and avoid raising her voice while speaking. The Paramedic may need to explain procedures and actions in more detail than is needed for patients with normal vision. If walking with a patient with vision impairment, the patient should grasp the Paramedic’s arm rather than the Paramedic grasping his or hers. The
Paramedic should avoid making any sudden movements that may increase the patient’s anxiety in what is likely already a stressful situation.
Family and Friends
Sometimes the Paramedic may need to elicit the history from family, friends, or other bystanders.33 Whenever possible, the Paramedic should get the patient’s permission to discuss the condition with the other person. If the Paramedic cannot get permission, then he should remember that all medical information derived from the patient interview or exam must be held confidential and not shared with the third party.34-37
Conclusion
The novice Paramedic must master the skill of history taking in order to be effective at providing care to the vast array of patients encountered during one’s career. With practice and by observing other experienced healthcare providers obtain a history from a patient, the novice Paramedic will soon develop and refine her skill.
key points:
• History taking is the medical questioning of a patient for purposes of ascertaining the disorder, syndrome, or condition affecting the patient that resulted in the activation of EMS.
• The Paramedic must be aware of the messages transmitted by words and actions and have a professional appearance and calm demeanor.
• The Paramedic should formally and respectfully introduce himself and explain his job function.
• The Paramedic should inquire as to the patient’s preferred manner of address.
• An open-ended question allows the patient to answer in his or her own words rather than give a simple answer of yes or no.
• Interviewing techniques which assist the Paramedic in developing questions and promote dialogue include facilitation, reflection, clarification, interpretation, and direct questioning.
• A comprehensive medical history is taken to discover as much information as possible about a patient’s concerns, interpersonal relationships, and medical history. However, it is often not used in emergent situations due to the extensive amount of data it collects and time required.
• A focused history can be conducted by the Paramedic to concentrate on the chief concern, history of present illness, significant past medical history, and pertinent current health status. The mnemonic SAMPLE is used to remember the different historical components of a focused history.
• The chief concern is the main reason EMS was activated and should be expressed and documented in the patient’s own words using quotation marks.
• Several methods can be used to assess a patient’s pain, from a simple "mild, moderate, severe" scale to a 0 to 10 or faces scale.
• The mnemonic device OPQRST AS/PN can be used for any concern of pain. The mnemonic AEIOU-TIPS is used for altered mental status.
• The mnemonic HAPI-SOCS is used for shortness of breath.
• The mnemonic IN SAD CAGES is used for psychiatric issues/depression.
• The mnemonic SAMPLE is used for gathering past history. Ask additional questions for clarification.
• The Paramedic should be conscious of nonverbal clues to anxiety or anger.
• When communicating with an acutely intoxicated patient, the Paramedic should use a calm direct voice, and give simple directions to encourage patient access to evaluation and treatment.
• Strong emotions exhibited by the patient during an interview may require the Paramedic to assist the patient through quiet acceptance or a supportive comment.
• The Paramedic should always keep the patient relationship professional.
• The Paramedic should use simple language, listen closely, and not make assumptions about a patient’s level of function when interviewing patients with mental impairments.
• When confronted with a patient-provider language barrier, the Paramedic should make every effort to obtain a translator.
• The Paramedic should explain who he is, where he is, and what he will be doing in a clear, normal tone of voice for the vision impaired patient.
• All medical information derived from the patient interview or exam must be held confidential and not shared with a third party.
