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History taking

For communcations Test

QuestionAnswer
Chief Complaint main reason EMS was called/ main source of distress
Primary Problem medical (physical and or emotional) cause of chief complaint
Secondary Problem additional contributing medical injury/illness/conditions
Final Problem what is determined to be the main resulting factor for patients condition after assessment and treatment / may vary drastically from Primary and Secondary problems
Chief Complain Increased Weakness
Primary Problem Diabetic Emergency
Secondary Problem Alcohol Intoxication
Final Problem Drug Overdose OR Diabetic Emergency
Load and Go fast // emergency call - relevant patient info and history
Stay and Play not so serious call - relevant patient info and history
Differential Diagnosis working diagnosis/variety of potential causes
Set the Stage appropriate language (professional and friendly), Read the situation, use open ended questioning then progress to more specific, be empathetic
Active listening Facilitate - present yourself as open to conversation with patient Reflection- Repeat certain phrases to encourage elaboration Clarification- re-word certain phrased to ensure you have all information
Active Listening Empathy - gesture or language that shoes understanding Confrontation - asking pointed questions about inconsistencies without making patient feel discomfort Interpretation - comprehension of what patient is attempting to say
Active Listening Summarization - encapsulating their story and giving it back (shows you are listening Validation - let them know their feelings are justified
Active Listening Transition - explain the next steps or the next line of questioning Reassurance - ensure them you'll do everything you can to help without saying it will all be okay
Assessment Components Preliminary Data, Chief Complaint, Present Illness, Past History (px), Current Health Status, Understanding the developmental level, Initiating a decision/treatment plan
OPQRST Onset, Provocation, Quality, Region, Severity, Time
ASPN Associated, Symptoms, Pertinent, Negatives
SAMPLE Signs/Symptoms, Allergies, Medications, Past Pertinent Hx, Last oral Intake, Events leading up
AEIOU - Altered Mental Status Alcohol/Acidosis, Epilepsy/Environmental, Insulin, Overdose/Oxygen, Underdose/Uremia
TIPS Altered Mental Status Trauma/Tumor, Infection, Psychogenic/Poison, Stroke/Shock
Signs/Symptoms signs = what you can see symptoms = what patient feels/describes trust instincts
Allergies Do you have any medication allergies, are there any you have been advised not to take
Medications Do you take prescription medication? Naturopathic Treatment? Have you been taking your medications as they are prescribed?
Past History General health = what is the baseline health of the patient? when was the last time they visited a doctor? - open ended questions if patient is vague Seizures/Epilepsy? Have you ever had a seizure? do you take medications for seizure or tremors?
Past History Heart conditions? have you ever had a heart attack? Have you ever been diagnosed with congestive HF? Respiratory Conditions? do you take any puffers for your breathing? do you have an Asthma or COPD history?
Past History Neurological Problems? have you ever had a stroke? have you ever had a mini-stroke? have you ever had an aneurysm? Hypertension/Hypotension? Do you take medications to control your BP? Have you ever been told your BP is too low?
Las Oral Intake What was the last thing you ate? what time did you eat? any alcohol today?
Events leading up What were you doing when this started? HAs there been any significant changes at home?
Created by: Dalton.evely
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