History taking Word Scramble
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| Question | Answer |
| 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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