Clinical History (Paramedic)

00:01 Welcome! In this lecture, we will discuss the importance of a well-structured patient interview. In the beginning, you may ask yourself what role a medical history has in medicine.

00:15 There are studies that suggest about 70% of all diagnoses made in medicine are based on or reinforced by a well-structured medical history.

00:27 Accordingly, the history is of extraordinary importance and therefore should not be neglected. There are two main forms of medical history, self-reported and external or supporting history.

00:41 The self-reported history is provided by the patient, while the external history is provided by witnesses, relatives, other individuals knowledgeable of the event. In addition, we differentiate the history into a targeted version, with the goal of collecting as much information about the patient in the short time, and a very detailed, long variant.

01:06 The detailed history may include information such as pregnancy complications, childhood illnesses, social factors, and a very detailed clinical picture, among other things.

01:19 For the focused history, I recommend a special mnemonic . Use the SAMPLER scheme coupled with the so-called OPQRST scheme.

01:34 You should absolutely memorize this chart by heart.

01:38 I promise you, it makes taking a medical history much easier and thus simplifies further diagnostics communication between doctors.

01:46 You can benefit in two main ways.

01:49 First, you avoid conversational gaps because you always know what to ask next. Secondly, the questions are structured hierarchically so that you gather the essential information early on.

02:04 Important components of the medical history are the patient's symptoms and allergies, most recently taken medications, past medical problems, recently ingested food, and their last bowel movement.

02:23 They should also be asked about their last primary care physician visit, last blood draw, or any other medical treatments.

02:30 They should be asked what treatment was done and why it was necessary.

02:37 Last, don't forget to ask the patient about risk factors.

02:42 These can be obesity, a family heart disease, genetic predispositions, diabetes, smoking, or similar.

02:51 If you want to classify the present illness, I recommend you use the OPQRST scheme to get structured information.

03:05 First, ask when the symptoms began, how they might be provoked or relieved.

03:11 They then rank the quality of the symptoms, especially pain.

03:22 Ask the patient if the pain is burning, throbbing, or stabbing, or if it radiates to any other region.

03:31 For example, the pain could radiate to the shoulders or arm, as in the case of a heart attack. In addition, the intensity of pain is also relevant.

03:43 You can use a numerical rating scale from 0 to 10.

03:47 The number ten stands for no longer unbearable pain and zero is no pain for children, these scales are often also available as Smiley Analog scales.

04:01 Now they must also be asked about the time course of the symptomatology.

04:05 So you ask if the pain started all of a sudden, how long they have had symptoms, if there have perhaps been breaks in the symptoms, or if the patient has had similar symptoms in the past.

04:19 At that point, you have then completed the OPQRST scheme.

04:25 Taking medical histories can present problems, especially if you are unable to communicate with the patient.

04:32 This not only complicates the taking of a medical history, but can also delay the diagnosis.

04:39 Hearing impairments or speech disorders, such as aphasia, are particularly hindering.

04:54 Other problems include foreign languages, impaired consciousness, mild or pronounced confusion in patients with dementia or delirium, or even if the patient has amnesia to the event or to themselves.

05:09 If you are facing such problems, there are a few suggestions that may ease the aggravated patient communication.

05:17 First and foremost, I recommend that you take an external medical history.

05:21 This takes place, as I have already said, not with the patient themselves, but with their relatives, friends, or witnesses.

05:29 The nursing staff or emergency personnel may also have valuable information you should gather.

05:38 If these individuals are not available, their documentation may also offer some clues. Another way to improve communication is to insert the patient's hearing aid and ensure it is active.

05:52 You can also look for someone who speaks the same language as the patient.

05:58 Consult doctor's notes or medication schedules, especially for patients with difficult pre-existing conditions.

06:08 Remember that some patients may have illness IDs, such as the diabetic ID or epileptic ID, which can help divulge their medical history. In the following technique video, I would like to demonstrate how you can take a structured medical history.

06:25 This will help you quickly obtain useful information within a few minutes, and help you then make educated medical decisions.

06:34 After the practitioner has completed the initial care of potentially life-threatening conditions in their patient, they move on to the history or interview.

06:46 It follows a logical scheme such as the SAMPLER scheme.

06:50 The S stands for the underlying symptomatology.

06:54 He can then evaluate these in a structured way using the OPQSRT scheme. The "O" stands for onset of the symptoms.

07:06 The "P" stands for palliation or provoking factors, as in what makes it better or worse.

07:13 The "Q" stands for the quality of the symptoms, while the "R" stands for radiation, especially with respect to pain. The "S" stands for severity, a nd finally, the "T" stands for time course of the symptoms.

07:36 Now he continues with the history according to the SAMPLER scheme.

07:41 The "A" stands for allergies, and the "M" for medications, especially those that are ongoing medications.

07:49 The "P" stands for personal History, including any previous diseases. The "L" stands for recent events in general, including the last meal, the last medication taken, last doctor's visits, or even the last bowel movement.

08:08 The "E" stands for the event that led to the presentation as a patient, and finally, the "R" stands for any risk factors.

08:16 In addition to the differential diagnosis, a good history can also have significance for further therapies.

08:22 I strongly recommend you follow this medical history scheme.

08:25 It improves the quality of the medical history and ensures that all essential content of patient information is not lost.

08:33 In closing, let us recall the important concepts of this presentation.

08:37 First, a well-managed history often ensures a good diagnosis.

08:41 There are different forms of histories, and the techniques for gathering them can differ.

08:46 A structured scheme helps you gather the important information during the history.

08:51 And finally, barriers of history taking should be identified early, and the technique adjusted as necessary.