Friday, November 18, 2011

How to take a Medical History



If you are in the position to give medical care to someone other than a family member, such as your kids or spouse, you will probably have to take some sort of medical history. Of course, this assumes that you have a leisurely time to interview them, and that it isn't some sort of emergency response situation. This is the interview you do after you have taken vitals (blood pressure, pulse, respiration) and  before you do a physical. A great resource for this procedure is Jarvis Pocket Companion for Physical Examination & Health Assessment.

Here is an acronym I learned in my recent first aid class (Hey! you learning skills or just buying things?!):

SAMPLE

S- Signs /Symptoms
  • what is wrong?
  • visual symptoms
  • reported symptoms
A- Allergies
  • medications
  • foods
  • environment, insects
M- Medications
  • currently taken
  • taken before TSHTF
  • recreational
  • include how much, frequency, if there is relief
P- Pertinent Past
  • surgery or illness in past
  • recurrent symptoms?
L- Last oral intake
  • when and what did he last eat or drink
  • how does he feel after eating
  • appetite
E- Events leading to injury or illness
  • what were you doing when you injured yourself
  • what changed in diet/ environment before fell ill

Don't forget to document, document, document. Not because you are going to be chased down and sued but to create a patient history.

Now, more about Jarvis Pocket Companion for Physical Examination & Health Assessment. I have it and I really like it for many reasons. It has 20 chapters, beginning with
  • the interview and health history
  • mental status
  • assessment techniques and the clinical setting
  • the general survey, measurement, vital signs and pain assessment
Then it has 16 chapters on the different body systems followed by one chapter called "Integration of the complete physical examination." It uses medical terminology that is familiar to anyone in the field. Each page is broken vertically in half, with the left being "normal range of findings" and the right being "abnormal findings." It is generous with the color illustrations and photos. In addition, they layer illustrations on top of photos, such as  showing the muscles of the neck. Another thing I really like is the way they list descriptions and details for pediatric, elderly, and dark-skinned groups so that what is "normal" won't be missed.


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