complete pt history

[chap20]

Does anyone know of any links to videos that demonstrate a proper complete medical history interview. Thanks

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[Rendar5]

I wish I could help you with that but I don't know of any. What I can tell you is that for a good history, the two keys are to always do stuff in the same order, and to just keep doing them doing them doing them. A lot of stuff really only takes time and organization. And then once you ahve enough practice, you can start reducing your history to something more focused to what you need to be doing (a good ob/gyn history is quite different from a good emergency history from a good internal medicine history).

For a very general and very complete history, always stick to an established order such as:
1. Chief Complaint
2. History of Present Illness (7 qualities of pain which can easily be adjust for non-pain complaints, associated symptoms, whatnot)
3. Past Medical History
-Ob/Gyn History if appicable
4. Past Surgical History
5. Medicines (and vitamins, supplements, and herbs)
6. Allergies (drug/food/[environmental])
-Sick Contacts if applicable
-Travel History if applicable
7. Family History
-Sexual History if applicable
8. Social History (basic is EtOH, tobacco, drug hx. extends to questioning about work environment, home environment, stressors as needed)
9. Review of Systems: again, until you know how to focus this based on the complaint, just organize yourself into clusters of symptoms starting at ones affecting the head, ending with ones affecting the toes, same order every time multiple times.

EDIT: the above pattern pertains to almost every field except psychiatry.

 

[Law2Doc]

Does anyone know of any links to videos that demonstrate a proper complete medical history interview. Thanks

This Amateur Transplants song covers most of it.
http://www.youtube.com/watch?v=8a8on1kxo_s

 

[Slow]

lalala

 

[Doctor Bob]

I guess that's a good case for practicing your standard interview until you have a heart attack yourself.

Indeed.
What is difficult and nerve-wracking the first year, becomes something that requires concentration the second year, then becomes something you just have to occasionally remind yourself about third year. That turns into an easy routine in 4th year. By residency, you don't even think about it any more and it just becomes an issue of refining your questions to suit your style.

 

[261766]

From my experience in EMS, asking the right questions is the easy part. Listening to and interpreiting their answers is the hard part. I've been so stressed trying to remember which part of GMCLT/OPQRST I was on I was busy thinking of the next question while the patient was answering the first. I guess that's a good case for practicing your standard interview until you have a heart attack yourself.

pardon the ignorance but gmclt?

 

[Dwindlin]

pardon the ignorance but gmclt?

I was curious about this as well...we learned "AMPLE/OPQRST" for basic histories.

 

[medical1812]

Whats AMPLE/OPQRST

 

[45408]

Whats AMPLE/OPQRST

AMPLE - allergies, medications, past medical history, last meal, events leading up to trauma

pain - OPQRST - onset time, provoking factors, quality (burning, sharp, aching), radiation, severity, timing (post-prandial, with menses, constant, waxing/waning)

 

[medical1812]

thank you for clarifying

 

[TMP-SMX]

At Wayne we do OPQRSTAA.

The P is provocative or palliative factors.
The As are Associated symptoms and Attribution (What they think is going on).

As for good websites:
UFL and UCSD have good info I used during my PD course this year.

 

[Slow]

lalala

 

[Warbux]

At Wayne we do OPQRSTAA.

The P is provocative or palliative factors.
The As are Associated symptoms and Attribution (What they think is going on).

As for good websites:
UFL and UCSD have good info I used during my PD course this year.

You linked UCSD twice.

 

[TMP-SMX]

You linked UCSD twice.

Thanks. Fixed now.

 

[KeyzerSoze]

I think Bates includes a CD with videos.

 

[DeeJay2728]

I can't see you needing it much outside of EMS/first responder roles, but GMCLT was how I remembered General impression/ Mechanism of injury (or illness)/ Consciousness/ Life Threats. You had to vocalize each step to get credit, so my whole ridiculous pneumonic to pass the EMT-B practical exam went something like:
BSI/SS/NoNoHelpC/GMCLT/ABCD/SAMPLE and OPQRST (depending on injury/illness) /and then a bunch more I have since forgotten. HAHA

Edit: For the curious, and my own practice, that's:
body substance isolation. scene safety. number of injured. I forgot? Evaluate need for ALS backup help. Evaluate need for C-spine. GMCLT as above. airway. Breathing. Circulation. Transport Decision. (take vitals) S=Signs and symptoms, AMPLE as above, OPQRST as above.

ABCD Instead of transport decision, we used the "D" for Deformities/Disabilities.