This skill demonstrates obtaining a history of an alert and oriented patient.
The first step in this skill is to obtain the patients demographic data.
When I approach the patient, I can observe that she is a caucasian female.
I'll introduce myself.
Hello mam my name is Nathan. I am a paramedic. Can you tell me your name?
Katrina
and Katrina how old are you?
I'm twenty four
And about how much do you weigh?
About a hundred and twenty five pounds.
Who called EMS today?
I did.
We've now determined that patient is fully alert and oriented.
and has the appropriate decision making capacity
to consent with treatment. We will now continue with our assessment.
Next I'm going to determine the patients cheif complaint.
Katrina, can you tell me why you called EMS today?
My stomach is really hurting.
and how long has this been going on?
Since last night.
And when did this start?
Last night after dinner.
And was the onset gradual or sudden?
It was pretty sudden but it has gradually increased.
Do anything make it better or worse?
No. Not really.
Can you point to exactly where the pain is located?
Right here.
Does it radiate anywhere?
Everywhere pretty much hurts but the severe pain is right here.
And on a scale of 0 to 10. How would you rate your pain right now?
It hurts really bad. I would say like an eight.
Next I am going to observe the environment
to see if there is anything particular about this setting.
After observing the setting for any unique findings.
I'm going to ask the patient about any treatments.
Katrina have you taken anything for this problem.
Well I have been feeling really nauseous
but I haven't thrown up so I've been drinking some ginger ale
and eating crackers.
So I have identified the pertinent negative that the patient has not been vomitting.
I'm not going to move on to my focused assessment.
I'm not going to determine the patients past medical history.
Katrina, how would you rate your overall health?
I'm overall pretty healthy.
Do you take any prescribed medications?
I take birth control.
Do you take any over the counter medications?
Just daily vitamins.
when was the last time you took your medications?
This morning. I take it every morning.
Have you ever had any problems like this before?
No.
So I've determined that this is an acute illness.
Do you have any allergies to medications or food?
I'm allergic to penicilan.
Have you had any surgeries in the past?
I've had my tonsels removed.
Do you consume alcohol?
Yes ocassionally.
Do you smoke?
No.
Do you use any other tobacco products?
No.
Do you use any street drugs?
No.
At this point I would continue to question the patient
if appropriate on pertinent family medical history
or psychological history related questions.
based on the patients presentation.
After I've obtained a thorough history from my patient
I'm going to organise a verbal report.
So I have a twenty four year old female
With a gradual onset of acute right lower quadrant abdominal pain
progressively worsening over the last eight hours.
The patient is complaining of nausea but denies any vomiting.
The patient has no significant past medical history
Is allergic to penicillin and takes birth control daily.
I'll now move on to a physical assessment of my patient.