Have you ever gone to obtain a history from a patient and found yourself struggling for one reason or another? Are there certain patient presentations that seem to always be slightly more challenging? For this episode, Patricia and John are joined by Tarlan Hedayati, MD and Matt Delaney, MD to discuss obtaining histories in challenging situations.
Why might it be challenging to gather a history from a patient?
It can be particularly difficult to obtain a history from a patient who can’t tell you the whole story, if any information at all. This can be the case with patients who are altered, whether that’s someone who is under the influence, who suffers from dementia, who is acutely psychotic, etc. We have all heard this type of patient referred to as a “poor historian,” but our job in these cases is to take a minute to recognize our own bias before we go into the room. It is in these scenarios that we need to go in with an open mind and double down on all of the resources available to us because these can be very high-risk patients.
What tips can we use to obtain a history in these challenging situations?
- Don’t assume you’re not going to get any history.
- We have so many resources to draw on outside of getting the history directly from the patient. By assuming you are not going to be able to obtain a good history, you are setting yourself up for failure.
- Get collateral history.
- Talk to whomever you can who may know more about the patient, whether that’s EMS, family members at the bedside or over the phone, ECF staff, and bystanders who may have brought the patient in, etc. Dig in on the details of where the patient was brought from and what the scene was like.
- Don’t forget to look through the medical record.
- Often the medical record can give you incredibly important information about past diagnoses, recent procedures, loved one’s contact information, language barriers, etc.
- Ask the question “What was different today?”.
- This can help you separate the patient’s chronic conditions from what their acute concern might be.
- Be patient.
- Know that it’s going to take more time to gather information from this patient. Try not to ask the patient too many questions at once and be ok with the fact that it may take them a little while to answer you.
- Expand your work up.
- The less history you have the more testing you may have to do to rule out the life-threatening things that could be going on.
What if you still have trouble getting a complete history?
Know that it’s ok if you aren’t able to get the complete history as a medical student. Your job is to try your best and know that the resident and/or the attending you are working with will also be there to help you. It’s also ok if the story changes because as John pointed out, if the story doesn’t change at all between the triage nurse, the medical student, the resident, and the attending, the patient may be providing a rehearsed story. This usually raises flags for other things. If you have a suspicion, based on the story, that there is a patient safety concern, remember that you’re not a detective, you’re a physician-in-training and your obligation is to the patient. Be sure to express your concern to the resident or attending and you can work together to ask the family to leave the room or the resident or attending can order a test like an x-ray that the patient would have to go back to radiology for. So next time you are having trouble gathering a history from a patient, remember that you are one member of a team and as a team, we have many tools to gather the history we need to do right by the patient.
Take-Home Points:
- Do your best to get report from EMS or anyone else that may have information on why the patient came in today.
- Be patient and take the time required to get the history that you need.
- Leave ego at the door and recognize that you have more tools than you think to obtain the history you need to take care of the patient.
Post by Patricia Capone, DO PGY2
About Our Guest:
Associate Professor, Department of Emergency Medicine, University of Alabama at Birmingham
Tarlan Hedayati, MD
Chair of Education at Cook County Health EM Residency Program, Associate Professor at Rush Medical School
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