Opqrst & Why

[skyemt]

ok, so in EMT class, we learn the basics of taking a good history on medical patients... OPQRSTI...

BUT, out in the field, there are many great assessment questions that we don't learn in class...

for example, for an asthmatic patient, a great question i learned after class was to ask if they've been intubated before... volumes of information gathered from the answer to that one simple question...

i would love to know, from the Medics especially, what are some great assessment questions that are outside the basics learned in EMT class...

thanks very much, as this thread could really help my assessment skills in the field.

 

[MedicDoug]

Ever had pain like this before? What did the doctor tell you it was? How is it different this time than last time?
And, even though we're taught to ask open-ended questions, there are some things that I want to know, so my yes/no questions are:
Ever had any (or ever been treated for: heart problems/CHF, Asthma/COPD, seizures, high blood pressure, stroke, or diabetes?
The "ever been intubated" question is a great one that is too often forgotten.

 

[griz1974]

opqrts

always try and use easy to understand words as emts we begin to talk at pts and not to them listen to your pts because u can get alot of your info from normal conversasions

 

[skyemt]

the questions about heart history, asthma, copd, strokes, seizures, etc...
are standard on our PCR forms... they are asked on every call...

i'm really looking for questions relating to specific presentations... i.e. the intubation question for asthmatics...

questions that are valuable, but do not appear in emt-b texts, or on pcr's...

thanks for the efforts!

 

[LucidResq]

Wow I feel lucky. We were taught the intubation question and several of the other questions mentioned pretty early on in class. It totally makes sense.

We were doing an abdominal pain scenario in class the other day, and I was the pt. The student assessing me asked a very tactful and clever question, IMO: "do you have any bleeding that I can't see or have you had bleeding anywhere lately?"

 

[Ops Paramedic]

Proper history taking requires good communication skills. It is not just about what is said and heard. You would have to include body language, speech, presentation and so forth. Make use of all your senses, sometimes even the "6th" sense during history taking. You can pick up a lot of info by just looking at the patient's presentation as well as the manner in which he presents himself, vice versa, you can scare the off with your presentation!! What about communication barriers and the use of a non certified interpreter??Try and get to know the cultures of the population you deal with.

You or the patient can lead the direction towards a diagnosis or differentiation thereoff. Such as: "Do you have any chest pain?" (The good old close ended question) The reply may vary well change to yes (...well now that you mention it, yes i do OR you have been waiting for a cardiac patient the whole, and this one fits the profile). The better question would have been: "Do you have pain ANYwhere?" Hereby no one is forcing the history taking in any direction, the history is leading the direction.

Once you have the problem narrowed down, you can start asking close ended question to performed a focused history take. Should the patient reply: "Yes, i have pain in my chest", you can now ask the patient: "Can you show me where the pain is?". Note that you don't ask the patient to point to the pain as he will most likely use his finger. What you are then looking for is where and how the patient shows you. If the patient uses his fist, or his whole hand and point the area of pain out in a circular mannor, it is likely to be cardiac related, in contrast, if the pinpoints using his finger, it likeley to muscular (Or leaning toward pulmunary rather than cardiac) in origan. Catch my drift...

I am not sure as to clued up your call takers, but here we often get dispatched to a "unknown" i.e., go and investigate, so when i arrive at any patient, one of my first questions are: "Why did you call the ambulance service today?" The reply to this question will give you the patient's chief complaint. As mentioned by Griz 1974, it is of great importance to listen to the patients general conversation. Here is one (A interfacility transfer whereby a healthy young adult male presented with dyspnea out of the ordinary): " I played golf 3 days ago got whacked hard by a golf ball on my ancle". We put 2 & 2 together, came up with a provisional diagnosis of pulmonary embolis which was later confirmed. The diagnosis we made was not soley based on this though, but it helped a lot.

The "AMPLE" & "PQRST"'s are great, and so are the standard questions on your patient record form, but should by no means substitute for a proper history taking!!

 

[skyemt]

thanks for the replies...

but before we get too off-track, my question is very specific...

it is not about body language, sample history questions, greeting the patient...

my question is SPECIFICALLY about targeted questions to ask patients to get great information other than what we learn from class..

these questions will be relative to the illness...

assume the chief complaint and all opqrst and sample and body language to have been performed adequately.

just to further illustrate, asking a pt with potential cardiac problems if their symptoms woke them up out of their sleep is a great question, again, not one taught in class.

thanks.

 

[traumaangel26]

I deal with a lot of sickle cell pt's, that are in crisis. One thing I always ask them is: "When was your last transfusion"?

It can help determine how bad their crisis may get.

 

[skyemt]

I deal with a lot of sickle cell pt's, that are in crisis. One thing I always ask them is: "When was your last transfusion"?

It can help determine how bad their crisis may get.

thank you... we have not had a sickle cell pt that i am aware of, but that is the kind of question i am talking about...

thanks.

 

[BossyCow]

I like to go over the meds and ask.. "What do you take this for?" I get a lot of information that way about history.

 

[LucidResq]

I like to go over the meds and ask.. "What do you take this for?" I get a lot of information that way about history.

That's a good idea, especially because a particular medication may have umpteen different uses and if you assume that they're using it for a particular condition you may be headed down the wrong path.

 

[Ridryder911]

I think many may miss OPS points (which was well written). I have had too many EMT's assume they are asking pertinent questions, when in reality the questions at the time of incidence I really could care less about.

History taking (which is really what one should be performing) is an art and skill that is usually developed with time and knowledge. Just knowing about if they took their medicine is not enough.

For example to ask the patient about being intubated (which most do not know what that is) but to ask if you ever been on a vent or breathing machine, most will understand. Now, what? That they have a pronounced hx.? So? You probably already knew that by your examination. Right? How about a DNR or Living Will? Maybe they do not wished to be placed upon one again? Now what?

Again as OPS was attempting to convey. Closed questioning will only get the answer you want and there are times for that. Just to remind to have open ended to elaborate on the details, along with that be prepared to guide them in the direction your pathway and information you need. Otherwise some patients will give non-pertinent hx. and wasted answers and time delay.

R/r 911

 

[skyemt]

For example to ask the patient about being intubated (which most do not know what that is) but to ask if you ever been on a vent or breathing machine, most will understand. Now, what? That they have a pronounced hx.? So? You probably already knew that by your examination.
R/r 911

of course, i'm not telling you anything you don't already know, but the asthmatics in these parts know if they have been intubated before...
many have never been, fortunately. but some have, enroute to the hospital.
to me, that means that this patient is very unstable, and has a history of going down hill very quickly. to be aware and prepared for that seems like a wise thing. that one question, to me anyway, seems to give information about the rate at which they may deteriorate. can all asthmatics potentially deteriorate quickly, sure, but if they have a history of it, all the more likely.

are you really saying that there is no value in questions like this? that the answers give you no more useful information?

that seems contrary to what i've seen you post about history taking in the past... you seemed to value good history taking.

what this thread is doing is giving you the opportunity to help others get better at it... if you don't think there are better questions to ask, that's ok...

if i am misunderstanding your post, please elaborate.

 

[Ridryder911]

What I am trying to point out, after one has found this out, what does this content mean to you? I have seen many basics ask some really good question only not to know when answered.

Back to your example. So the patient describes that they have been intubated before, now what? Do you know what to ask next? Is this going to change your assessment or treatment plan? I would hope so. One can find out quickly if this patient is usually resilient to routine treatment(s) and excaberates.

I am definitely not saying not to interview and ask questions. Rather to be sure you have a pathway to ask, to eliminate being side track and only to ask pertinent questions (dependent upon the ability of the patient to answer).

I have studied and been quizzed to death on history and interviewing techniques, but the best is by watching many different forms. One of the few things I am proud of the most is my interviewing techniques. It took me years (and continuously) to master it. What to ask, when to ask, pertinent to non pertinent, keep patient on track and to listen actively for fine points that might aid and direct me onto a better hypothesis for a diagnosis.

I highly suggest reading any article upon history taking. We do not have very much time to gather nor is the patients usually able to give much as well. So we have to utilize our other assessment skills such as physical examination, other available clues such as medications, medical devices, MOI, etc. to get a better picture.

Practice make one better...

R/r 911

 

[skyemt]

What I am trying to point out, after one has found this out, what does this content mean to you? I have seen many basics ask some really good question only not to know when answered.

Back to your example. So the patient describes that they have been intubated before, now what? Do you know what to ask next? Is this going to change your assessment or treatment plan? I would hope so. One can find out quickly if this patient is usually resilient to routine treatment(s) and excaberates.

I am definitely not saying not to interview and ask questions. Rather to be sure you have a pathway to ask, to eliminate being side track and only to ask pertinent questions (dependent upon the ability of the patient to answer).

I have studied and been quizzed to death on history and interviewing techniques, but the best is by watching many different forms. One of the few things I am proud of the most is my interviewing techniques. It took me years (and continuously) to master it. What to ask, when to ask, pertinent to non pertinent, keep patient on track and to listen actively for fine points that might aid and direct me onto a better hypothesis for a diagnosis.

I highly suggest reading any article upon history taking. We do not have very much time to gather nor is the patients usually able to give much as well. So we have to utilize our other assessment skills such as physical examination, other available clues such as medications, medical devices, MOI, etc. to get a better picture.

Practice make one better...

R/r 911

so, my question to you, as a student of assessments, is how to master it...
yes, i know it will take years if i am lucky enough to do it, but how did you do it? what articles? what worked best for you?

i am fully aware of the scope of the question... but i am also aware of the import of the topic... i want to be very good at this one day...

 

[MSDeltaFlt]

Here's one that's common.

On chest pain pts with PMHx of AMI, CABG, stents. Ask them if the pain they're feeling now was similar to the pain of the AMI, or the pain that prompted the CABG or Stents.

Also, if they've had recent stents (6 weeks or less (Rid correct me if I'm off)), that is an immediate LOAD & GO!. The stent is clotting off, and they will probably go directly to OR for CABG.

 

[Ridryder911]

There are tons of videos and assessment skills free on the Internet. What is difficult for many prehospital providers is when to and how to use the interview. Learning how to clarify and get to the point is sometimes difficult.

Mosby has great assessment and history/interviewing client type books, as well as professional journals such as JEMS and Air Medical Journal, EMS, etc. Do a search and find out different techniques. Remember, one can only ask questions if they know the disease processes and problems they are attempting to get information about.
i.e. recent weight loss.. which could be the etiology of several hundred illnesses and diseases or simply r/t to stress or purposeful weight reduction.

I have some links on interviewing techniques for physicians that can be adapted, I will try to locate them and post them.

R/r 911

 

[MSDeltaFlt]

so, my question to you, as a student of assessments, is how to master it...
yes, i know it will take years if i am lucky enough to do it, but how did you do it? what articles? what worked best for you?

i am fully aware of the scope of the question... but i am also aware of the import of the topic... i want to be very good at this one day...

Find the smart people; the ones who are well respected in their field: medics, nurses, doctors. And pick their brains for years.

 

[Ridryder911]

Here's one that's common.

On chest pain pts with PMHx of AMI, CABG, stents. Ask them if the pain they're feeling now was similar to the pain of the AMI, or the pain that prompted the CABG or Stents.

Also, if they've had recent stents (6 weeks or less (Rid correct me if I'm off)), that is an immediate LOAD & GO!. The stent is clotting off, and they will probably go directly to OR for CABG.

Very good points! As well as if they have a hx. of reocculsions, if the stent was coated or percentage of occlusion will give you an estimate that the Doc should had done a CABG instead of a stent, but chose a more conservative route, then again another question... why? Maybe too unstable for a CABG... & on and on. All building and painting a picture of your patient.

 

[EMTIA2-7747]

Opqrst

No book can teach you everything. experience and continuing education articles and seminars will continually reinforce your knowledge. Watching Techs with years of experience will be your best tool, but beware of those who have become complacent. As an instructor, I can tell you that the material to cover in the class room is huge, and cannot be covered in its entirety in the time allowed.