best source of information regarding a patient

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mreid99

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What is the best source of information regarding a patient? I assume its the patient himself. is that the consensus here?
 
it is if they're OX3 & willing to tell you about themselves

~S~
 
It depends on the patient, their condition, and other sources available.

I first talk to the patient, have a partner talk to family-bystanders, and then collect any meds. It's amazing what a few pills can tell you about someone. Significant others are good, and I find adult children to be even better sometimes.

If I'm running an inter-facility transfer, the person teching the call will usually go through medical files/discharge information while the driver will do an in-person interview and get a baseline set of vitals.

To answer your question, yes, the patient is often the best source of information. :)
 
i, as a general rule, dont believe anything out of a pt's mouth. they lie. they forget. they dont know to begin with. thats not to say i dont talk to my pt and listen to what they ahve to say. i just dont take it too the bank. besides, anyone ever have a pt's story change the minute they cross the er threshold?????

if its an interfacility transfer, hit the chart. home to H, check the pills. either from memory or using a pdr, you can generate a fairly accurate history just from their meds.
 
I agree with the previous posters. Going thro their meds gives tons of information regarding their hx. Use any information given, but put together your own conclusion.
 
Like a detective, I will attempt to get as much from the patient, others and the surroundings, and m/o/i .

R/r911
 
Ditto on the meds. I can't count the times I've asked... Any previous hx and been told, "nope.... I'm pretty healthy"...then out comes the medication suitcase! Asking the Pt... 'what do you take this one for' usually fills in the hx gaps.

Also asking... "has anything like this ever happened before?" can sometimes jog their memories a bit.

Funniest incident with getting a pt hx though. Lovely little old lady with a beatific smile, after asking a few questions, found out that since her last stroke all she could say was 'yes' and 'no' and used them pretty much indiscriminately. So, rephrasing the question and asking it again is always good.
 
Ever heard the saying "all patients lie"? Well, I'm not completely condoning that statement, but there can be some pretty big discrepancies between the patient's version of the truth and what's really going on. If there are others on-scene who are not completely hysterical, ask them if they know any of the information. If you get info, cross-reference that with what the patient says. But also trust yourself and your perception. If you see pill bottles, but your patient insists they have no prior medical hx, then check the meds, see what's there. Another sign, though albeit a bad one, is when the pt. has a bag filled with meds. Sure sign that there's a lot more going on than what you might learn from the pt. Also, use your senses. We had a pt. who said that she couldn't feel her arm. We quickly discovered the source of the disability, not with sight or touch, but with smell. Her left brest and side were completely necrotic; the necrosis ravaged her arm, rendering the musculature useless.

Basically, be your own best judge.
 
Sometimes getting the story is like playing EMS:CSI with the patient, family, and surroundings. I will sometimes just take a mental step back and really *look* at the scene. One question will generate another, and pretty soon the fog will usually begin to lift.
 
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