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The importance of history taking

Paramedics discuss the importance of history taking.
Ok, Marie and Charlotte, just to put your mind at rest, so far I haven’t found anything that’s of any concern at the moment. We’re going to ask you a few more questions, go through some things and then decide what best course of action we need to take, once we get to that point. Is that ok? So for the last week or so, you said she has not been unwell at all. No, no she’s been fine. Ok, has she been complaining of any stomach ache at all? No. Has she been eating ok? Eating, drinking, yeah. Ok, that’s what she would have told you but… Everything ok, darling? Have you been to the toilet, ok?
No burning sensation at the loo at all? No? Have you noticed her have any sort of little coughs? Actually, now I think about it… she was sort of coughing a bit this morning at breakfast, and I noticed too that she sort of was working at her ear. Ok, what sort of cough, was it like a dry, tickly cough, you noticed or she cough any phlegm up? No, there was a bit of, start of, maybe something coming on her. Have you noticed any rashes appear anywhere at all? Nothing. Has she been itching anywhere? Nothing. Any problems with her skin at all? No. Ok, so her diets been absolutely fine? Yes.
Eating and drinking as usual. OK so far, you just got tickling in the ear. Yes, and a bit of a cough. Charlotte, which ear hurts you, my sweet? I think it’s that one. You think it’s that’s one? How does it feel? Does it feel really hot? No. No, can you still hear out of it ok? Yes. There’s no muffled sounds or anything from there? No.
Have you got a sore throat at all? Is your throat ok? Can you drink ok? Yes. Yes. No pain when you swallow? No.
Now that we have a detailed history, ask yourself:
  • Are there any red flag signs within the history?
  • What sort of red flags would I look out for?
  • What’s my differential diagnosis at this point?
  • What examinations am I going to conduct at this point?

Have a think about these questions and discuss below.

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Emergency and Urgent Care for Children: a Survival Guide

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