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Advanced Health Assessment Exam 1 > Adult Health History > Flashcards

Adult Health History Flashcards

1
Q

What are the 7 different components of a comprehensive health history?

A
  1. Identify data and source of the history; reliability
  2. Chief complaint
  3. History of Present illness
  4. Past History
  5. Family History
  6. Personal and social history
  7. Review of sysems
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2
Q

When taking a health history, what should you ask when trying to identify data and the source of the history?

A
  • Identifying data: Age, gender, occupation, marital status
  • Source of the history: Usually the patient, but can be a family member or friend, letter of referral, or the clinical record
    • If appropriate, establish the source of referral, b/c a written report may be needed.
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3
Q

When taking a health history, what is meant by the “reliability”?

A
  • This section of the health history assesses the quality of the information provided by the pt. and is usually made at the end of the interview.
  • Can vary according to the patient’s memory, trust, and mood
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4
Q

When taking a health history what should be asked during the “chief complaint(s)” section of the interview?

A

In this section you should ask the patient the one or more symptoms or concerns causing the patient to seek care

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5
Q

When taking a health history what should be asked during the “History of present illness” section of the interview?

A
  • This section amplifies the chief complaint and you will ask the patient how each symptom developed
  • Include the patient’s thoughts and feelings
  • May include medications, allergies, and tobacco use and alcohol, which are frequently pertinent to the present illness
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6
Q

When taking a health history what should be asked during the “past history” section of the interview?

A
  • Ask about any childhood illnesses
  • Ask about any adult illnesses for medical, surgical, OB, and psych issues
  • Ask about any previous immunizations, screening tests, lifestyle issues, and home safety
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7
Q

When taking a health history what should be asked during the “family history” section of the interview?

A
  • Ask about family members age and health
  • Age and cause of death for siblings, parents, and grandparents
  • Ask about specific illnesses in the family such as: hypertension, diabetes, or cancer
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8
Q

When taking a health history what should be asked during the “personal and social history” section of the interview?

A

Ask the patient to describe their level of education, family origin, household composition/size, personal interests, and lifestyle choices, and ADLs (exercise etc)

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9
Q

When taking a health history what should be asked during the “Review of systems” section of the interview?

A
  • Ask if the patient has had any general symptoms: unusual weight changes, weakness, fatigue, fever
  • Skin symptoms: rashes, lumps, sores, itching, dryness,
  • HEENT: Headaches, dizziness, lightheadedness, vision changes, hearing changes, nasal discharge, sinus issues, date of last dental exam
  • Neck: Swollen glands, lumps, pain in the neck
  • Breasts: Lumps, pain, discomfort, discharge, self-exam practices
  • Resp: Coughing, sputum, SOB, wheezing, pain w/ breathing, last CXR
  • Cardio: High BP, murmurs, chest pain, SOB, swelling in hands, ankles, or feet
  • GI: trouble swallowing, heartburn, N/v/D, changes in stools, constipation, abd pain
  • Peripheral Vascular: Leg pain/cramps, varicose veins, swelling, changes in temperature
  • GU: Frequent urination, nocturia, urgency, burning, blood, kidney pain, hesitancy
  • MUSK: Joint pain, stiffness, gout, backaches, etc
  • Psych: Mood changes, depression, memory changes
  • Neuro: Attention changes, speech changes, orientation changes, memory changes, judgment changes, vertigo
  • Hemat: Easy bruising, bleeding,
  • Endo: Heat or cold intolerance, excessive sweating, excessive thirst or hunger
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10
Q

When should you conduct a comprehensive assessment?

A
  • New patients
  • To strengthen the clinician-patient relationship
  • Helps to identify/rule out physical causes related to patient concerns
  • To establish a baseline for future assessment
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11
Q

When should you conduct a focused assessment?

A
  • This assessment is for established patients (during routine or urgent care visits
  • To address focused concerns or symptoms
  • To assess symptoms restricted to a specific body system

This exam is focused on assessing the concern or problems and thoroughly and carefully as possible

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12
Q

What does the mnemonic OLD CARTS stand for?

A
  • O - Onset
  • L - Location
  • D - Duration
  • C - Character
  • A - Aggravating/alleviating factors
  • R - Radiation
  • T - Timing
  • S - Severity
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13
Q

What does the mnemonic OPQRST stand for?

A
  • O - Onset
  • P - Palliating/provoking factors
  • Q - Quality
  • R - Radiation
  • S - Site
  • T - Timing
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14
Q

What are the 7 attributes of a patient symptom?

A
  1. Location - Where is it? Does it radiate?
  2. Quality - What is it like?
  3. Quantity or severity - How bad is it? (For pain, ask for a rating on a scale of 1 to 10.)
  4. Timing - When did (does) it start? How long does it last? How often does it come?
  5. Onset (setting in which symptom occurs) - Include environmental factors, personal activities, emotional reactions, or other circumstances that may have contributed to the illness.
  6. Remitting or exacerbating factors - Is there anything that makes it better or worse?
  7. Associated manifestations - Have you noticed anything else that
    accompanies it?
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15
Q

What are the 10 skilled interviewing techniques?

A
  1. Active listening
  2. Empathetic responses
  3. Guided questioning
  4. Nonverbal communication
  5. Validation
  6. Reassurance
  7. Partnering
  8. Summarization
  9. Transitions
  10. Empowering the pt.
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16
Q

Describe the active listening skilled interviewing technique

A
  • Lies at the heart of the pt. interview
  • Closely attend to what the pt. is communicating, connecting to the pt’s emotional state, and using verbal and nonverbal skills to encourage the pt. to expand on his or her feelings and concerns.
  • Focus on what the pt. is telling you verbally and nonverbally
17
Q

Describe the empathic responses skilled interviewing technique

A
  • The capacity to identify with the pt. and feel the pts pain as your own, then respond in a supportive manner
  • Ask the pt. to expand or clarify a point than assume you understand “what has that been like for you?”
  • Can be nonverbal, such as with touch.
18
Q

Describe the guided questioning skilled interviewing technique

A
  • Moving from open-ended to focused questions
    • Move from general to specific
    • “What brings you in today” → “Can you tell me what happened about ____”
  • Using questioning that elicits a graded response
    • “How many steps can you climb before you get SOB?”
  • Asking a series of questions, one at a time
    • “Do you have any of the following problems?”
  • Offering multiple choices for answers
    • “Which of following best describes your pain: aching, sharp, pressing, burning, shooting, or something else?”
  • Clarifying what the pt. means
    • “You said _______. What did you mean?”
  • Encouraging with continuers
    • “Mm-hmm”, “Go-on”
    • Lean forward / make eye contact
  • Using echoing
    • Repeat the patient’s last words
19
Q

Describe the nonverbal communication skilled interviewing technique

A

Pay close attention to eye contact, facial expression, posture, head position and movements such as shaking or nodding, interpersonal distance, and placement of the arms & legs.

20
Q

Describe the validation skilled interviewing technique

A
  • Affirm the patient by validating the legitimacy of their emotional experience
    • “_________ must have been hard for you”
    • “Perhaps that explains why ___________”.
21
Q

Describe the reassurance skilled interviewing technique

A
  • The first step to effective reassurance is simply identifying and acknowledging the patient’s feelings
    • “You seem upset today”
  • Reassurance is more appropriate when the patient feels that problems have been fully understood and are being addressed
22
Q

Describe the partnering skilled interviewing technique

A
  • When building rapport with patients, express your commitment to an ongoing relationship
  • Make pt. feel that no matter what happens, you will continue to provide their care
23
Q

Describe the summarization skilled interviewing technique

A
  • Give the patient a summary of their story to identify what you know and don’t know
  • Allows pt to add any further information and clear up any misunderstandings.
  • Allows you to organize your clinical reasoning and convey thinking to the patient
24
Q

Describe the transitions skilled interviewing technique

A
  • Use them to move from one part of the health history from another
  • “Now i’d like to ask some questions about your past health”
  • “Before we move on to _______, was there anything else about _______?”
    *
25
Q

How do you empower a patient during a health interview?

A
  • Ask the patient’s perspective
  • Convery interest in the person, not just the problem
  • Follow the pt’s leads
  • Elicit and validate emotional content
  • Make your clinical reasoning transparent to the pt.
  • Reveal the limits of your knowledge
26
Q

What is motivational interviewing?

A

Techniques used when interviewing pts that focuses on a collaborative, patient-centered form of guiding to elicit and strengthen motivation for a change.

27
Q

How does motivational interviewing work?

A

It is designed to strengthen an individuals motivation for and movement toward a specific goal by eliciting and exploring the person’s own arguments for change.

28
Q

How do you conduct motivational interviewing?

A
  1. “Ask” open-ended questions. Invite the pt. to consider how and why they might change
  2. “Listen” to understand your pts experience. Capture their account with brief summaries or reflective listening statements such as, “quitting smoking feels beyond you atm”; these express empathy, encourage the pt to elaborate, and are often the best way to respond to resistance.
  3. “inform” by asking permission to provide information, and then asking what the implications might be for the pt.
29
Q

What are the elements of decision-making capacity?

A
  • Understand the relevant info about proposed diagnostic tests or treatment
  • Appreciate their situation (including their underlying values and current clinical situation)
  • Use reason to make a decision and communicate their choice
30
Q

What are some guidelines for approaching sensitive topics?

A
  • Be nonjudgmental. Your role is to learn from the patient and help the patient achieve better health. Acceptance is the best way to reach this goal.
  • Explain why you need to know certain information. This makes patients less apprehensive. For example, say to patients, “Because sexual practices put people at risk for certain diseases, I ask all of my patients the following questions.”
  • Find opening questions for sensitive topics and learn the specific kinds of information needed for your shared assessment and plan.
  • Consciously acknowledge whatever discomfort you are feeling. Denying your discomfort may lead you to avoid the topic altogether.
31
Q

How do you ask a patient’s about their sexual history?

A
  • Include it in the review of systems
  • Be specific when referring to genitalia: penis/vagina
  • “when was the last time you had intimate physical contact with someone?”
  • Don’t use the term sexually active
  • Ask about # of sexual partners
32
Q

What are some tips when asking a patient about their mental health?

A
  • Ask open-ended questions, “Have you ever had any problem with emotional or mental illnesses?” then move to specific questions
  • Screen for depression with the questions:
    • Over the past 2 weeks, have you felt down, depressed, or hopeless?”
    • “Over the past 2 weeks, have you felt little interest or pleasure in doing things?
33
Q

What does CAGE stand for?

A
  • Cutting down
  • Annoyance when criticized
  • Guilty feelings
  • Eye openers

Two or more affirmative answers to the CAGE questionnaire suggest alcohol misuse.

34
Q

What are some clues to physical and sexual abuse?

A
  • Unexplained injuries that are inconsistent with the patient’s story, are concealed by the pt/cause embarrassment
  • Pt. delay’s in getting treatment for trauma
  • Has a history of repeated injuries or accidents
  • Presence of alcohol or drug abuse in pt/partner
  • Partner tries to dominate the visit, will not leave the room, seems unusually anxious or solicitous
  • Pregnancy at a young age; multiple partners
  • Repeated vaginal infections/ STIs
  • Difficulty walking/sitting due to genital/anal pain
  • Vaginal lacerations/bruises
  • Fear of pelvic examination/physical contact
  • Fear of leaving the exam room
35
Q

What are some questions that can be used to determine a patient’s explanatory model/beliefs relevant to their complaint/condition?

A
  1. What do you call your problem? Does it have a name?
  2. What do you think has caused your problem?
  3. Why do you think it started when it did?
  4. What does your sickness do to you? How does it work?
  5. How severe is it? Will it have a short or a long course?
  6. What do you fear most about your sickness?
  7. What are the chief problems your sickness has caused for you?
  8. What kinds of treatments do you think you should receive? What are the most important results you hope to receive from the treatments?
36
Q

What is a mnemonic to understand the patient’s perspective on their illness?

A

Their:

  • F - Feelings about the problems
  • I - Ideas about the nature/cause of the problem
  • F - How it affects their life and function
  • E - Expectations of the disease/clinician/healthcare
37
Q

What are the 3 dimensions of cultural humility?

A
  1. Self-awareness. Learn about your own biases; we all have them.
  2. Respectful communication. Work to eliminate assumptions about what is “normal.” Learn directly from your patients; they are the experts on their culture and illness.
  3. Collaborative partnerships. Build your patient relationships on respect and mutually acceptable plans.

Advanced Health Assessment Exam 1 (5 decks)

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