Chapter 1: The Interviewing Process Flashcards
The History and Interviewing Process
“Build” a history rather than “take” one because you and your patient are involved in a joint effort.
Context of that relationship expressed in emotional, physical, and ethical terms.
Approaches to the structure of a history with adaptations suggested for age, children, adolescents, gender, pregnant patients, older adults, and patients with disabilities.
The history is vital to the appropriate interpretation of the physical examination.
Developing a Relationship and Effective Communication With the Patient
To prevent misinterpretations/misperceptions, you must make every effort to sense the world of the patient as the patient sees it.
Establishing a positive patient relationship depends on communication built on:
Courtesy
Comfort
Connection
Confirmation
Confidentiality
Enhancing Patient Responses
Open-ended question
Allows patient discretion about the extent of an answer
Direct question
Seeks specific information
Leading question
May limit the information provided to what the patient thinks you want to know
If the patient does not understand what you are asking, remember to:
Facilitate: Encourage your patient to say more.
Reflect: Repeat what you have heard.
Clarify: Ask “What do you mean?”
Empathize: Show understanding and acceptance.
Confront: Address disturbing patient behavior.
Interpret: Repeat what you have heard to confirm the patient’s meaning.
Potential Barriers to Communication
Curiosity about you
Anxiety
Silence
Depression
Crying/compassionate moments
Physical intimacy
Emotional intimacy
Seduction
Anger
Avoidance
Financial considerations
Patient History and Setting for the Interview
The history is built on the patient’s perspective, not yours.
The setting requires:
Comfort for all involved
Removal of physical barriers
Unobtrusive access to clock
Maintaining eye contact
Using a conversational tone
Building the History
Introduce yourself.
Address patient properly.
Make eye contact.
Proceed at a reasonable pace.
Listen.
Do not interrupt.
Clarify responses with where, when, what, how, and why questions.
Review with the patient what you have heard.
Approaching Sensitive Issues
Provide privacy.
Do not waffle.
Do not apologize for asking questions.
Do not preach.
Do not use medical jargon.
Do not push too hard.
sensitive issues
Alcohol and drug use
Screen to find out if a problem exists: CAGE, CRAFT, TACE.
Intimate partner violence (IPV)
When IPV is detected, child abuse should be considered.
HITS
Spirituality
FICA
Sexuality and gender identity
Use “gender-neutral” language.
Structure and Outline of the History
The identifiers: name, date, time, age, gender identity, race, source of information, and referral source
Chief concern (CC)
History of present illness/problem (HPI)
Past medical history (PMH)
Family history (FH)
Personal and social history (PSH)
Review of systems (ROS)
General Constitutional Symptoms
Pain
Fever
Chills
Malaise
Fatigue
Night sweats
Sleep patterns
Weight
Average
Preferred
Present
Change
Skin, Hair, and Nails
Rash, eruption, itching
Pigmentation or texture change
Excessive sweating
Abnormal nail or hair growth
Head and Neck: General
Headaches
Dizziness
Syncope
Head injuries
Concussions
Loss of consciousness
Head and Neck: Eyes
Acuity
Blurring
Diplopia
Photophobia
Pain
Vision changes
Glaucoma
Eye medications
Trauma
Head and Neck: Ears and Nose
Ears:
Hearing loss
Pain
Discharge
Tinnitus
Vertigo
Infections
nose:
Sense of smell
Frequency of colds
Obstruction
Epistaxis
Postnasal discharge
Sinus pain
Head and Neck: Throat and Mouth
Hoarseness or change in voice
Frequent sore throats
Bleeding or swelling of gums
Tooth abscesses, extractions
Soreness or ulcers of tongue/mucosa
Taste changes
Dental care
Lymph Nodes
Enlargement
Tenderness
Suppuration
Chest and Lungs
Pain
Dyspnea
Cyanosis
Wheezing
Cough
Sputum
Hemoptysis
Night sweats
Exposure to tuberculosis
Last chest radiograph
Breasts
Development
Pain
Tenderness
Discharge
Lumps
Galactorrhea
Mammogram -Screening, Diagnostic
Self-awareness
Self-examination
heart and BV
Chest pain
Palpitations
Dyspnea
Orthopnea
Edema
Hypertension
Previous myocardial infarction
Exercise tolerance
Date of last electrocardiogram
Other cardiac tests
Peripheral Vascular and Hematologic
Peripheral vascular:
Claudication -Frequency, Severity
Tendency to bruise or bleed
Thromboses
Thrombophlebitis
Hematologic:
Anemia
Bruising
Blood cell abnormalities
Gastrointestinal
Appetite
Digestion
Food intolerances
Dysphagia
Heartburn
Nausea/vomiting
Hematemesis
History of ulcer/polyps/tumor/
Gallstones
Regularity of bowels
Constipation
Diarrhea
Change in stools
Flatulence/hemorrhoids
Jaundice
Previous imaging studies
Diet
Appetite
Likes and dislikes
Diet restrictions, cultural constraints
Vitamins and other supplements
Caffeine
Dietary recall
Endocrine: General
Thyroid enlargement or tenderness
Heat/cold intolerance
Weight change
Diabetes
Polydipsia
Thyroid enlargement or tenderness
Heat/cold intolerance
Weight change
Diabetes
Polydipsia
Endocrine: Female and Male
Female:
Menses
Discharge, itching
Last Pap smear
Libido, intercourse
Birth control
Infertility, pregnancy
Menopause
Male:
Puberty onset
Erections
Emissions
Testicular pain
Libido
Infertility
Genitourinary
Sexually transmitted infections
Dysuria
Pain
Urgency
Frequency
Nocturia
Hematuria
Discolored urine
Polyuria
Hesitancy
Dribbling
Loss in force of stream
Passage of stone
Edema of face
Stress incontinence
Hernias
Musculoskeletal and Neurologic
Musculoskeletal:
Joint stiffness, pain
Restriction of motion
Swelling, redness, heat
Bony deformity
Neurologic:
Syncope
Seizures
Weakness or paralysis
Abnormalities of sensation or coordination
Tremors
Loss of memory
Psychiatric
Depression
Mood changes
Difficulty concentrating
Anxiety
Agitation
Tension
Suicidal thoughts
Irritability
Sleep disturbances
Special Populations
Every special populations patient requires a ROS that is appropriate for the individual.
Children
Use appropriate language.
Play with child.
Child’s neonatal period, feeding, developmental milestones
School adjustment, habits, home conditions
Adolescents
Provide confidentiality.
Assess home, school, work, activities, and friends.
HEEADSSS
PACES
CRAFFT
Pregnant/postpartum women
Obstetric/menstrual/gynecologic history
Risk assessment
Sexual minorities
Demonstrate respect.
Use gender-neutral language.
Older/frail adults
Cognitive/sensory/motor changes
Risk assessment
Physically/cognitively/emotionally disabled
Adapt to patient’s needs.
Involve patient and family.
Concluding History Questions
Is there anything else that you think would be important for me to know?
What problem concerns you most?
What do you think is the matter with you?
What worries you the most about how you are feeling?
Types of Histories
Complete history
Most often recorded the first time you see the patient
Inventory history
Touches on major points without complete detail
Problem (or focused) history
For acute problems
Interim history
Chronicles events since last visit
Current medications/allergies should be assessed regardless of history type.
A health history that is designed to chronicle events that have occurred since the patient’s last visit is called a(n):
Interim history
Problem history
Inventory history
Complete history
ANS: A
Rationale: A history that is gathered since the patient’s last visit is called an interim history as it only examines what has happened since the patient’s last visit.
Which tools are beneficial to use when screening adolescents?
PACES
KATZ
CRAFFT
HEEADSSS
ANS: A, C, D
Rationale: These tool assess issues that are important during the adolescent period, such as substance use, school and home issues, relationships with friends, etc.
Which communication technique should the nurse use to confirm the patient’s meaning?
Facilitate
Reflect
Empathize
Interpret
ANS: B
Rationale: Reflection allows the nurse to process what the patient has said and then repeat it back to the patient to ensure the patient’s meaning was correctly interpreted.
