Chapter 1: The Interviewing Process Flashcards

1
Q

The History and Interviewing Process

A

“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.

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2
Q

Developing a Relationship and Effective Communication With the Patient

A

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

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3
Q

Enhancing Patient Responses

A

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

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4
Q

If the patient does not understand what you are asking, remember to:

A

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.

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5
Q

Potential Barriers to Communication

A

Curiosity about you
Anxiety
Silence
Depression
Crying/compassionate moments
Physical intimacy
Emotional intimacy
Seduction
Anger
Avoidance
Financial considerations

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6
Q

Patient History and Setting for the Interview

A

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

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7
Q

Building the History

A

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.

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8
Q

Approaching Sensitive Issues

A

Provide privacy.
Do not waffle.
Do not apologize for asking questions.
Do not preach.
Do not use medical jargon.
Do not push too hard.

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9
Q

sensitive issues

A

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.

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10
Q

Structure and Outline of the History

A

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)

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11
Q

General Constitutional Symptoms

A

Pain
Fever
Chills
Malaise
Fatigue
Night sweats
Sleep patterns

Weight
Average
Preferred
Present
Change

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12
Q

Skin, Hair, and Nails

A

Rash, eruption, itching
Pigmentation or texture change
Excessive sweating
Abnormal nail or hair growth

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13
Q

Head and Neck: General

A

Headaches
Dizziness
Syncope
Head injuries
Concussions
Loss of consciousness

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14
Q

Head and Neck: Eyes

A

Acuity
Blurring
Diplopia
Photophobia
Pain
Vision changes
Glaucoma
Eye medications
Trauma

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15
Q

Head and Neck: Ears and Nose

A

Ears:
Hearing loss
Pain
Discharge
Tinnitus
Vertigo
Infections

nose:
Sense of smell
Frequency of colds
Obstruction
Epistaxis
Postnasal discharge
Sinus pain

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16
Q

Head and Neck: Throat and Mouth

A

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

17
Q

Lymph Nodes

A

Enlargement
Tenderness
Suppuration

18
Q

Chest and Lungs

A

Pain
Dyspnea
Cyanosis
Wheezing
Cough
Sputum
Hemoptysis
Night sweats
Exposure to tuberculosis
Last chest radiograph

19
Q

Breasts

A

Development
Pain
Tenderness
Discharge
Lumps
Galactorrhea
Mammogram -Screening, Diagnostic
Self-awareness
Self-examination

20
Q

heart and BV

A

Chest pain
Palpitations
Dyspnea
Orthopnea
Edema
Hypertension
Previous myocardial infarction
Exercise tolerance
Date of last electrocardiogram
Other cardiac tests

21
Q

Peripheral Vascular and Hematologic

A

Peripheral vascular:
Claudication -Frequency, Severity
Tendency to bruise or bleed
Thromboses
Thrombophlebitis

Hematologic:
Anemia
Bruising
Blood cell abnormalities

22
Q

Gastrointestinal

A

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

23
Q

Diet

A

Appetite
Likes and dislikes
Diet restrictions, cultural constraints
Vitamins and other supplements
Caffeine
Dietary recall

24
Q

Endocrine: General

A

Thyroid enlargement or tenderness
Heat/cold intolerance
Weight change
Diabetes
Polydipsia
Thyroid enlargement or tenderness
Heat/cold intolerance
Weight change
Diabetes
Polydipsia

25
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
26
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
27
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
28
Psychiatric
Depression Mood changes Difficulty concentrating Anxiety Agitation Tension Suicidal thoughts Irritability Sleep disturbances
29
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.
30
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?
31
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.
32
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.
33
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.
34
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.