health history Flashcards
Sequence of the Interview:
- Greeting the Patient and Establishing Rapport
- Establish agenda/Inviting the Patients Story
-Open ended questions
-Use continuers
-No interrupting
-Get their perspective of the illness - Reestablish an Agenda
- Expanding and Clarifying a Patient’s Story
-OLDCART - Generating and Testing Diagnostic Hypotheses
-Use ROS for pertinent positive and negatives - Create a Shared Understanding of the Problem
-Learning pt perception of illness is critical to patient satisfaction
-Approaches they’ve tried
-Expectations
-Similar experiences to current CC
-Feelings and fears - Negotiate a Plan
- Planning and Follow Up and Closing
-Do not be abrupt
-Repeat the plan and when to follow up
whats in the history before the CC
History:
1. Date and Time of History:
2. Patient Name: D.S.
3. DOB: 03/08/1967
4. Age: 55
5. Gender: Male
6. Pronouns: He/Him/His
7. Ethnicity: White
8. Reliability of Information: Seems reliable
9. Source: Patient
10. Location: Clinic
Past Medical History components
Childhood Illnesses
Adult Illnesses
- Medical: diabetes, HTN, asthma, cancer etc. include time frame and hospitalizations
- Surgical: dates and type of operation
- Obstetric/gynecologic: Menstrual history, Contraception use, Sexual dysfunction
- Psychiatric: Hx of depression, anxiety, suicide etc. include time frame, hospitalization and tx
- Ask open ended questions: “Have you ever had any emotional problems?”
Health maintenance practices:
- immunizations
- screening tests
-lifestyle issues
- home safety
Health Maintenance:
Immunizations
Screening tests: pap smear, mammograms
Lifestyle Issues
Home safety
Family History:
- Get 3 generations, age at death and specific illness
- Outlines or diagrams age and health, or age and cause of death, of siblings, parents, and grandparents
- Documents presence or absence of specific illnesses in family, such as hypertension, diabetes, or type of cancer
Medication and Allergies
Medications:
- name
- dose
- route,
- frequency of use.
Allergies:
- Medications, food, environment, and latex
- Include specific reaction to differentiate drug reaction vs allergic vs side effect of medication
Social History:
- Includes any history of tobacco, alcohol, or recreational drug use
- Describes educational level, family of origin, current household, personal interests, and lifestyle
Sexual history:
- Important to determine risk for pregnancy, STDs and can prevent them
- Sexual dysfunction
- Do not assume anything!!!!
- Use anatomic terms
Pertinent Positive vs Pertinent Negatives:
Pertinent Positives
- Symptoms or signs that are present and support a particular diagnosis.
- are what you would expect to find if a suspected cause for the patient’s problem is true
- Ex: cardiovascular issue: episodes of palpitations
Pertinent Negatives
- Expected symptoms or signs that are absent, which WEAKENS the likelihood of certain diagnoses.
- They are what you would expect to find if a suspected cause were true, but are not present.
-Ex: Respiratory infection: NO cough with sputum production
How to Communicate with Patients:
Use understandable language
Use non stigmatizing language
The disabled vs people with disabilities
Empower the pt
“Do I” vs “Am I”: balance between listening and speaking to the pt
“Do I listen more than I talk” or Am i talking too much?
Create a supportive environment for pt to feel heard
Invite the pt to talk about his ideas for change
Be nonjudgmental
Alcohol Hx
CAGE Questions: 2+ = alcohol abuse/dependence
Cutting down
Annoyance when criticized
Guilty feelings about drinking
Eye openers
Have you ever had a drink in the morning to steady your nerves or get rid of a hangover?
Want to know patterns of alcohol consumption not average level of consumption
“Tell me about your use of alcohol”
Tobacco/Smoking Use:
Determine tobacco use, type (smoking vs chewing)
Cigarettes: reported in pack-years
-Multiply the number of packs of cigarettes smoked per day by the number of years the person has smoked
-Ex: Pt smokes 1.5 packs/day for 12 years = 18-pack-year Hx
-If they quit: report for how long
Sexual Hx The Five Ps+:
Partners
Practices
Protection from STIs
Past History of STIs
Pregnancy Plans
Plus: assess trauma, violence, sexual satisfaction, sexual health concerns
Sexual Hx How to approach:
Make no assumptions and validate their feelings
Use anatomical and specific language that is gender neutral
Ask the patient what terms they use for their own body parts and then use those terms throughout the visit
Transmasculine patients may use the term “front hole” or “bottom” to describe the vagina and “chest” rather than breasts
Family Violence:
MC: women, children, elderly
Clues to abuse
- Unexplained injuries with inconsistent story
Delay in getting tx for trauma
Repeated “accidents”
Close family member with alcohol and drug abuse
Partner tries to dominate the interview
Death and Dying: spikes
S- Setting up the Interview
P - Assessing the Patient’s Perception
I - Obtaining the Patient’s Invitation
K - Giving Knowledge and Information to the Patient
E - Addressing the Patient’s Emotions with Empathic Responses
S - Strategy and Summary
