History and Interviewing Flashcards
What are the goals of history an interviewing?
Lead pt to maximum wellness Discover info leading to diagnosis and management Provide information about diagnosis Share info with health care management Education and prevention
Privileged Communication
Protects physicians, APNs or dentists from disclosing information against a patient on trial
Pitfalls in taking Hx
not appreciating cultural differences judgmental making medical model the only paradigm bias and lack of personal awareness medical jargon failing to check for pt understanding
Patient Level Barriers
Lack of Assertiveness
Trust
Fund of Knowledge - Lack of understanding about dx
Provider Level Barriers
Lack of Cultural Competence
Stereotyping
Intersection of Patient and Provider Barriers
Ethical Context Respect and Flexibility
Autonomy Beneficence Utilitarinaism Nonmaleficience Fairness of Justice Deontological
Factors that Enhance Communication
Courtesy Comfort Connection Confirmation Confidentiality Patient Centered
Leading Questions
“Have you been taking your meds?”
Techniques to Enhance Communication
Facilitate - encourage to say more Reflect - Repeat back Clarify Empathize Confront - Address disturbing behavior Interpret - Repeat back
Communication Tensions
Curiosity about you Anxiety Silence Depression Crying Physical intimacy Seduction Anger Avoidance of full story Financial Considerations - Can they afford meds
Structure of Hx
Identifiers: name, date, time, age, gender, race, occupation, and referral source Chief Complaint History of present illness (HPI) Past medical history (PMH) Family history Personal and social history (SH) Review of Systems(ROS)
Building the History
Avoid medical jargon
Take notes sparingly
Avoid leading questions
Start with general concerns, then move to specific descriptions
Clarify responses (where, when, what, how, and why)
Verify and summarize
Goal of screening
Find out if a problem exists
CAGE Questionnaire
Cutting down
Annoyance by criticism
Guilty Feeling
Eye-opener
TACE Questionnaire
how many drinks does it TAKE to feel high?
ANNOYANCE by criticism
have you felt you ought to CUT down on drinking
do you take EYE-OPENER drinks in morning for hangovers
CRAFFT Questionnnaire
More so for adolescents
have you driven or ridden a CAR driven by someone under the influence?
do you ever take drugs to RELAX, feel better or fit in?
do you ever take drugs when you’re ALONE?
do you FORGET the things you did when using drugs?
do you have a FAMILY member or FRIEND tell you to cut down?
have you ever gotten into TROUBLE from using?
Three questions to detect partner violence
Have you been hit, kicked, punched or otherwise hurt by someone in the past year?
Do you feel safe in your current relationship?
Is there a partner from a previous relationship who is making you feel unsafe now?
HITS questionnaire
Hurt you physically?
Insult or talk down to you?
Threaten you with physical harm?
Scream or curse at you?
FICA Questionnaire
Faith - spiritual heritage? writings important to you?
Importance - beliefs influence how you handle stress?
Community - belong to a spiritual community?
Address - do religious beliefs affect health decisions?
Gender neutral questions
Tell me about your living situation
Are you sexually active? In what way?
Different types of health history
Brief
Complete Inventory
Interim (see pt 6mo.-1yr)
PE (physical examination)
OLD CARTS for HPI
Onset Location Duration Character - Stabbing or dull? Aggravating/associated factors Relieving factors Temporal factors - continuous in the morning? Severity
Chief Complaint
Note all significant complaints
What symptoms brought you here?
How long has problem been present?
Note age, gender, marital status, occupation and previous hospital admissions
HPI
Chronology of events Health state before present problem First symptoms Exposure to infection or toxic agents Typical attack Illness impact on lifestyle Stability of problem Immediate reason for visit Review of involved systems Medications list Complementary or alternative therapies Chronology review Problem list
PMH
General health Childhood illnesses Major adult illnesses Hospitalizations Serious injuries Accidents Disability Immunizations Past medication Blood transfusions Allergies Recent Screening Tests Emotional Health
Social History
Socioeconomic status Access to care Occupation Living conditions Drugs Smoking Intimate Partner Violence Spiritual Sexual hx Military hx Living or traveling abroad Home Conditions Safety - guns, seat belts or helmets
Obstetric Hx
GTPAL - gravida, term, preterm, abortions, living
Menstrual hx
age of menarche, frequency, duration, amount of flow, pain or other problems, LMP (last menstrual period) , LNMP (last normal menstrual period)
Family Hx
Blood relatives with similar illness
Blood relatives with hx of major disease
Determine if any cancers have been multiple, bilateral, occuring more than once and occuring at a young age (less than 50 y/o)
Note age and outcome of illnesses
Ethnic and racial background
Note the age and health of spouse or patients parents
ROS
General constitutional symptoms, Skin, hair and nails Head and neck Lymph nodes Chest and lungs Breasts Heart and blood vessels Peripheral vascular Hematologic GI Diet Endocrine Genitourinary Musculoskeletal Neurological Psychiatric Concluding questions
General Constitutional Symptoms
Fever, chills, malaise, fatigability, night sweats, sleep patterns,
Weight - average, preferred, present, change
Skin, hair and nails
rash, eruption, itching
pigmentation
excessive sweating
abnormal nail or hair growth
Head and Neck: General
Headaches, dizziness, syncope, head injuries, Loss of Conciousness
Head and Neck: Eyes
Acuity, blurring, diplopia, photophobia, pain, vision changes, glaucoma, trauma
Head and Neck: Ears
Hearing loss, pain, discharge, tinnitus, vertigo
Head and Neck: Nose
Sense of smell, colds, obstruction, epistaxis, postnasal discharge, sinus pain
Head and Neck: Throat and Mouth
Hoarseness or change in voice, sore throats, bleeding gum, tooth abscesses, extractions, soreness or ulcers of tongue/mucosa, taste changes
Lymph Nodes
Enlargement, tenderness, suppuration (pus forming)
Chest and Lunga
Pain, dyspnea, cyanosis, wheezing, cough, sputum, hemoptysis, night sweats, exposure to TB, last chest radiograph
Breasts
Development, pain, tenderness, discharge, lumps, galactorrhea, mammograms (screening and diagnostic), self-awareness, self-examination
Heart and Blood Vessels
Chest pain, palpitations, dyspnea, orthopnea, edema, claudication, hypertension, previous MI, exercise tolerance, date of last ECG, other cardiac tests
Peripheral Vascular
Claudication - frequency, severity
Tendency to bruise or bleed
Thromboses
Thrombophlebitis
Hematologic
Anemia, blood cell abnormalities, past transfusions
GI
Appetite, digestion, food intolerance, dysphagia, heartburn, N/V/D, hematemesis, regularity of bowels, constipation, change in stools, 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, polyuria, changes in facial or body hair, increased hat or glove size, skin striae
Endocrine: Female
Menses, discharge, itching, lasp pap smear, libido, intercourse, birth control, infertility, pregnancy, menopause
Endocrine: Male
Puberty onset, erections, emissions, testicular pain, libido, infertility
Genitourinary
STIs, dysuria, pain, urgency, frequency, nocturia, hematuria, polyuria, hesitancy, dribbling, loss in force of stream, passage of stone, edema of face, stress incontinence, hernias
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, nervousness, tension, SI, irritability, sleep disturbances
Concluding Questions
Is there anything else you think would be important for me to know?
What problem concerns you most?
Considerations for Children
Mother’s gestational history, pregnancy, and birth
Child’s neonatal period, feeding, and development
Child’s school adjustment, habits and home life
Review systems for child-specific conditions
HEEADSSS
For adolescents Home environment Education Eating Activities, affect, ambitious, anger Drugs Sexuality Suicide/depression Safety
PACES
For adolescents Parents, peers Accidents (alcohol/drugs) Cigarettes Emotional issues School, sexuality
Considerations for Pregnant Women
Current pregnancy and obstetric hx
exposure to environmental/occupational hazards
family genetic conditions/congenital
personal and social issues of pregnancy and parenting
Reproductive, CV, endocrine, resp. focus
Risk factors that threaten mother and fetus
Older Adults
Watch age-related changes like sensory loss, visual impairment, cognitive impairment, or memory loss
Draw on persons cumulative lifetime experience
Health history of older adults
Multiple overlapping health problems
Chronic symptoms
Complete drug assessment
Assessment of functional capacity
