History Taking

Question 1

Chief complaint

Answer 1

Primary medical problem as defined by the patient.
- Focuses the clinical history towards the single most important issue

Question 2

Chronology

Answer 2

Time element of the history, usually included the onset, duration, frequency and course of the symptoms

Question 3

Clinical history

Answer 3

Information available regarding a patient’s condition

Question 4

What is a clinical history comprised of?

Answer 4

Localization, Quality, Quantity, Chronology, Setting, Aggravating or Alleviating factors, and associated manifestations

Question 5

Leading questions

Answer 5

Undesirable method of questioning; provides information that may direct answers toward a suggested symptom

Question 6

Localization

Answer 6

The exact area of the complaint

Question 7

Objective

Answer 7

Perceptible to the external senses

Question 8

Quality

Answer 8

Description of the character of symptoms; color, quantity and consistency of blood or size or number of lumps/lesions

Question 9

Subjective

Answer 9

Pertaining to or perceived only by the affected individual and not perceptible to the senses

Question 10

What are the 3 main roles of the radiographer?

Answer 10

• Obtain a clinical history to assist the radiologist in diagnosing
• To record information on the requisition
• Check all information on the requisition for accuracy

Question 11

What is the x-ray requisition?

Answer 11

The formal order for a diagnostic procedure and is a medical legal document

Question 12

What information is included on a X-ray requisition?

Answer 12

• Patient Name
• Sex of patient
• Diagnosis (Dx) and pertinent clinical history (Hx)
• Date of exam and date when arrived
• Date of Birth (DOB)
• Signature of the requesting physician
• Pregnancy status and LMP (last menstrual period)
• Medical record number and insurance information

Question 13

How to greet a patient?

Answer 13

• First introduce yourself and explain you’re the radiographer
• Ask the patient their name and check wristband for inpatient
• Always address patient by their last name, Mr or Mrs

Question 14

What are the important features of interviewing a patient?

Answer 14

• Speaking slowly and clearly
• Listening to the patient
• Maintaining eye contact
• Using language the patient can understand
• Only asking one question at a time

Question 15

What are patient interview Do’s?

Answer 15

• Ask open-ended, non-leading questions - to let the patient tell their story
• Facilitation (nodding, saying yes or no) - to encourage elaboration
• Silence (giving patient time to remember) - facilitates accuracy and elaboration
• Probing questions (to focus the interview)
• Repetition (rewording) clarifies information
• Summarization (condensing) verifies accuracy

Question 16

What are patient interviews Don’ts?

Answer 16

• Do not ask personal questions

Question 17

What are features of Objective Data?

Answer 17

• Perceptible to the senses
• Signs that can be seen, heard, felt
• Able to be measured
• Often physiologic

Question 18

What are features of subjective data?

Answer 18

• Patient feeling
• Pain level
• Attitude
• Opinion of the observer
• Subject to interpretation

Question 19

What are elements of a clinical history?

Answer 19

• Chief complaint

Question 20

What are the sacred seven?

Answer 20

• Localization
• Chronology
• Quality
• Severity
• Onset
• Aggravating or alleviating factors
• Associated manifestations

Question 21

Severity

Answer 21

The intensity and quantity of the symptom

Question 22

Onset

Answer 22

When the symptoms began

Question 23

Aggravating or alleviating factors

Answer 23

What makes the symptoms worse or better

Question 24

Associated manifestations

Answer 24

Any other symptoms that accompany the chief complaint

Question 25

What is informed consent?

Answer 25

Also called valid consent, and is a full explanation of the procedure including risks and benefits

Question 26

What are the conditions for informed consent?

Answer 26

- patient must be mentally competent and of legal aged to make an informed consent - consent must be voluntary - consent must be signed by the parent or guardian - explanation of the procedure must be in terms that the patient understands

Question 27

What is implied consent?

Answer 27

Provides care when the patient is unconscious, and is based on the assumption that the patient would approve if conscious

Question 28

What is simple consent?

Answer 28

Patient agrees with no explanation

Question 29

What is confidentiality?

Answer 29

To hold in strict confidence any information learned about a patient in the course of medical treatment

Question 30

What is HIPAA?

Answer 30

The federal health insurance portability and accountability act of 1996

Question 31

What is the primary goal of HIPAA?

Answer 31

To make it easier to keep health insurance, protect the confidentiality and security of healthcare information and help the industry control admin costs

Question 32

What is privacy?

Answer 32

The right to be left alone, the right of a person to be free of unwanted publicity

Question 33

What is access to information?

Answer 33

A patient has the right to access their medical reports/information

Question 34

What is a living will?

Answer 34

A document that allows the patient to state their wishes for end of life care, it has no power after death

Question 35

What is a health care proxy?

Answer 35

Patient names a person to be their spokesperson if they become incapacitated

Question 36

What is research participation?

Answer 36

A patient has the right to decide whether or not they want to participate in reasearch

Question 37

What is duty?

Answer 37

What should have been done

Question 38

What is breach?

Answer 38

Deviation from duty

Question 39

What are examples of invasion of privacy?

Answer 39

- Violation of confidentiality - Improperly touching a patient - Taking radiographs without patient's permission

Question 40

What is a violation of professional conduct?

Answer 40

Conduct that causes the patient to fear (verbally threatening more films, exams, etc)

Question 41

What is the rule of personal responsibility?

Answer 41

Individuals are responsible for their own actions

Question 42

What patient assessment should be done before imaging?

Answer 42

- Identify the patient - Confirm age and DOB - Confirm the correct exam has been ordered - Record a brief clinical HX - Access the patient's general condition and ability to cooperate - Check pregnancy status by verifying LMP - Check for allergies if applicable - Check for metal artifacts

Question 43

What patient assessment should be done during imaging?

Answer 43

- continuously monitoring the patient's health and vital signs - reassure the patient throughout the procedure

Question 44

What patient assessment should be done after imaging?

Answer 44

- record any problems or concerns on the requisition - discuss with the patient what will happen after the exam - list any modifications to the procedure

Question 45

What to do when a patient refuses an x-ray exam?

Answer 45

- Try and explain why the doctor ordered the exam - Explain the procedure to the patient and how it will benefit them by helping the doctor make a diagnosis

Question 46

How should data on an x-ray be validated?

Answer 46

- Radiographer should initial or sign any information that they added to the request or patient record. - Also mark the films with lead markers that identify who took the radiographs

Question 47

AP

Answer 47

Anteroposterior

Question 48

PA

Answer 48

Posteroanterior

Question 49

LAT

Answer 49

Lateral

Question 50

OBL

Answer 50

Oblique

Question 51

CXR

Answer 51

Chest x-ray

Question 52

BP

Answer 52

Blood Pressure

Question 53

Abd

Answer 53

Abdomen

Question 54

ABX

Answer 54

Abdominal x-ray

Question 55

KUB

Answer 55

Kidneys, ureters and bladder

Question 56

HX

Answer 56

History

Question 57

FX

Answer 57

Fracture

Question 58

MVA

Answer 58

Motor Vehicle Accident

Question 59

GSW

Answer 59

Gun shot wound

Question 60

DOB

Answer 60

Date of Birth

Question 61

R or RT

Answer 61

Right

Question 62

L or LT

Answer 62

Left

Question 63

c/o

Answer 63

complains of

Question 64

LMP

Answer 64

Last menstrual period

Question 65

PE

Answer 65

Physical Exam

Question 66

Post op

Answer 66

After surgery

Question 67

Pre op

Answer 67

Before surgery

Question 68

pt or PT

Answer 68

patient

Question 69

stat or STAT

Answer 69

immediately

Question 70

ARDS

Answer 70

acute respiratory distress syndrome

Question 71

CA

Answer 71

cancer

Question 72

R/O

Answer 72

rule out