Interview Basics 3-4 Flashcards
Past medical history (PMH)
Can screen for hospital stays or ER visits
Illnesses theft has had/has now that may not have been diagnosed by a doctor or may be ongoing
Whether or not active problems are uncontrolled or controlled
Past surgical history (PMH)
Any time the pt has had an operation
Tonsillectomy and/or appendectomy in childhood as well as C section all count
Most dental surgeries (unless in a hospital) or sutures for minor injuries dont count
What is required when asking about current medications?
Must ask about prescriptions, OTC meds and supplements
Must record positive and negative findings
What should you keep in mind when asking about current meds?
Prescribed by physician or by the internet/someone in the fam?
Need to know why they take it and how much they take
Women usually dont consider birth control as a medication so you may have to specifically ask about it
What is required when asking about allergies?
Ask if they are allergic to any meds, environment or food
Must record positive and negative
What should you keep in mind when asking about allergies?
Not prescribing something on their allergy list
Could an allergy be the source of any of their sx?
Does it need to be in PMH section (ex seasonal allergies)?
What to ask about when taking family history (FH)?
First degree relatives (mom, dad, siblings and kids)
Things that run in the family such as cancers, mental health issues and cardiac episodes (make sure to ask when ex Dad had MI at age 30 vs 92)
What are the elements of a social history?
Food - nutrition and diet
Exercise - daily activities and exercise
Drugs - recreational drug use
Tobacco - smoking and smokeless
Alcohol
Caffeine
Occupation - demographics and occupational history
Spirituality and sexual relationships, safety (at home, in car, with leisure activity, etc)
What does the CDC recommend for adults in regards to exercise?
To get 150 mins per week of moderate activity (brisk walking) and strength training 2 days of the week that focuses on all major muscle groups
What does the CDC recommend for children and adolescents 6 years and older in regards to exercise?
They can achieve important health benefits by getting 1 hour or more of daily physical activity
Asking about recreational drug use
Ask about quantity (how much), frequency (how often) and route of administration
Establish confidentiality with the pt
Important for them to know resources within the community
Can exacerbate certain health issues
Ask if they use recreational drugs or street drugs NOT illegal drugs
Tobacco use as an element of social history
Ask about quantity, duration and ppd/pack years (ppdxyears)
Smoking is linked to cardiovascular events, lung disease, etc
A person has to WANT to quit before they will be successful
AAA screening
The USPSTF recommends one time screening for abdominal aortic aneurysm (AAA) with ultrasonography in men ages 65-75 years who have ever smoked
Lung cancer screening
The USPSTF recommends annual screening for lung cancer with low dose computed tomography (LDCT) in adults 55-80 years old who have a 30 pack year smoking history and currently smoke or have quit within the past 15 years
What is Important to ask about when asking the pt about alcohol?
Quantity and frequency
What are the two methods used to determine alcohol use by the pt?
AUDIT (alcohol disorders identification test) and CAGE questionnaire
AUDIT
Better sensitivity than CAGE
More questions for physicians to remember and somewhat difficult to score
CAGE questionnaire
Useful to screen for pt who drink more than one drink OR who drink a lot on the weekends
Can open a door to conversation about getting help
If pt is a daily drinker you cannot say “just quit” could go through DTs —need medical support
Lots of false positives
CAGE questions
Has anyone ever suggested you cut back?
Are you every annoyed when people talk about your drinking?
Do you ever feel guilty about your drinking?
Do you ever need a drink in the morning to steady your nerves (an eye opener)?
What are the safe drinking limits for women and those over 65?
Low risk drinking is defined as no more than 3 drinks on any single day and no more than 7 drinks per week
What is the safe drinking limit for men?
No more than 4 drinks on any single day and no more than 14 drinks per week
What is considered a drink?
Beer = 12oz Wine = 5 oz Liquor = 1 oz
Caffeine as an element of social history
Ask how much and how often?
Ask what form—coffee, tea, soda, energy drinks, pills, etc
Things to consider: why so much? Health consequences? Why is the pt here? Starting/stopping?
Caffeine affects cardiovascular, pulmonary, wake/sleep, HAs, etc
Occupation as an element of social history
How do they make a living? “What kind of work do you do?”
Considerations: stress, exposure and work policies like excused absences
Do you think anything at work or home is affecting your sx now?
Spirituality and religion as an element of social history
Spirituality does not always mean religion or belief in higher power
Do you feel supported by any specific faith community? Is spirituality important to you?
F - faith and belief
I - importance
C - community
A - address in care or assessment & plan
What to address when asking the pt about safety?
Seatbelt use, helmet use, car seats, fences around pools, medication storage around young children, immunizations, etc
Asking about living environment as an element of social history
Who do you share a home with? Who do you live with?
Screening for domestic violence
Be careful when you screen for domestic violence — may not want to give pamphlet to women’s or men’s shelter so the abuser does not see
If pt is in a potentially dangerous situation ask about guns or other weapons in the home
SAFE acronym for domestic violence
S - stress/safety
A - afraid/abused
F - friends/family
E - emergency plan
What is the ROS?
An inventory of body systems obtained by asking a series of questions to identify signs and/or sx the patient may be experiencing or has experienced
What are some time savers when obtaining an ROS?
Define a time frame that pts may have experienced their sx
Use a list/template when you are starting so you can stay organized
Why do we obtain an ROS?
Idenitfy co-existing medical conditions
Build your case medically and legally
Provide accurate billing info
What do associated sx refer to?
The presenting problem (chief complaint)
The ROS refers to
Other potential problems in systems OTHER than the one where the CC falls
When may the ROS be obtainable?
If the pt is unconsciousness, demented, severely intellectually disabled, nonverbal or otherwise unable to communicate
