Interviewing as a screening tool Flashcards
Do’s of interviewing
Extend small courtesies
Use a sequence of questions that begins with open-ended questions
Leave close-ended questions for the end of interviewing to clarify
Select a private location for confidentiality
Undivided attention; re-assuring comments; eye contact
Ask one question at a time, allow time for patient to respond
Encourage patient to ask questions
Listen with attention of assessing patient’s current level of understanding and knowledge of his/her condition
Eliminate unnecessary info and speak at patient’s level of understanding
Correlate signs and symptoms with medical history and objective findings to rule-out systemic disease
Provide several choices/selections to questions that require descriptive response
Don’ts of interviewing
Jump to pre-mature conclusions based on answers to one or two questions
Interrupt or take over conversation when client speaking
Destroy helpful open-ended questions with closed-ended follow-up questions before patient has chance to respond
Use professional or medical jargon when it is possible to use common language
Overreact to info presented by the patient (including facial expressions)
Use leading questions
- Where is your pain?
(Do you have pain associated with your injury, if so tell me about it)
- Does it hurt when you first get out of bed?
(When does your back hurt?)
- Does the pain radiate down your leg?
(Do you have this pain anywhere else)
- Do you have pain in your lower back?
(Point to the exact location of your pain)
What are different racial or ethnic designations?
American Indian/Alaska Native
Asian
Black/African American
Hispanic or Latino (of any race)
Native Hawaiian/Pacific Islander
White/Caucasian
What are important aspects of cultural competency while interviewing?
Wait until patient is finished speaking before interrupting or asking questions
Allow “wait time” for some cultures (English could be 2nd language)
Be aware that eye-contact, body-space boundaries, even handshaking may differ from culture to culture
Keys to successful interactions via interpreter
Choose a competent medical interpreter
Interpreter who is older than the patient important in some cultures
Info about client’s diagnosis and condition is relayed to head of household in some cultures who makes decisions for members of family (Muslim)
Listen to interpreter, but direct gaze at patient
Watch body language while speaking for cues
Head nodding and smiling does not necessarily mean that the patient understands you
Keep remarks simple and short
Avoid using medical jargon
What are the topics of data that can be gleaned from a client history?
General demographics
Medical/Surgical history
Current conditions/Chief complaints
Functional status and activity level
Medications
Other clinical tests
Family history
Social/Health habits (past and current)
General health status (self-report, family report, caregiver report)
Living environment
Growth and development
Employment/work (job/school/play)
Social history
FIGURE 2.1
What age and sex is related to Guillain Barre syndrome?
Any age (hx of infection/alcoholism)
Men > Women
What age and sex is related to Multiple sclerosis?
15-35 y.o.
Women > Men
What age and sex is related to Rotator cuff degeneration?
30+ y.o.
No difference between sexes
What age and sex is related to spinal stenosis?
60+ y.o.
Men > Women
What age and sex is related to Tietze’s syndrome?
Before 40 y.o., including children
No differences between sexes
What age and sex is related to Costochondritis?
40+ y.o.
Women > Men
What age and sex is related to Neurogenic claudication?
40-60 y.o.
No difference between sexes
What age and sex is related to AIDS/HIV?
20-49 y.o.
Men > Women
What age and sex is related to Ankylosing spondylitis?
15-30 y.o.
Men > Women
What age and sex is related to abdominal aortic aneurism?
40-70 y.o.
(Hypertensive) Men > Women
What age and sex is related to Buerger’s disease?
20-40 y.o. (smokers)
Men > Women
What age and sex is related to cancer?
Any age; incidence rises over age of 50 y.o.
Men > Women
What age and sex is related to Breast cancer?
45-70 y.o.
Women > Men
What age and sex is related to Hodgkin’s disease?
20-40, 50-60 y.o
Men > Women
What age and sex is related to Osteoid osteoma?
10-20 y.o.
Men > Women
What age and sex is related to Pancreatic carcinoma?
50-70 y.o.
Men > Women
What age and sex is related to RA?
20-50 y.o.
Women > Men
What age and sex is related to skin cancer?
Rarely before puberty; increased incidence with age
Men = women
What age and sex is related to Gallstones?
40+ y.o.
Women > Men
What age and sex is related to Gout?
40-59 y.o.
Men > Women
What age and sex is related to Gynecologic conditions?
20-45 y.o.
Women
What age and sex is related to Paget’s disease of the bone?
60+ y.o.
Men > Women
What age and sex is related to Prostatitis?
40+ y.o.
Men
What age and sex is related to Primary biliary cirrhosis?
40-60 y.o.
Women > Men
What age and sex is related to Reiter’s syndrome?
20-40 y.o.
Men > Women
What age and sex is related to Renal tuberculosis?
20-40 y.o.
Men > Women
What age and sex is related to Rheumatic fever?
4-9; 18-30 y.o.
Girls > Boys
What age and sex is related to Shingles?
60+ y.o.; increasing incidence with age
No difference between sexes
What age and sex is related to Spontaneous pneumothorax?
20-40 y.o.
Men > Women
What age and sex is related to Systemic backache?
45+ y.o.
No difference between sexes
What age and sex is related to Thyroiditis?
30-50 y.o.
Women > Men
What age and sex is related to Vascular claudication?
40-60+ y.o.
No difference between sexes
What are the life cycles of a woman?
Premenes (before start of monthly menstrual cycle; may include early puberty)
Reproductive years (including birth, delivery, miscarriage, and/or abortion history; the time period may include puberty)
Perimenopause (usually begins with obvious symptoms in the mid-30s and continues until symptoms of menopause occur)
Menopausal (may be a natural or surgical menopause)
Postmenopausal (cessation of blood flow associated with menstrual cycle)
What are the clinical signs and symptoms of MENOPAUSE?
Fatigue and malaise
Depression, mood swings
Difficulty concentrating: “brain fog”
Headache
Altered sleep pattern (insomnia/sleep disturbance)
Hot flashes
Irregular menes, cessation of menes
Vaginal dryness, pain during intercourse
Atrophy of breasts and vaginal tissue
Pelvic floor relaxation (Cystosele/rectocele)
Urge incontinence
What are the PHYSICAL clinical signs and symptoms of EATING DISORDERS?
Weight loss or gain
Skeletal myopathy and weakness
Chronic fatigue
Dehydration or rebound water retention; pitting edema
Discoloration or staining of the teeth from contact with stomach acid
Broken blood vessels in the eyes from induced vomiting
Enlarged parotid glands from repeated contact with vomit
Tooth marks, scratches, scars, or calluses on back of hands from induced vomiting (Russell’s sign)
Irregular or absent menstrual periods; delay of menes onset in young adolescent girls
Inability to tolerate cold
Dry skin and hair; brittle nails, hair loss and growth of downy hair all over the body, including face
Reports of heartburn, abdominal bloating or gas, constipation, or diarrhea
Vital signs: slow HR, low BP
In women/girls: irregular or absent menstrual cycles
What are the BEHAVIORAL clinical signs and symptoms of EATING DISORDERS?
Preoccupation with weight, food, calories, fat grams, dieting, clothing size, body shape
Mood swings, irritability
Binging and purging (bulimia) or food restriction (anorexia); frequent visits to the bathroom after eating
Frequent comments about being fat or overweight despite looking very thin
Excessive exercise to burn off calories
Use of diuretics, laxatives, enemas, or other drugs to induce urination, bowel movements, and vomiting
What are the physiologic effects/adverse reactions to CAFFEINE (Coffee, expresso, chocolate, OTC “alert aids,” black tea, red bull, etc)?
Vasoconstriction
Irritability
Enhanced pain perception
Intestinal disorders
Headaches
Muscle tension
Fatigue
Sleep disturbances
Urinary frequency
Tachypenia
Sensory disturbances
Agitation
Nervousness
Heart palpitation
What are the physiologic effects/adverse reactions to CANNABIS (Marijuana, hashish)?
Short-term memory loss
Sedation
Tachycardia
Euphoria
Increased appetite
Relaxed inhibitions
Fatigue
Paranoia
Psychosis
Ataxia, tremor
What are the physiologic effects/adverse reactions to DEPRESSANTS (Alcohol, sedatives/sleeping pills, barbiturates, tranquilizers)?
Agitation, mood swings, anxiety, depression
Vasodilation; red eyes
Fatigue
Altered pain perception
Excessive sleepiness/insomnia
Coma (over-dose)
Altered behavior
Slow, shallow breathing
Clammy skin
Slurred speech
What are the physiologic effects/adverse reactions to NARCOTICS (Heroine, opium, morphine, codeine)?
Euphoria
Drowsiness
Respiratory depression
What are the physiologic effects/adverse reactions to STIMULANTS (Cocaine and its derivatives, amphetimines, methamphetimine, ecstasy)?
Increased alertness
Excitation
Euphoria
Loss of appetite
Increase in BP
Insomnia
Increase in pulse
Agitation, increase in body temperature, hallucinations, convulsions, death
What are the physiologic effects/adverse reactions to TOBACCO (Cigarettes, cigars, pipe smoking, smokeless tobacco products)?
Increase in HR
Vasoconstriction
Decreased oxygen to heart
Increase in risk of thrombosis
Loss of appetite
Poor wound healing
Poor bone grafting
Increased risk of pneumonia
Increased risk of cataracts
Disk degeneration
What are the clinical signs and symptoms of alcohol use disorders in older adults?
Memory loss or cognitive impairment (new onset or worsening of previous condition)
Depression or anxiety
Neglect of hygiene and appearance
Poor appetite and nutritional deficits
Sleep disruption
Refractory (resistant) hypertension
Blood glucose control problems
Refractory seizures
Impaired gait, balance, and falls
Recurrent gastritis and esophagitis
Difficulty managing warfarin dosing
What are the clinical signs and symptoms of alcohol withdrawal?
Agitation
Headache
Insomnia
Hallucinations
Anorexia, nausea, vomiting, diarrhea
Loss of balance, incoordination (apraxia)
Seizures (occurs 12-48 hrs after the last drink)
Delirium tremens (occurs 2-3 days after last drink)
Motor hyperactivity, tachycardia
Elevated BP
Risk factors for falls secondary to AGE CHANGES
Muscle weakness; loss of joint motion (especially LEs)
Abnormal gait
Impaired or abnormal balance
Impaired proprioception or sensation
Delayed muscle response/increased reaction time
Decreased systolic BP
Stooped or forward bent posture
Risk factors for falls secondary to ENVIRONMENTAL/LIVING CONDITIONS
Poor lighting
Throw rugs, loose carpet, complex carpet designs
Cluster of electric wires or cords
Stairs without handrails
Bathroom without grab bars
Slippery floors
Restraints
Use of alcohol or other drugs
Footwear, especially slippers
Risk factors for falls secondary to PATHOLOGIC CONDITIONS
Vestibular disorders; episodes of dizziness or vertigo from any cause
Orthostatic hypotension (especially before breakfast)
Chronic pain condition
Neuropathies
Cervical myelopathy
Osteoarthritis; RA
Visual or hearing impairment; multifocal eyeglasses; change in perception of color; loss of depth perception; decreased contrast sensitivity
Cardiovascular disease
Urinary incontinence
Central nervous system disorders (stroke, PD, MS)
Motor disturbance
Osteopenia, osteoporosis
Pathologic fractures
Any mobility impairments
Cognitive impairment; dementia; depression
Risk factors for falls secondary to MEDICATIONS
Antianxiety; benzodiazepines
Anticonvulsants
Antidepressants
Antihypertensives
Antipsychotics
Diuretics
Narcotics
Sedative-hypnotics
Phenothiazines
Use of more than four medications (polypharmacy/hyperpharmacology)
Risk factors for falls secondary to OTHER
History of falls
Female sex; postmenopausal status
Living alone
Elder abuse/assault
Nonambulatory status (requires transfers)
Gait changes (decreased stride length or speed)
Postural instability; reduced postural control
Fear of falling; history of falls
Dehydration from any cause
Recent surgery (general anesthesia, epidural)
Sleep disorder/disturbance; sleep deprivation; daytime drowsiness; brief disorientation after waking up from a nap
What is INTRINSIC trauma?
Unguarded movement that can occur during normal motion
Ex: patient who reaches to the back of a cupboard while turning his or her head away from the extended arm to reach the last inch or two–a sudden pop or twinge experienced with subsequent pain
What is EXTRINSIC trauma?
Force or load external to the body is exerted against the body
Trauma we typically think of
What is ASSAULT trauma?
Domestic abuse-type trauma
Any physical, sexual, or psychologic attack (verbal, emotional, economic)
Violence against women
Must be able to identify the signs of abuse
What is ABUSE?
Infliction of physical or mental injury, or the depravation of food, shelter, clothing, or services needed to maintain physical or mental health
What is SEXUAL ABUSE?
Sexual assault, sexual intercourse without consent, indecent exposure, deviate sexual conduct, or incest; adult using a child for sexual gratification without physical contact is considered sexual abuse
What is NEGLECT?
Failure to provide food, shelter, clothing, or help with daily activities needed to maintain physical of mental well-being; client often displays signs of poor hygiene, hunger, or inappropriate clothing
What is MATERIAL EXPLOITATION?
Unreasonable use of a person, power of attorney, guardianship, or personal trust to obtain, control of the ownership, use, benefit, or possession of the person’s money, assets, or property by means of deception, duress, menace, fraud, undue influence, or intimidation
What is MENTAL ABUSE?
Impairment of a person’s intellectual or psychologic functioning or well-being
What is EMOTIONAL ABUSE?
Anguish inflicted through threats, intimidation, humiliation, and/or isolation; belittling, embarrassing, blaming, rejecting behaviors from adult toward child; withholding love, affection, approval
What is PHYSICAL ABUSE?
Physical injury resulting in pain, impairment, or bodily injury of any bodily organ or function, permanent or temporary disfigurement, or death
What is SELF-NEGLECT?
Individual is not physically or mentally able to obtain and perform the daily activities of life to avoid physical or mental injury
What are the risk factors and red flags for domestic violence?
Women with disabilities
Cognitively impaired adult
Chronically ill and dependent adult (especially over 75 y.o.)
Chronic pain clients
Physical and/or sexual abuse history (men and women)
Daily headache
Previous history of many injuries and accidents (including multiple MVAs)
Somatic disorders
- Injury seems inconsistent with client’s explanation; injury in a child that is not consistent with the child’s developmental level
- Injury takes much longer to heal than expected
Pelvic floor problems
- Incontinence
- Infertility
- Pain
Recurrent unwanted pregnancies
History of alcohol abuse in a male partner
What are warning signs of elder abuse?
Multiple trips to the emergency department
Depression
“Falls”/Fractures
Bruising/suspicious sores
Malnutrition/weight loss
Pressure ulcers
Changing physicians/therapists often
Confusion attributed to dementia
What are the clinical signs and symptoms of domestic violence: PHYSICAL CUES
Bruises, black eyes, malnutrition
Sprains, dislocations, foot injuries, fractures in various stages of healing
Skin problems
Chronic or migraine headaches
Diffuse pain, vague or non-specific symptoms
Chronic or multiple injuries in various stages of healing
Vision and hearing loss
Chronic low back, sacral, or pelvic pain
Temporomandibular joint pain (TMJ)
Dysphagia and easy gagging
Gastrointestinal disorders
Patchy hair loss, redness, or swelling over the scalp from violent hair pulling
Easily startled, flinching when approached
What are the clinical signs and symptoms of domestic violence: SOCIAL CUES
Continually missing appointments; won’t return phone calls, unable to talk on phone
Bringing all of the children to the clinic
Spouse, companion, or partner always accompanying patient
Changes physicians often
Multiple visits to the ER
Multiple car accidents
What are the clinical signs and symptoms of domestic violence: PSYCHOLOGIC CUES
Anorexia/bulimia
Panic attacks, nightmares, phobias
Hypervigilance, tendency to startle easily or be very guarded
Substance abuse
Depression, anxiety, insomnia
Self-mutilation or suicide attempts
Multiple personality disorders
Mistrust of authority figures
Demanding, angry, distrustful of healthcare provider
What are the risk factors for adverse drug reactions?
Age (over 65 y.o., especially over 75 y.o.)
Small physical size of stature
Sex (men and women respond differently)
Polypharmacy/hyperpharmacotherapy
Prescribing cascade (failure to recognize signs and symptoms of an ADE and treating it as the onset of a new illness)
Taking meds prescribed to someone else
Organ impairment and dysfunction
Concomitant alcohol consumption
Concomitant use of certain nutraceuticals
Previous history of ADEs
Mental deterioration or dementia
Difficulty opening medication bottles, difficulty swallowing, unable to read or understand directions
Racial/ethnic variations
Clinical signs and symptoms of NSAID Complications: GI
May be asymptomatic
May cause confusion and memory loss in older adults
Indigestion, heartburn, epigastric or abdominal pain
Esophagitis, dysphagia, odynophagia
Nausea
Unexplained fatigue lasting more than 1-2 weeks
Ulcers (gastric, duodenal), perforations, bleeding
Melena
Clinical signs and symptoms of NSAID Complications: RENAL
Polyuria, nocturia
Nausea, pallor
Edema, dehydration
Muscle weakness, restless leg syndrome
Clinical signs and symptoms of NSAID Complications: INTEGUMENTARY
Pruritis (symptom of renal impairment)
Delayed wound healing
Skin reaction to light (photodermatitis)
Clinical signs and symptoms of NSAID Complications: CARDIOVASCULAR
Elevated BP
Peripheral edema
Asthma attacks in individuals with asthma
Clinical signs and symptoms of NSAID Complications: MSK
Increase symptoms after taking medication
Symptoms linked with ingestion of food (increased or decreased depending on ulcer location)
Midthoracic back, shoulder, or scapular pain
Neuromuscular
Muscle weakness (sign of renal impairment)
Restless leg syndrome (sign of renal impairment)
Paresthesias (sign of renal impairment)
What are the risk factors for NSAID Gastropathy?
Back, shoulder, neck, or scapular pain in any client taking NSAIDs in the presence of the following risk factors for NSAID-induced gastropathy raises a red flag of suspicion:
- Age ( > 65 y.o.)
- History of peptic ulcer disease, GI disease, or RA
- Tobacco or alcohol use
- NSAIDs combined with oral corticosteroid use
- NSAIDs combined with anticoagulants
- NSAIDs combined with selective serotonin re-uptake inhibitors
- Chronic use of NSAIDs ( > 3 months)
- Higher doses of NSAIDs, including the use of more than one NSAID
- Concomitant infection with Heliobactor pylori
- Use of acid suppressants; these agents may mask the warning symptoms of more serious GI complications, leaving the patient unaware of ongoing damage
What are the clinical signs and symptoms of anabolic steroid use?
Rapid weight gain
Elevated BP
Peripheral edema associated with increased BP
Acne on face and upper body
Muscular hypertrophy
Stretch marks around the trunk
Abdominal pain, diarrhea
Needle marks in large muscle groups
Personality changes (aggression, mood swings, “roid” rages)
Bladder irritation, urinary frequency, UTIs
Sleep apnea, insomnia
Altered ejection fraction (lower end of normal: under 55%)
WHAT IS ON PAGES 50-51???
GENERAL HEALTH INFO,
READ IT!!
What is the effect of NSAIDs (Naprosyn, Motrin, Anaprox, ibuprofen) on BP?
INCREASE IN BP
NSAIDs can be renal vasoconstrictors causing and increase in BP; resultant LE edema as sodium and water are conserved by body
Most of the information needed to determine the cause of symptoms is contained in what?
SUBJECTIVE EXAM
It is well documented that 80% or more of info needed to determine cause of symptoms is gathered during interview with patient
With what final question should you always end an interview?
“Is there anything else you think I should know?”
A risk factor for NSAID-related gastropathy is the use of what?
ANTIDEPRESSANTS
After interviewing a new client, you summarize what she has told you by saying, “You told me you are here because of right neck and shoulder pain that began 5 years ago as a result of a car accident. You also have a ‘pins and needles’ sensation in your third and fourth fingers but no other symptoms at this time. You have noticed a considerable decrease in grip strength, and you would like to be able to pick up a pot of coffee without fear of spilling it.”
WHAT IS THIS SCENARIO AN EXAMPLE OF?
PARAPHRASING TECHNIQUE
True of false?
Screening for alcohol use would be appropriate when the client reports a history of accidents.
True
What is the significance of “sweats?”
SIGN OF SYSTEMIC DISEASE
SIDE EFFECT OF CHEMOTHERAPY OR OTHER MEDS
POOR VENTILATION WHILE SLEEPING
True or false?
Spontaneous uterine bleeding after 12 consecutive months w/o menstrual bleeding requires medical referral
TRUE
Includes women who have experienced surgical menopause (oophorectomy for ovarian cancer) or postmenopausal women not taking hormone replacements
What are red flags to consider when screening for systemic or viscerogenic causes of neuromuscular and musculoskeletal S&S?
FEVER, (NIGHT) SWEATS, DIZZINESS
SYMPTOMS OUT OF PROPORTION TO INJURY
INSIDIOUS ONSET
NO POSITION OF COMFORT
A 52 year-old man with LBP and sciatica on the left side has been referred to you by his family physician. He has had a disectomy and laminectomy on two separate occasions about 5-7 years ago. No imaging studies have been performed since that time.
What follow-up questions would you want to ask to screen for medical disease?
“Did you actually see your physician?”
“Are you having any other symptoms of any kind that you have not mentioned yet” (checking for constitutional symptoms)
What physiologic effect associated with risk of HTN should be assessed for patients receiving NSAIDs?
WATER RETENTION
Look for sacral and pedal edema
How should you proceed with patients with a history of HTN and arthritis?
INFORM THEIR PRIMARY CARE PROVIDER OF BOTH CONDITIONS
Also screen for potential adverse effects of NSAIDs and can monitor BP
Alcohol screening tools should be…?
Brief, easy to administer, and non-threatening
