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Physical Diagnosis > Introduction and History Taking > Flashcards

Introduction and History Taking Flashcards

1
Q

SOAP note

A
  • Subjective
  • Objective
  • Assessment
  • Plan
  • Format for all medical notes (initial, followup, procedure, etc.)
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2
Q

SOAP note contents

A
  • Subjective = what patient says, history
  • Objective = what you observe, physical exam and diagnostic study results
  • Assessment = what you think is wrong
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3
Q

Additional components of assessment portion

A
  • Differential Diagnosis (DDx) of a CC-possibilities of what is wrong
  • Ongoing problem
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4
Q

Differential diagnosis (DDx)

A
  • List of what patient may have
  • Helps with clinical reasoning
  • Hx narrows it down, then PE and diagnostic studies confirm your Assessment
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5
Q

Plan components

A
  • What you propose to do to cure or workup the patient’s complaint or problem
  • Includes medications, procedures, patient education, and orders for more diagnostic tests to narrow the differential diagnosis
  • Plans for ongoing problems may be listed by problem
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6
Q

Goals of interview

A
  • Discovery of information that leads to correct A&P
  • Sharing with patient why you need to know or examine or test (share clinical thinking process and DDx, within reason)
  • Negotiation to arrive at a course of workup or care that is consistent with patient’s needs, beliefs, desires
  • Union to establish a joint effort
  • Support in the ways you can, refer when you cannot
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7
Q

Ethical aspect of autonomy

A
  • Autonomy respects the patient’s need for self-determination
  • This suggests the patient has choices and may make them, which requires patient education
  • Autonomy is confusing when the patient is a child or not competent to make decisions
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8
Q

Task of interview

A
  • Gather data that is precise, specific, sensitive, and reliable
  • Discover information that leads to diagnosis and management
  • Provide information to patient regarding diagnosis and management
  • Negotiate with patient concerning management, that is not to be invariably imposed.
  • Counsel about disease prevention
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9
Q

Patient goals

A
  • Fix what’s wrong
  • Have their symptoms and feelings understood
  • Have their questions answered
  • Have their fears allayed
  • To be respected and comforted in a therapeutic setting
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10
Q

Interviewer goals

A
  • To heal, improve
    To show concern, sensitivity, awareness
  • To establish a bond, rapport
  • To obtain accurate data that is precise, specific, sensitive, and reliable
  • To appear knowledgeable, competent, confident
  • To be respected, trusted, and to teach
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11
Q

Ensure proper setting

A
  • Clean, organized setting
  • Friendly, polite support staff
  • Avoid loud, personal discussions in patient areas
  • Do what you can
  • Serenity, courage, wisdom
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12
Q

Patient’s desire

A
  • A nonjudgmental attitude-objectivity
  • To be allowed to express problems and concerns in their own words
  • You to pay attention to detail so you can diagnose and treat effectively-precision
  • You to express concern, interest, understanding, respect and friendliness-empathy
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13
Q

Objectivity

A
  • You must remove your beliefs, biases, prejudices, preconceptions, and systemic distortions
  • You must value traits and beliefs of others
  • Premature interpretation compromises objectivity
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14
Q

Precision

A
  • A history should be reproducible by others
  • Avoid vagueness, poor listening, lack of attention to detail
  • Maximize precision and objectivity to produce more accurate data and correct diagnosis
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15
Q

Empathy

A
  • Means listening to total communication, including words, gestures, body language with attention to feelings
  • And letting the patient know you are hearing, interested, concerned, accepting and understanding of what they are saying
  • Empathy is not a state of feeling sorry for someone or sympathy
  • Nor is it just compassion or being nice
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16
Q

Be a good listener

A
  • Make eye contact, nod
  • Direct full attention to patient by facing them without barriers
  • Avoid distractions like phone calls, interruptions, noise
  • Keep note-taking to a minimum
  • Avoid turning away to do electronic medical records
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17
Q

Interviewing techniques

A
  • Open-ended questions
  • Closed-ended questions
  • Clarification and elaboration
  • Facilitation
  • Confrontation
  • Silence
  • Direction
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18
Q

Leading questions

A
  • Should NOT be used
  • They lead a patient in a certain direction
  • “But you didn’t feel chest pain, did you?”
  • “You only have one drink per day, right?”
  • “So you take your medication every day, right?”
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19
Q

Avoid leading questions

A
  • Leading questions lead a patient to say a particular thing
  • They can be judgmental
  • “Don’t you think that is too many beers for one evening?”
  • “You don’t really need physical exam, do you?”
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20
Q

Clarification and elaboration

A
  • Reflection = repeat what you have heard to encourage more detail
  • Ask the patient to explain or provide more detail
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21
Q

Facilitation

A
  • Encourages the patient to go on, with words or silence
  • “Please go on”
  • “So you felt [repeat patient’s words]”
  • May be nonverbal cues such as nodding
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22
Q

Confrontation

A
  • Attempts to bring patient’s behavior or awareness to conscious awareness
  • “You seem worried about this”
  • “I can imagine this could affect your work, life, marriage.”
  • “You seem angry”
  • “Did you take your blood pressure medication today?”
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23
Q

Silence

A
  • Allows the patient to organize their thoughts and reflect
  • Silence and tears are hard for an interviewer to deal with.
  • Silence and expressions of emotion are therapeutic
24
Q

Direction/transition

A
  • Facilitate transitions and explain the next step of interviewing
  • “I am going to ask about your family”
  • “Next we will do the physical exam”
  • “ I am going to ask you some questions you may find simple to assess your mental status”
25
Q

Provider-patient relationship skills

A
  • Expressing partnership or willingness to work together
  • Patients who take an active role in planning their care have better health outcomes.
  • “Let’s work together to try to solve these problems.”
26
Q

Nonverbal communication

A
  • Appearance and grooming
  • Touch
  • Eye contact: being on laptop or smartphone
  • Comfortable social distance
  • Body language
  • Speech patterns
  • Self-assessment
27
Q

Appearance and grooming

A
  • It is your job to make the patient comfortable in every way you can
  • It is best to err on the side of conservatism
  • Remember, as you are interviewing and examining the patient, they are interviewing and examining you
28
Q

Fingernails

A
  • Most hospitals forbid acrylic nails in healthcare workers
  • They dry-out the cuticle, making it vulnerable to infection by MRSA, among other bacteria
  • Consider real nails with no polish
  • You will need very short nails on 2nd and 3rd fingers of dominant hand to perform percussion
29
Q

Touch

A
  • Handshake-fist-bump?
  • Handholding, when appropriate
  • Hugs and draping arms around patients is inappropriate
  • Pay attention to cultural conventions
  • Cheek kissing is the norm in some places, but is best avoided to prevent air droplet contagion
  • Pay attention to body language
30
Q

Eye contact

A
  • Conveys interest in Western cultures
  • In some cultures is impolite or a sign of disrespect
  • Depressed patients often avoid eye contact (this would be noted in Observation of document)
31
Q

Comfortable social distance and body language

A
  • Comfortable social distance is often culturally mediated
  • Pay attention to patient’s body language
  • Note foot-tapping, arms over chest, leaning back, expressions. Grimaces may look like smiles. Ask if you are unclear
  • “You seem uncomfortable. Is there anything that will make you feel better?”
32
Q

Speech patterns

A
  • Slow speech may indicate depression
  • Rapid speech with flight of ideas may indicate mania.
  • Rapid, “pressured” speech may indicate anxiety.
  • Note quality of speech in O and suspicion of psych issues in A
33
Q

Self-assessment

A
  • Notice if you are mirroring the patient’s speech patterns or body language
  • Depressed patients may actually make you feel depressed
  • Pay attention to your own feelings
34
Q

History taking skills pearls

A
  • Remember “What you ask is complemented by how you ask it”
  • Always try to clarify patient’s point of view
  • Ask often what patient thinks & feels about an issue
  • Make sure you know what CC is
  • Make sure all is well in family & in workplace, that nothing major extraneous to CC & HPI has happened recently
  • Suggest at appropriate times that you have a “feeling” that there is more to say or that things may not be as well as they are reported
  • Suggest at appropriate times that it is all right to be angry, sad, nervous & it is all right to talk about it
  • Make sure that patient’s expectations in visit are met & that there are no other questions
35
Q

Recording information

A
  • Record on patient’s visit immediately
    or even better, in front of patient so they may clarify or correct
  • The act of recording may remind you of what was missed, and can be asked or completed before the patient leaves
  • Use direct quotes for CC
36
Q

Symptoms

A
  • A symptom is something a patient feels
  • Pruritis = itching
  • Urgency = need to go to bathroom
  • Dysuria = burning on urination
  • Polyuria = frequent urination
  • Polydipsia = increased thirst
37
Q

Signs

A
  • A sign of illness is something observed
  • For instance, fever is a sign of infection
  • Erythema is a sign of inflammation
38
Q

Structure of the history

A
  • Chief Complaint (CC)
  • History of Present Illness (HPI)
  • Past Medical History (PMH)
  • Family History (FH)
  • Personal & Social History (SH)
  • Review of Systems (ROS)
39
Q

Chief complaints (CC)

A
  • Should state patient’s age and gender
  • Should state complaint in patient’s own words
  • Obese 66 year old diabetic male states, “My butt itches.”
  • 20 year old female states “I am here for my Pap results”
  • 80 year old wheelchair-bound male says “I cannot go to the bathroom”
40
Q

History of the present illness (HPI)

A
  • Should be in chronological order, explaining each symptom clearly
  • HPI should read like a story, sentence style
  • Include all pertinent material
  • Chronology Flows from the beginning of symptoms to the time of presentation
  • All symptoms fully described: onset, location, duration, character, aggravators, relievers, treatment, timing, severity
  • All associated symptoms are included and described well
  • HPI provides a clear and concise story allowing the reader to develop a differential diagnosis & uses correct medical terminology
41
Q

Pain is often in HPI PQRST mnemonic

A
  • P = Precipitating, Palliating factors
  • Q = Quality
  • R = Radiation
  • S = Severity
  • T = Temporal factors
42
Q

OLDCARTS mnemonic for pain and other symptoms

A
  • O = Onset
  • L = Location
  • D = Duration
  • C = Character
  • A = Aggravating/associated factors
  • R = Relieving factors
  • T = Temporal factors
  • S = Severity
43
Q

Associated symptoms

A
  • Refer to symptoms that may be associated with a particular complaint
  • For instance, for CC of sore throat or any other potential infection, you would ask about fatigue and fever, and document whether positive or negative in HPI, because it relates to CC
  • Associated symptoms vary per complaint
44
Q

Thorough HPI

A
  • Include recent hospitalizations for complaint
  • Include patient compliance with medications
  • Include pertinent positives or negatives relating to the CC or reason for visit
  • Explore all associated symptoms, whether positive or negative
45
Q

Past medical history (PMH)

A
  • Allergies make this stand out! (include reaction)
  • Current ongoing problems (HTN, DM)
  • General health
  • Childhood illnesses and immunizations
  • Hospitalizations, reasons, dates, location
  • Surgeries, reasons, dates, location
  • Accidents, injuries, Limitations of Ability
  • Psych history
  • Medications (current, recent, dosage, prescription & non-compliance)
  • Immunizations
  • Blood transfusions
  • Pregnancies, LMP
  • Recent Tests, screening
46
Q

Family history

A
  • Looking for genetic links to illness and disease
  • Include pedigree, if relevant
  • Include infectious contacts
47
Q

Social history

A
  • Etoh, drugs, Tobacco, in pack-years
  • CAGE if appropriate
  • Living situation (with whom?) or ALF (why?), marital status
  • Occupation/education/military
  • Health habits exercise, diet, caffeine
  • Travel, pets
  • Current stressors (separation, death, marriage, childbirth, job change, unemployment, incarceration, financial)
48
Q

CAGE

A
  • Do you feel you are in a Cage?
  • Crappy, Annoyed, Gullible, Emaciated.
  • Cut-down, Annoyed, Guilty, Eye-opener?
  • Cigarettes, Accidents, Parents, Emotional issues
49
Q

Social history, sexual history

A
  • Most relevant to Medical History is–Number of current partners and if a barrier method of STD transmission/ birth control is used every time.
  • Screen for domestic violence and prostitution if pregnant, ETOH or drugs are involved, or for any injury.
  • Marital status, “patient’s term for” sexual or domestic partners
50
Q

Sexual history

A
  • Do not assume married people are monogamous.
  • Do not assume adolescents or older adults are not sexually active
  • Ask: Do you kiss/ touch genitals/ have intercourse?
  • Do you think your partner is monogamous?
51
Q

Sequence

A
  • We document in SOAP format, but you may be getting information in another chronological order
  • The patient may not tell you about their cholecystectomy until you see the scar and ask about it, but the information the patient tells you still goes in the History (S of SOAP)
52
Q

Review of systems (ROS)

A
  • General
  • Skin, Hair, Nails
  • Head, Neck
  • Pulmonary
  • Cardiovascular
  • GI
  • GU
  • Peripheral vasc
  • Musculoskeletal
  • Neurological
  • Hematological
  • Endocrine
  • Psychiatric
53
Q

ROS is subjective

A
  • Only what the patient reports
  • Do not confuse with the PE, which may follow a similar order
  • PE is Objective, only what you see, hear, feel, smell
54
Q

ROS vs. HPI

A
  • If information given by the patient (or other health care providers) is related to the Chief complaint, it is recorded in the HPI (History of Present Illness)
  • It may also be duplicated in the ROS, PMH, FH, and SH for a more complete record
55
Q

ROS: be comprehensive

A
  • You must write every denial/ negative to prove you asked
  • Denies fever, weight change, body aches
    You must explore every abnormal/ positive
  • Reports cough for the last 3 months that is dry, without throat pain, chest pain, or shortness of breath

Physical Diagnosis (1 decks)

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