Lecture 2 E1- Health History pt 2

Question 1

What are the components of a comprehensive history

Answer 1

Identifying data/historian, CC, HPI, past medical history- (surgical social meds, allergies), ROS

Question 2

what are the seven perimeters of the symptoms?

Answer 2

Location, onset, characteristics, associated symptoms – aggravating, and alleviating factors, timing, environment, severity

Question 3

What is a health history interview and what is its purpose?

Answer 3

It is a conversation with a purpose

To establish a trusting and supportive relationship, to gather information, to offer information-

so patient trusts what you say and do as you suggest

Question 4

what is a clinician patient relationship

Answer 4

A feeling of connectedness with the healthcare provider, reduces the feeling of isolation and despair that can come with illness and is at the very heart of healing

Question 5

what is the health history format

Answer 5

A structured framework for organizing patient information in written or verbal form for other healthcare providers

(patient will deliver info out of format-you need to document in correct format)

Question 6

what is the interviewing process?

Answer 6

The process of acquiring information needed to develop the health history

Demands effective communication and relational skills

Question 7

what are the techniques of structured questioning?

Answer 7

Start with an open ended question like what brings you in today for I see you’re having belly pain. Tell me more about that.

Allow patient to talk for two minutes without interruption

Guided questioning – focused, close, ended questions, one question at a time, echoing, etc.

Question 8

What is the most important aspect of skilled interviewing?

Answer 8

Active listening

Question 9

what is active listening

Answer 9

Approaching a conversation with a genuine desire, to understand the persons, feelings and perspective, without judgment, or defensiveness

may be hard in a distracting environment like ER- try to limit distractions

Question 10

What is nonverbal communication?

Answer 10

Nonverbal cues, convey the extent of your interest, attention, acceptance and understanding.

Negative nonverbal communication blocks communication from the patient

Nonverbal communication accounts for 65% of total communication

Question 11

facts about facial expression

Answer 11

Facial expressions are universal language of emotion,

be sure that you are displaying facial expressions. That patience won’t take in the wrong way.

Question 12

verbal communication

Answer 12

Avoid medical jargon, abbreviations, or any complex words or phrases

When talking to the patient instead of saying, does the pain radiate say does the pain move anywhere?

Avoid giving too much information at one time and use non-stigmatizing language

Question 13

what is empathy

Answer 13

Empathy is linked to improve patient satisfaction and compliance.

Put yourself in their shoes and try to understand how they feel and are processing

In a small study of 20 audio recorded interactions, physicians seldom responded empathetically to concerns raised by lung cancer patients

Question 14

what is reassurance as a technique of skilled interviewing

Answer 14

Simply identifying and acknowledging the patient’s feelings, promotes a feeling of connection

good- I’m going to do all I can to help
bad-everything is going to be OK (dont say- you never know the outcome of their situations)

Question 15

what is validation as a technique of skilled interviewing?

Answer 15

Validating the legitimacy of the patient’s emotional experience helps them feel that their emotions are acceptable and understood

“I understand how scary this can be “

Question 16

What is summarization?

Answer 16

Summarizing the patient story after they have completed, providing their history,

Identifies what you know and don’t know,
gives the patient the opportunity to add to the history if they forgot some thing,
allows you to organize your thoughts and strengthens your clinical reasoning.

Conveys your thought process to the patient,
creates a more collaborative relationship with the patient,
great fall back if you draw a blank on what to ask next

Question 17

What are transition

Answer 17

Statements that help guide the patient through the encounter

HPI-PMH
“now id like to ask you some questions about your past health”
PMH-Meds/allergies
meds/allergies-social history
social history-ROS
“some of these questions may seem personal but your answers will help me take better care of you”
ROS-PE
“I would like to perform a physical exam now”

Question 18

describe partnering

Answer 18

Your relationship with the patient should be a partnership, you are an educator, not a dictator in the situation

Question 19

what is disease in a health history

Answer 19

How the clinician explains the constellation of symptoms that leads to a diagnosis

How we take with a patient tells us and come up with a possible condition (assessment)

Question 20

What is illness in a health history?

Answer 20

How the patient experiences all aspects of the disease, including its affect on relationships, function, and sense of well-being

how it affects patients life

Question 21

what four things should be taken into consideration, when considering the patient’s perspectives

Answer 21

Feelings – fears, or concerns about the problem

Ideas – about the nature and the cause of the problem( pt may have googled sx)

Quality of life – effect of the problem on the patient’s life

Patient expectations – often based on prior personal our family experiences (what they want out of this visit)

Question 22

what is empowering the patient

Answer 22

empowering with knowledge

Patients often feel vulnerable and overwhelmed by the encounter

Ultimately, the patient is responsible for their care

Empowered patient = a compliant patient

A good example of empowering a patient would be saying based on what you provided I think it could be x, y, or z disease, so I’m going to order these test to figure out which one.
- this allows patient o be filled in and see my decision making

Question 23

what are techniques for empowering the patient

Answer 23

• Discover the patient’s perspective,
• convey interest in the patient, not just the problem,
• validate patient emotions,
• share and be transparent with your clinical reasoning,
• reveal the limitations to your knowledge

Question 24

what should you do before walking into a patient room?

Answer 24

Check your appearance, reflect on your personal biases, review the medical record, review the cc and develop diagnosis, set goals for the interview, consider patient goals, make the patient comfortable

Question 25

how to greet the patient and establish rapport

Answer 25

• Great patient by first and last name,
• introduce yourself and identify your role,
• acknowledge others in the room,
• pull up a chair and put yourself at eye level,
• ensure equal distance to the door,
• if it’s your first encounter, explain how the interview will proceed

Question 26

how to establish agenda

Answer 26

Determine or confirm the complaint or patient concerns at the beginning of the interview, and if there are multiple concerns, narrow the focus of a visit to those that are most pressing

Question 27

putting it all together, what are the techniques of skilled interview

Answer 27

Expand and clarify the patient story (may be embarrassed and tell nurse different complaint)

Encourage a chronological timeline of events

Appropriate use of open ended and close ended questions

Avoid medical terminologies

Use active listening skills

Identify and respond to emotional cues

Shared understanding

Question 28

how to close encounter

Answer 28

At the end of every encounter give the patient a summary of findings treatments, and plans for follow up

Give patient the chance to ask any final questions or get further clarification

Close with “tell them three”
-theri main diagnosis
- what they need ot do
- why is it important to follow my directions

Use the teach back method to assess how well you explain things

Question 29

what is the teach back method?

Answer 29

Have the patient tell you what theyre going to do when they get home

Question 30

what is the tell them three

Answer 30

Telling the patient their main diagnosis, what they need to do, why it’s important for them to follow your instructions or follow up

at the end of an encounter

Question 31

The silent patient

Answer 31

Silence can have a purpose, or it can be in response to how you’re asking questions

Patience may fall silent to collect thoughts, remember details, consider your trustworthiness

During periods of silence, watch the patient for nonverbal cues

Consider if you’re asking questions to quickly if you offended the patient or if you failed to recognize an overwhelming symptom

Question 32

Confusing patient

Answer 32

Poor communicators,
- unable to make sense of story
-flight of ideas (psychosis)- one topic to next and dont relate

vague history,
-ideas poorly connected
- language hard to follow

the yes patient,
- respond yes to every question

bizarre statements
- my stomach knots up like a snake
(try to get what that feels like from them- pain? diarrhea?)

Question 33

for patients with capacity

Answer 33

Know HIPAA laws
Communicate your responsibility of confidentiality with the patient
Obtain consent before sharing patient information (including fmaily members)

Question 34

your patience with impaired capacity

Answer 34

Ask yourself, can you rely on what they say?

Does the patient have a durable medical power of attorney?

If not find a surrogate informant or decision-maker to assist with the history

Question 35

the talkative patient

Answer 35

Initially give the patient free reign for a few minutes, listening closely to get out of it what you can

consider why patient is talkative
- pent up concerns
- anxious
- story/joke teller
- obsessively detailed
- flight of ideas

Question 36

the crying patient

Answer 36

Crime can be therapeutic, as is your quiet acceptance of the patient’s distress or pain
Offer tissue and wait for the patient to recover
Probe gently in the cause of emotion
Respond with empathetic remarks

Question 37

angry patient

Answer 37

Consider why the patients angry, are they angry with you? Were you late is their anger justified?

accept angry feelings from patients

Allow them to express their anger without getting angry in return

Don’t join patients in their hostility toward other providers, even if you agree

Question 38

the abusive or disruptive patient

Answer 38

Patient may become overly disruptive, before approaching patients, alert, security staff, keep yourself and your staff safe

Question 39

Adapting to specific situations

Answer 39

Patients with language barriers, patient with low literacy, patient with impaired vision, or hearing, patient with limited intelligence, patient with personal problems, flirtatious patient, patient who is discriminatory, patient with limited language, proficiency, terminal patient

review topics in bates-will be tested on them

Question 40

How do you approach sensitive topics?

Answer 40

Use a transition statement when needing to ask sensitive questions

Explain why you need to know certain information

Consciously acknowledge your discomfort, denying your discomfort, may lead you to avoid the topic altogethe

Patients are less likely to be honest if you’re not comfortable

Question 41

Approaching sexual history

Answer 41

This can be acquired during the HPI if it’s pertinent to the chief complaint or social history

Be matter-of-fact, and use correct anatomical language

Your questions should always be about the behavior not the lifestyle

Do you have sex with men women or both – how many sexual partners have you had in the last six months five years lifetime – do use condoms for protection – what form of birth control do you use?

Question 42

approaching mental health history

Answer 42

Be sensitive when a patient reports symptoms known to be associated with mental illness

If the patient seems depressed, ask him about thoughts and/or plans of suicide

Over the past two weeks, have you felt down depressed or hopeless – over the past two weeks have you felt little interest or pleasure in doing things – have you felt like harming yourself or would you prefer to be dead?

Question 43

approaching Substance-abuse history

Answer 43

Routinely ask about current and past use of tobacco vaping, alcohol and drugs- get the pattern and amount of use and modes of consumption

Question 44

how do you document cigarette use?

Answer 44

pack years

take number of packs smoked per day multiplied bynumber of years smoking

(1 pack a day for 15 years= 15 pack years
2 pack a day for 15 years = 30 pack year)

Question 45

approaching substance-abuse history

Answer 45

CAGE Questionnaire

Have you ever felt you should Cut down on your drinking?

Have you ever been Annoyed when people criticize your drinking?

Have you ever felt bad or Guilty about your drinking?

Do you ever need an Eye-opener a drink first thing in the morning to study your nerves and get rid of a hangover?

Question 46

Approaching family violent history

Answer 46

Possible physical abuse, cues are

• injuries that are unexplained in consistent with the patient story or concealed by the patient
• delayed treatment for trauma
  -past history of repeated injuries, or “accidents”
  -if the patient or person close to the patient has a history of alcohol or drug abuse
  -partner tries to dominate. The interview will not leave the room or seems unusually anxious or solicitous.

Question 47

Approaching the dying patient

Answer 47

Understand the patient wishes about treatment at the end of life,

ask direct and specific questions, even if discussions of death, and dying or difficult for you,

explore, and understand the patient’s religious or spiritual beliefs

Question 48

Sexuality in the clinician patient relationship

Answer 48

Any sexual contact or romantic relationship with the patient is unethical

If unwelcome behavior continues leave the room and find a chaperone to continue the interview

Reflect on your own image and appearance

Question 49

What is cultural humility?

Answer 49

Approach each patient as a unique individual

Work on an appropriate and informed clinical approach to all patients by becoming aware of your own values and biases

Develop communication skills that transcend cultural differences

Build therapeutic partnerships, based on respect for patients life experiences