Module 1 Interviewing for Health History and Genetics Flashcards
partnership goals (5)
building rapport determine patient concerns discover information determine diagnosis negotiate and share in health care management
autonomy
self determination
beneficence
to do good for the patient
nonmaleficence
to do no harm
utilitarianism
appropriate use of resource for greater good
fairness and justice
equitable treatment of all
deontologic imperatives
care delivered according to traditions and cultural context
enhancing partnership (5)
Courtesy comfort connection confirmation confidentiality
Enhancing communication (5)
facilitate: open ended questions
reflect: repeat what you heard
clarify
empathize
interpret
Complete Hx
used for new patient or consultation
Makes you as thoroughly familiar with the patient as possible
interim hx
event since last seeing patient
designed to chronicle events that have occurred since last meeting with pt
problem or focus hx
used in urgent care or with sick visit
taken when the problem is acute, possibly life threatening, requiring immediate attention
CC
chief compaint/concern
HPI
Hx of present illness
- chronological course of events
PMH
Past medical hx
FH
family hx
SH
personal and social hx
- socio and economic factors
ROS
review of systems
- current s/s
OLDCARTS
Onset Location Duration Characteristics Aggravating/Associated Relieving Timing Severity
Family Hx
3 generations in pedigree
- self
- parents/aunts/uncles
- grandparents
- 1st cousins (3rd generation)
ROS
General/constitutional Skin, Hair, Nails Head and neck Lymph Nodes Eyes Ears Nose Throat and Mouth Chest and Lungs Breasts Heart and Blood vessels Peripheral Vascular Hematologic Gastrointestinal Endocrine Genitourinary Musculoskeletal Neurological Psychiatric Menses Diet Pregnancies
Personal and Social Hx
nutrition exercise sleep substances sexual hx ome conditions occupation environment religion access to care
Spirituality FICA
Faith, belief, meaning
Importance and influence
Community
Address/Action in care
CRAFFT
screening tool for alcohol and substance abuse in adolescents
Car: ever ridden in car driven by individual using
Relax: use alcohol or drugs to relax?
Alone: use alcohol or drugs when alone?
Forget: Do you ever forget things you did while using?
Friends: friends ever tell you you should cut down?
Trouble: ever gotten into trouble while using?
CAGE
Screen for alcoholism Cutting Down Annoyance by criticism Guilty feeling Eye-openers: need for drink in the am
TACE
screening for alcoholism Take: how many drinks does it take to feel high Annoyed by criticism Cut down Eye opener
HITS
screening for domestic violence Hurt: you physically Insult: or talk down to you Threaten: with physical harm Scream: or curse at you
5 P’s of sexuality
Partners Practices Protection from STI's Past hx of STI Prevention of pregnancy
HEEADSSS
screening tool for Adolescent issues Home environment Education, employment Eating Activities (peer-related), affect, ambitions, anger Drugs Sexuality Suicide/Depression Safety from injury and violence
PACES
Screening tool for adolescent issues Parents, peers Accident, alcohol/drugs Cigarettes Emotional issues School, sexuality
inventory hx
related to but does not replace the complete hx
touches on the major points without going into detail
- useful when getting a feel for the situation
