Patient Health History Investigation Flashcards
Dimensions of the Illness Experience
- patient profile (capacities)
- pts goals
- functional limitations
- Patients perceptions about the disorder
- Patients feelings about the disorder
Goals of Patient History
- Establish Rapport
- ID barriers to communication
- ID pt’s learning style preference
- Establishing the pt’s goals for PT
- SINNS
Know the difference between Open and Closed ended Questions
Can you think of anything that makes your pain worse?
Does coughing or sneezing or being increase your pain?
Additional Communication Strategies
Ask 1 question at at time Periodic restatement or summarization Avoid medical jargon Use pt's line of thought Avoid assumptions Self Assessment
Patients with hearing deficits
Utilize quiet area for interview
Patient should use hear and visual aids when available
Clinician should position to facilitate lip reading
Use of Interpreter ASL may be needed
Angry patients
Be cautious
- patient tensely moving to edge of char, gripping arm rest, loud/forceful speech, restless agitation/pacing/inability to sit still
Depressed Patients
Impaired concentration, poor compliance
Clinician should acknowledge the situation
Explore potential reasons
Recognize potential for suicide
Importance of a thorough exam
- Differential diagnosis
- Safe delivery of physical examination
- Review patients list of medication
- Assess potential impact of comorbidities
Tobacco
Leading cause of preventable death
leads to disease and disability
harms every organ in the body
Alcoholism
30% adults in US at risk
Quantity alone doesnt determine if someone is alc dependent
CAGE
- cut down?
- Annoyed from criticizing your drinking?
- Felt guilty about drinking?
- Drink first thing in the AM or to get rid of hang over? (eye opener)
Caffeine intoxication
recent consumption >2-3 cups Caffeine withdrawal - head ache - lethargy - fatigue - Dysphoric mood - muscle pain/stiffness
