Patient Health History Investigation Flashcards

1
Q

Patient centered interview

A

Exploring the patient’s disease/diagnosis and its effect on his or her life.
Understanding the whole person.
Finding common ground regarding intervention or management.
Advocating prevention and health promotion.
Enhancing the patient-provider relationship.
Providing realistic expectations.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Goals of Patient history

A
  1. Establishing rapport
  2. Identifying any barriers to communication
  3. Identifying the patient’s preferred learning style
  4. Establishing the patient’s goals for physical therapy
  5. SINSS
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Communication strategies

A
Ask one question at a time. 
Periodic restatement or summarization. 
Avoid medical jargon. 
Use patient’s line of thought. 
Avoid assumptions. 
Self-assessment.
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

Patients with hearing deficits

A
  1. Utilize a quiet area for the interview.
  2. Patient should use hearing and visual aids when available.
  3. Clinician should position themselves to facilitate lip reading.
  4. Use of interpreter (ASL) may be needed.
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

Angry patients: manifestations

A
Obvious 
Use of sarcasm or cynicism
Negativity 
Lack of compliance 
Non-verbal forms of communication
Escalation
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Angry patients: be cautions

A

Patient tensely moving to the edge of the chair.
Patient tensely gripping the arm rests.
Loud, forceful speech.
Restless agitation, pacing, and inability to sit still

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Depressed Patients

A
Impaired concentration. 
Poor compliance with home instructions.
Clinician should acknowledge the situation. 
Explore potential reasons. 
Recognize potential for suicide.
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

Importance of a thorough exam

A
  1. Differential diagnosis.
  2. Safe delivery of physical examination.
  3. Review patient’s list of medications.
  4. Assess potential impact of co-morbidities.
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

Patient Health History Data

A

1.Patient demographics.
2.Social history
3.Current medical situation
4.Past personal medical history
Illnesses
Allergies
Surgeries
Injuries
Medications
5.Social habits
6.Family medical history.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

Patient demographics

A
  • Age
  • Sex
  • Race
  • Marital status
  • Level of education
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Information from a body chart

A
  • Area of symptoms … and free of symptoms
  • Qualifications of the symptoms
  • Chronology of symptoms
  • Relationship between symptoms
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Social History

A
  • Cultural customs
  • Religious beliefs
  • Occupation and work status
  • Living environment
  • Family and social support
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Social Habits

A
  • Exercise: Frequency and Intensity
  • Use of tobacco
  • Alcohol intake
  • Caffeine intake
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Tobacco

A
•   Leading cause of preventable death
•   Smoking leads to disease and disability
•   Harms virtually every organ system in the body
•   Primary risk factor/causes:
Cancer
Heart disease
Strokes
Lung diseases
Diabetes
COPD
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

CAGE (alcoholism)

A
  • Have you ever felt you should Cut down on your drinking?
  • Have people Annoyed you by criticizing your drinking?
  • Have you ever felt bad or Guilty about your drinking?
  • Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover (Eye-opener)?
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Caffeine intoxication

A
  • Recent consumption of caffeine (≥ 2-3 cups)
  • Multiple typical clinical manifestations
  • Distress or impairment in social, occupational, rehabilitation, school, etc.
17
Q

Caffeine symptoms

A
  • restlessness
  • nervousness
  • excitement
  • insomnia
  • flushed face
  • diuresis
  • GI disturbance
  • muscle twitching
  • rambiling flow of thought or speech
  • periods of inexhaustibility
  • psychomotor agitation
18
Q

Caffeine withdrawal

A
  • headache
  • lethargy
  • fatigue
  • dysphoric mood
  • muscle pain/stiffness
19
Q

Family medical history

A

o Who in your family has heart/other disease?
o What type of disease do (did) they have?
o At what age was he or she diagnosed?
o What is his or her current health status?
o If the person has died, was it from the heart/other problem, and at what age?

20
Q

Documentation

A
Medical records 
Patient self-reports 
Screening Questionnaires 
- Red flags
- Yellow flags 
- Pregnancy (when indicated)
- Other