Patient Health History Investigation Flashcards
Patient centered interview
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.
Goals of Patient history
- Establishing rapport
- Identifying any barriers to communication
- Identifying the patient’s preferred learning style
- Establishing the patient’s goals for physical therapy
- SINSS
Communication strategies
Ask one question at a time. Periodic restatement or summarization. Avoid medical jargon. Use patient’s line of thought. Avoid assumptions. Self-assessment.
Patients with hearing deficits
- Utilize a quiet area for the interview.
- Patient should use hearing and visual aids when available.
- Clinician should position themselves to facilitate lip reading.
- Use of interpreter (ASL) may be needed.
Angry patients: manifestations
Obvious Use of sarcasm or cynicism Negativity Lack of compliance Non-verbal forms of communication Escalation
Angry patients: be cautions
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
Depressed Patients
Impaired concentration. Poor compliance with home instructions. 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 patient’s list of medications.
- Assess potential impact of co-morbidities.
Patient Health History Data
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.
Patient demographics
- Age
- Sex
- Race
- Marital status
- Level of education
Information from a body chart
- Area of symptoms … and free of symptoms
- Qualifications of the symptoms
- Chronology of symptoms
- Relationship between symptoms
Social History
- Cultural customs
- Religious beliefs
- Occupation and work status
- Living environment
- Family and social support
Social Habits
- Exercise: Frequency and Intensity
- Use of tobacco
- Alcohol intake
- Caffeine intake
Tobacco
• 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
CAGE (alcoholism)
- 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)?