Week 1 - Approach to Clinical Encounter Flashcards
The interviewing process
- Active listening
- Guided questioning (open–>closed ended)
- Summarization
- Transitions (pt knows what to expect)
o Partnering - Validation/empowering
- Reassurance
Types of interviewing techniques
Patient centered
- Patient’s concerns, feelings and emotions
Provider centered
- clinician takes charge of the interaction to meet own needs to acquire symptoms, details, or other data to diagnose the disease
Setting the stage for examination
- Adjust environment for comfort
- Review clinical record
- Set your agenda – clarify goals
Establishing rapport
- Feeling of connectedness
- Making them feel deeply heard and understood
- Explain your role in their care
Illness
Patient’s experience of their symptoms
FIFE Model
Feelings (fears, worries)
Ideas (what may have caused illness, what does the pain mean, what is going on?)
Functional effect (how does this affect QOL, people in life, day to day effects)
Expectations (what can the provider do, expectations, hopes)
Fundamentals of skilled interviewing
- Active or attentive listening
- Guided questioning
- Empathic responses
- Summarization
- Transitions
- Partnering
- Validation
- Empowering the patient
- Reassurance
- Appropriate verbal communication
- Appropriate nonverbal communication
People first language
- Person with substance use disorder vs. drug abuser
- Person diagnosed with schizophrenia vs. schizophrenic
- Person living with HIV vs HIV patient
Verbal communication
- Use understandable language (avoid jargon, communicate only essential information)
- Use short simple sentences, clear concrete words and phrases
Nonverbal communication
- Eye contact
- Calm and unhurried
- Positive, professional regard
- Read the patient’s nonverbal cues
- Mirror patient posture to help form connection
Challenging patient situations and behaviors
Silent
- may be therapeutic, collecting thoughts, “what are you thinking about”
Talkative
- Allow to talk 5-10 min uninterrupted, focus on what is most important for patient, summarize, use more focused questions
With confusing narrative
- Use guiding questions, clarification, summarization
With altered state or cognition
-Seek family to assist
With emotional lability
-Provide support, allow crying
Angry or aggressive
- Acknowledge situation, validate feelings without agreeing, actively listen, try to understand patient
Flirtatious
- Set clear boundaries
Discriminatory
- Set clear boundaries
- Assess illness acuity of patient, cultivate therapeutic alliance
With hearing loss
- Use aids, sit on hearing side
With low or impaired vision
- Wear glasses, use verbal explanations
With limited intelligence
- Mini mental exam
Burdened by personal problems
- Look at pros and cons rather than giving advice, what other options have been considered
Nonadherent
- Use reminders, emails, letters, forms, simplify dosing schedule, alter management plan
- Ask about reading, be sensitive
With low health literacy/ With limited language proficiency
-Medical interpreter
With terminal illness or dying
- Effective communication on needs
Focused assessment
- Address focused concerns/symptoms
- Restricted to specific body system
- Applies exam relevant to the concern
Comprehensive Assessment
Components:
- Patient information
- CC
- HPI
- PMH
- FH
- PSH
- ROS
Focused assessments used for
- Patients seeking care for a specific concern
- Ongoing care for chronic problems
- Health maintenance visits
Comprehensive assessment used for
- New patients in most settings (office, hospital)
OLDCARTS
- Onset
- Location
- Duration
- Character
- Aggravating
- Reliving
- Time
- Severity
Subjective data
something the “subject” or patient tells you
- headache
- pain level
- symptoms
- how they feel
Objective data
can be measured
- VSS
- CT scan
- CXR
Head to toe physical assessment
The head-to-toe physical assessment
o General survey
o Vital signs
o Skin
o HEENT
o Neck
o Back
o Posterior thorax and lungs
o Breasts and axillae
o Anterior thorax and lungs
o CV system
o Abdomen
o Lower extremities
o Nervous system
- Mental status
- Cranial nerves
- Motor system
- Sensory system
- Reflexes
o Genital/Rectal exam men –/– Genital rectal exam in women
The problem list
List most active and serious problems first and their date of onset
Can list active/inactive problems separately and may include
- Symptoms
- Signs
- Past health events (hospital admissions, surgery, diagnoses)
Differential diagnosis list
- Generate an exhaustive list
- Match findings against conditions that produce them
- Eliminate diagnostic possibilities that fail to explain findings
- Weigh competing possibilities and select the most likely diagnosis
- Give special attention to possibly life-threatening conditions
The summary statement
The key characteristics included are the patient information (age) and the chief complaint (duration, quality, associated symptoms). Only the salient characteristics are included.
For example, the chronic duration of 3 months rules out many acute life-threatening processes such as meningitis, subarachnoid hemorrhage, and stroke.
The clinical context here is her history of migraines since childhood.
Assessment (medical diagnoses)
- Can be diagnostic or therapeutic or both
- List problems in order of priority and expanded with an explanation of supporting findings and a differential diagnosis
- If symptom has unknown cause then include brief description of possible diagnoses
- Known diagnoses or chronic conditions assessment will describe the current status
Planning (treatment and interventions)
o Plan for addressing the problem list
o Plan for management of chronic conditions moving forward
o May include symptom or disease control, complications, current mangagement with adherence to treatment or any adverse effects
