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Advanced Clinical Assessment > Week 3 Health History and Motivational Interviewing > Flashcards

Week 3 Health History and Motivational Interviewing Flashcards

1
Q

Why is History so Important?

  • 70-80% of diagnoses can be made from ___ alone
  • 90-100% of diagnoses can be made when __ __ is added
  • Diagnostic tests often ____ what is found during HP (2)
  • The skills necessary to perform HP are the ____ of clinical practice
A
  • History
  • Physical exam
  • Confirms (lab, radiology)
  • Foundation
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2
Q

Keys to obtaining a good health history

1) Ask ___ question at a time
2) Move from ___ ended to ___ questions
3) Be _____ in asking questions so that you can get a ____ response
4) Offer _____ choice answers
5) Clarify when patient uses general terms such “I felt ____”
6) Use ___ language or words to encourage the patient to elaborate 7) _____ what the patient said

A

1) one
2) open to focused
3) specific, graded
ex) “how many stairs before you become SOB”
4) multiple
ex) “describe the pain is it pounding, aching, stabbing”
5) “funny” 6) body 7) Review

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3
Q

Communication is key to obtaining a good heath history

2 types of factors

A

Internal Factors

External Factors

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4
Q

Internal factors of communication

A

Liking others

Empathy

Ability to listen

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5
Q

External factors of communication

A

Ensure privacy

Refuse interruptions

Physical Environment (too hot or cold in room)

Dress (can have them stay in regular clothes for a bit)

Note Taking (don’t be rude, you can say excuse me I just want to make sure I got this down)

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6
Q

Nonverbal skills of communication

A

Physical Appearance

Posture - ex) arms crossed

Gestures - ex) on your phone, body language

Facial expression

Eye Contact

Voice and Touch - ex) if someone was just sexually assaulted obvs don’t touch them, but if they just lost someone then maybe you can touch

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7
Q

Verbal skills of communication

A

Open ended questions

Wait for response

Use closed or directional questions

Avoid asking more than one question at a time

Choose your responses (facilitation, silence, empathy, clarification, confrontation, explanation) - ex) Confrontation not to argue but if child has asthma and you smell smoke on parents clothing

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8
Q

Ten Traps of Interviewing

1) Providing ____ assurance
2) Giving unwanted _____
3) Using a____
4) Using a_____ language
5) Using professional _____
6) Using l____ or b____ questions
7) ____ too much
8) Int______
9) Engaging in d____
10) Using “___” questions

A

1) False
2) advice
3) authority - ex) I am the doctor
4) avoidance
5) jargon
6) leading or biased - ex) obtaining sexual hx -> who’s your gf? instead do you have a sexual partner
7) talking
8) Interrupting
9) distance
10) “why” - ex) why do you smoke? why do you eat too much?

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9
Q

Types of Visits (4)

A

Well Exam/Physical

New Visit

Acute/Episodic

Follow up

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10
Q

Types of Acute Visits (4)

A

Problem focused

Extended Problem focused

Detailed

Comprehensive

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11
Q

Problem Focused =

A

limited to one system or simple problem, ie follow up ear infection

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12
Q

Extended Problem Focused

A

Involves more than one system low complexity medical decision making

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13
Q

Detailed

A

Multiple systems and problems moderate complexity of medical decision making

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14
Q

Comprehensive

A

Multiple systems and data points highly complex level of clinical decision making

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15
Q

Well Physical Exam

1) Performed ____ or for a ___ pt in primary care setting
2) Provides _____ and personalized knowledge about pt
3) _____ pt-clinician relationship
4) Identifies causes of pt’s ____
5) Allows for health promotion through ___ and counseling
6) Develops proficiency in the essential ____ or ____ exam
7) Consists of (4)

A

1) annually, new
2) fundamental
3) strengthens
4) concerns
5) educating
6) skills, physical exam
7) Health History, Physical Exam, Assessment, Plan

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16
Q

SOAP

A

Subjective: what pt or family tells you

Objective: what you observe in physical exam and diagnostic testing

Assessment: what you think is going on

Plan: what you intend to do

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17
Q

World of EMR

Subjective (3)

Objective (2)

Assessment

Plan

A

Chief Complaint, History of Present Illness, ROS

Physical Exam, Labs/Testing

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18
Q

Obtaining a History: Identifying data

A
  • Name
  • Age
  • Sex/Gender
  • Race/Ethnicity
  • Place of birth
  • Marital Status
  • Occupation
  • Reliability (poor historian?)
  • Source of information
  • Referral (if referred from another, can send back notes to main provider)
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19
Q

Health History -Consists of Identifying Data

1) Chief _____
2) Hx of _____ illness
3) _ _ _
4) ____ Hx
5) P____/S_____ Hx
6) Review of _____

A

1) Complaint
2) present
3) PMH
4) Fam
5) Personal/Social
6) ROS

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20
Q

Chief Complaint

Diagnostic?

A
  • Represents primary reason for seeking medical attention
  • By convention, it is stated in the patient’s words and written in quotation marks
  • May include short statement on duration

It is NOT** diagnostic

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21
Q

Hx of Present Illness Consists of (2)

A

Detailed evaluation of pt’s symptoms*** SUBJECTIVE DATA

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22
Q

HPI Symptoms

1) Well Person:
2) Ill Person:
3) Written in ______ language, in ____ order
4) The goal is to elicit and intelligent, _____, and sequential _____ of the pt’s illness or perhaps current state of health
5) You will include __ key points of information referred to as an analysis of a Symptom Mneumonic (2)

A

1) Short statement about their general health
2) Succint chronological account of their CC
3) subjective, chronological
4) logical, account
5) 8 (OPQRST, OLDCART)

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23
Q

Medical History includes (5)

A

Medication - OTC, prescription, herbal meds? bring meds to office

Immunizations - adults and peds

Allergies - specific reactions, document food, insect and environmental factors

Alcohol/Drugs - frequency, amount, type, duration

Tobacco use - type, duration (pack year), when they quit

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24
Q

O P Q R S T

A

Onset

Provocative or Palliative

Quality or Quanitity

Reign or Radiation

Severity Scale/Site

Timing

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**O L D C A R T**
**O**nset **L**ocation **D**uration **C**haracter **A**ssociated/Aggravating Factors **R**adiation **T**iming
26
Past Medical History
Childhood illnesses Adult illnesses Immunizations Screening tests (mammo, colonoscopy) Women: obstetric/contraceptive hx Hospitalizations (dates) Surgeries (dates, procedures) Accidents or injuries Psych Hx
27
Personal/Social History
Living Situation Relationship Status Education level Employment Sleep Safety measures Religious beliefs Life style habits (smoking, alcohol, drugs, sleep) Exercise Diet
28
Pediatric Health History (4)
Maternity Hx - complications w pregnancy? Birth Hx - full term, pre-mature, complications at birth, vaginal or c-section, induced/natural/spinal Developmental Hx - met developmental milestones Bottle or Breastfed?
29
Older Adult Functional Assessment (2)
ADL's IADL's
30
**ADLs**
Transfer Toileting Continence Bathing Dressing Feeding
31
**Instrumental ADLs**
Using telephone (cell phone, even life alert?) Traveling Shopping Preparing meals Doing housework Manage meds Manage money
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Complete history ends with?
ROS
33
ROS =
An inventory of body systems used to uncover signs and symptoms not directly expressed by patient (if covered in HPI, not usually in ROS)
34
Each question in ROS usually starts with? How to document ROS?
Have you ever had any.... Pt reports, Pt denies
35
Head to Toe
Constitutional (weight loss/fever) Neuro HEENT CV/PV Respiratory GI/GU GYN/Sexual MSK Skin Endocrine Heme/Lymph Allergic/Immunologic Psych/Sleep
36
Additional Assessment Factors ## Footnote 1) G\_\_\_ and D\_\_\_\_\_\_ 2) E\_\_\_\_\_ status 3) C\_\_\_\_, R\_\_\_\_\_ and S\_\_\_\_ background 4) Performance of \_\_\_\_ 5) Patterns of C\_\_\_\_\_ 6) Client/patient p\_\_\_\_ and s\_\_\_\_ with his or her health \_\_\_\_ 7) "Anything you would: "
1) Growth, Development 2) Emotional 3) Cultural, Religious, SES 4) ADLs 5) Coping 6) Perception, Satisfaction, status 7) "Anything you would like me to know that I have no asked about"
37
Ending the Health Hx ## Footnote 1) End of the ____ data 2) Next phase is? - will be focused or comprehensive depending of visit reason 3) Beginning phase of what starts here? 4) Or in the event of a well visit: developing a? (3)
1) Subjective 2) **PHYSICAL EXAM\*** 3) **Diagnostic reasoning** 4) Problem list (nutrition, sleep, health maintenance)
38
**Physical Exam** ## Footnote Enhancing your power's of \_\_\_\_\_\* (nurse's ___ feeling)
**Observation**\* (Gut feeling) - learning physical exam techniques is all about becoming a better observer - skilled clinical has enhanced power of observation and knowledge to use these observations in care of pts
39
**Assessment Techniques (4)**
Inspection Palpation Percussion Auscultation
40
**Inspection**
Concentrated and active looking Provides enormous amount of information Least mechanical but yields most physical signs
41
**Palpation**
Use diff parts of hands Light vs. Deep palpation
42
**Percussion**
Indirect percussion - stationary hand Striking hand
43
**Auscultation**
Fit the quality of stethoscope Diaphragm and Bell Eliminate confusing artifacts
44
Complete Physical Exam Includes
General Survery/Function Neuro/Psych Skin/Hair/Nails HEENT Neck CV/PV Respiratory Breast/Axilla GI/Rectal/GU/Urinary MSK
45
**Clinical Decision Making** ## Footnote 1) ____ approach to pt care, provides a consistent \_\_\_\_\_ 2) Move from ____ to ____ data collection 3) Compilation of: 4) Use a ___ health assessment approach if possible 5) A complete and accurate ____ database is essential
1) Systematic, structure 2) General to Specific 3) Differential Diagnoses 4) Comprehensive 5) History
46
Clinical Decision Making Routine Decisions ie) Complex Decisions ie)
Earaches, sore throats, annual exams 21 yr old female w abdoinal pain * - History * - Physical (pelvic/rectal/abdominal) * - Lab (urine dipstick, culture, HCG, wet mount, gonorrhea, chlamydia and CBC)
47
**_Steps in CDM (7)_**
1) Identify the patient problem 2) Assess: collect history and physical data 3) **Formulate competing diagnoses (differential)** 4) Order diagnostics 5) Select diagnosis 6) Develop treatment plan 7) Implement and Evaluate: Follow up
48
CDM Step 3) Formulating Competing Diagnoses - S\_\_\_/S\_\_\_ - \_\_\_-related illness - E\_\_\_\_\_ trends of disease - Illnesses common in the \_\_\_\_\_\_\_ - F\_\_\_\_\_ diseases - T\_\_\_\_ course of illness **- ______ likelihood of a given disease**
- Signs/Symptoms - Age - Epidemiologic - Community - Familial - Time **- Statistical**
49
CDM Step 4) Order Diagnostics Things to take into consideration when ordering tests * What is the ____ and _____ of the test? * What ____ will the test provide? * Will I treat the patient _____ based on the \_\_\_\_ * Is the diagnostic ___ the \_\_\_\_?
* specificity, sensitivity * data * differently based on results * for the disease
50
Benefits of Laboratory Tests 1) Screening * Identify ____ \_\_\_\_\_ for disease * Detect occult disease in _______ persons 2) Diagnosis * Assists in _____ diagnosis * Assists in differential diagnosis of _____ possible disease 3) Patient Management * Evaluate ____ of disease * Estimate p\_\_\_\_\_ * Helps to m\_\_\_\_\_ course of disease * Detect disease r\_\_\_\_\_\_ * Select _____ and a\_\_\_\_ dosages of therapy
* risk factors * asymptomatic * early * various * severity * prognosis * monitor * drugs, adjust
51
Disadvantages of Diagnostic Tests - Tests can be \_\_\_\_\_ - Some tests carry a risk of _____ or \_\_\_\_\_ - Some can cause d\_\_\_\_\_\_ to pts - Results of a diagnostic test have ____ for further ___ by further ____ or follow up - May classify a healthy pt as diseased based on:
- expensive - morbidity, mortality - discomfort - implications, care, testing - fale positive
52
Interpreting Tests - Lab tests are not perfect. The best tehy can do is affect what we think is the _____ of some outcome - Does a positive test guarantee the patient has the disease and does a negative test ensure absence of a disease?
- probability - NO does not guarantee
53
**Sensitivity** **=** * ____ \_\_\_\_ Rate * \_\_/(\_\_+\_\_\_) * "\_\_\_\_\_ disease"
**The proportion of truly diseased persons in the screened population who are identified as diseased by the screening test** * True Positive * TP/(TP + FN) * "Detecting disease"
54
**Specificity** **=** * ____ \_\_\_\_ Test * \_\_/(\_\_+\_\_) * "Identifying \_\_\_\_\_"
**The proportion of truly non-diseased persons** * True Negative * TN/(TN + FP) * "Healthy"
55
Selecting a Diagnosis - Select the _____ b\_\_\_ diagnosis - C\_\_\_\_ clues to see \_\_\_\_ - As skills develop, _____ of ____ problems will be integrated - At this point, may decide to ____ colleagues or refer
- single best - cluster, patterns - management, multiple - consult
56
Treatment Plan - Utilize both ____ and ____ knowledge - The plan must include:
- nursing, medical 1. What is to be done 2. How is it to be done 3. What and who is to do it 4. When is it to be done 5. For how long is it to be done
57
Plan - Diagnostic: - Therapeutic: - Patient Education: - Referrals: - Follow up:
- What diagnostic tests are you ordering to be completed outside of the visit - what prescriptions or medications are you ordering, must include name, dose, duration - what education/counseling did you provide - who are you sending them to for evaluation and treatemtn - when are you going to see them again
58
**Prescription Writing** A Valid Prescription includes * ______ name * \_\_\_, \_\_\_\_, A\_\_\_\_\_ * _____ name, ______ #, and ____ # * Name of ____ (brand or generic) with a ____ dosage * Sig: a\_\_\_\_, r\_\_\_\_\_, f\_\_\_\_\_ * ______ amount
* Patient's * Age, DOB, Address * Prescriber's, License, DEA * Drug, unit * Amount, Route, Frequency * Dispense
59
Problem Lists Include - A firmly established \_\_\_\_\_ - A ___ symptom of physical finding or unknown etiology or significance (fatigue) - Unexpected or new findings revealed by ___ tests (low iron) - P\_\_\_\_\_ or S\_\_\_\_\_ difficulties (recovering ETOH) - ___ factors for serious conditions - Factors crucial to ____ for ___ term
- Diagnosis - New - New by Lab - Personal, Social - Risk - Remember, long
60
Oral Case Presentations - The logical flow emerges from a good workup and write up - Pt info-addressograph plate if available What is the flow?
1. Intro sentence 2. CC and duration 3. HPI 4. PMH 5. Allergies/Meds 6. ROS 7. Physical findings 8. Lab tests 9. Brief two sentence summary
61
**Ambivalence**
The **unresolved conflict** between pros and cons, and leads to continued engagement of a behavior
62
What is the principal impediment to change? (of bad health behaviors)
Persistent Ambivalence
63
**The Stages of Change**
64
Stages Involved in Behavior Change 1) Identifying the \_\_\_\_\_\_\_ 2) Identifying the \_\_\_\_\_\_\_ 3) D\_\_\_\_ a ch\_\_\_\_\_ 4) Feeling _____ about a change 5) _____ it!
1) behavior 2) problem 3) desiring change 4) confident 5) doing
65
Motivational Interviewing Background - First described in the 1980's by William Miller and Stephen Rollnick, two _____ who had experience treating \_\_\_\_\_\_ - Spirit or ______ of MI and behavior change considered most important
- psychologists, alcoholism - philosophy
66
Goal of Motivational Interviewing - Finding out which ____ the patient is at, and addressing the _____ specific to their stage - Have the patient articulate their "\_\_\_" and "\_\_\_" so they can better process and ultimately ____ the _____ between them - E\_\_\_\_ and E\_\_\_\_\_ the patient to take steps toward ____ by _____ their strength as well as the centrality of *their* initiative in _____ change
- stage, concerns - "pros", "cons", resolve, conflict - Empathizing, Empowering, change, affirming, lasting
67
A common way of assessing as well as cultivating confidence or importance is the use of? \_\_\_\_\_ can help pts verbalize and process their ambivalence further
Use of scales Scales "On a scale of 1-10 how important do you think it is for you to quit smoking?" (9/10) "On a scale of 1-10, how confident are you that you can quit smoking?" (4/10)
68
Once the patient gives scaled scores to questions, what do we do? * Affirmations * Reflecting pros and cons * Look for patient driven strengths Give examples of each
"Why did you give yourself a 4 instead of 2? "I am impressed that you have been trying to quit despite all the stress you are going through" "So, it is important for you to smoke in order to deal with the stress in your life, but you also wish you could quit in the interest of your child's health" "What would make you go up to a 6 or 7?"
69
Motivational interviewing, what do you do with resistance?! (3)
1. **"Roll" with resistance** * ex) "Yes it does seem that you've been smoking for quite some time and your child's asthma has only recently been flaring up." 2. **Empathize with the patient****​** * ex) "It sounds like many of us have not been telling you what you should do and we're not listening to what you would like to do for your child" 3. **EMPOWER the patient** * **​​**"You know, its up to you what you like to do with your daughter's medication- after all you are mohter" *(as long as mother is not endangering daughter's health)*
70
Motivational Interviewing You can try using a Decisional Matrix
71
Motivational Interviewing is what type of philosophy?
**Patient centered Philosophy!**
72
Final Thoughts on Motivational Interviewing ## Footnote - What type of tone and attitude helps patients be more open about their "pros" and "cons" - Focus on the ____ of the patient: ie. don't address confidence issues if the patient isn't interested in changing their behavior - What should we dismantle?
- NON-JUDGEMENTAL! - stage - Assumption that we have FAILED if pt doesn't make decisions toward change at each visit

Advanced Clinical Assessment (1 decks)

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