Use LEFT and RIGHT arrow keys to navigate between flashcards;
Use UP and DOWN arrow keys to flip the card;
H to show hint;
A reads text to speech;
46 Cards in this Set
- Front
- Back
|
goals of the history interview? |
1. discover info leading to diagnosis and management 2. provide info about diagnosis 3. negotiate health care management 4. counsel about disease prevention 5. develop rapport with pt |
|
|
what are the three types of histories? |
1. complete 2. problem-based (used for most of our pt encounters) 3. interim |
|
|
what is a complete health history used for? and what does it include? |
-used as a baseline for the initial exam -used on admission to the hospital
-includes all aspects of the pts health status |
|
|
what is problem-focused history used for? and attention is focused on? |
-used for emergency department, walk-in clinic or office visit
-focused on the presenting problem with attention to any related system |
|
|
what is interim history used for? this type records events since? and frequently records the results of? |
-used when the examiner has previously evaluated the patient -records events since the last visit -frequently records the results of therapy previously instated |
|
|
how to arrange the setting for history taking? |
-comfort for pt and family -removal of physical barriers -good lighting -privacy -relative quiet -unobtrusive access to clock |
|
|
what factors enhance communication? |
-flexibility -clarity -subtlety -lack of value judgements -exploration of the pts feelings |
|
|
factors that inhibit communication? |
curiosity, anxiety, silence, depression, crying, anger, money, intimacy, etc |
|
|
what are the two forms of communication? |
1. verbal--what we say
2. non-verbal--body language and attitude |
|
|
what are the three aspects of verbal communication? |
1. speaker 2. words 3. listner |
|
|
what are the two types of questioning for obtaining a history? |
1. open-ended
2. closed-ended |
|
|
components of open-ended questioning? |
1. silence 2. nonverbal encouragment 3. neutral utterances and continuers 4. reflection and echoing 5. open-ended requests 6. summary and paraphrasing |
|
|
components of closed-ended questions? |
1. yes or no 2. brief answers |
|
|
it is said over ___% of diagnoses are made on history alone, a further 5-10% on examination, the remainder on investigation? |
80% |
|
|
avoid writing while the patient is? |
is talking |
|
|
document what the patient ___, not ___? |
what they tell you, not your interpretations |
|
|
tell the patient you are just taking notes to? |
to keep the order straight |
|
|
you want to ask ____questions, and avoid ___questions? |
ask open-ended, and avoid leading questions |
|
|
examples of gentle steering phrases may include? |
-please tell me which problem is troubling you most?
-perhaps we could come back to that |
|
|
always phrase the chief complaint in? note all significant? |
in the patients own words, and put quotes around their words
-note all significant complaints and seek an answer to the question |
|
|
the history of present illness section of the record should tell their? you may have to ____the patients words? ___is a key element of any disease process? |
-should tell their story -summarize and paraphrase the pts words -timing is a key element of any disease process |
|
|
in the history of present illness section of the record, ___are as important as ___? |
pertinent negatives are as important as pertinent positives |
|
|
for the history of present illness what does OLDCAARTS stand for? |
o- onset l- location d- duration c- character a- aggravating/assoicated factors r- relieving factors t- temporal factors s- severity of symptoms |
|
|
Onset section of the history of present illness section is? |
-how and when the problem began -what what the pt doing when the symptoms began? -is there anything the pt does that reliably causes the symptoms? -establishes the framework for the temporal sequence of event |
|
|
the onset section of the present illness history establishes the framework for the ___? |
for the temporal sequence of event |
|
|
"location" in the present illness history section means? |
-if the symptom is pain, establish exactly where it is located. have the pt point to the area -is the sensation localized or does the pt feel it elsewhere? |
|
|
"duration" in the present illness history section means? |
-are the symptoms constant? -if the problem is episodic, how long does each episode last? |
|
|
"character" in the present illness history section means? |
-have the pt describe how they perceive the sensation -if it is pain, is it sharp, dull, etc? |
|
|
"aggravating/associated symptoms" in the present history section means? |
-is there anything the pt does that make the symptoms worse and what is the temporal relationship? -are there any other symptoms that have a temporal relationship to the main complaint? -if there is something produced, have them describe it: amount, color, oder, appearence |
|
|
"reliveing factors" in the present history section means? |
-is there anything the pt does that make the symptoms better and what is the temporal relationship? |
|
|
"temporal factors" in the present history section means? |
--are the symptoms single occurrence or a recurring problem? -have the symptoms changed in character or severity over time? |
|
|
"severity of symptoms" in the present history section means? |
-have pt rate pain on 1-10 scale and record whether the severity changes -how has this impacted their quality of life -has there been an effect on their lifestyle |
|
|
where do appropriate questions arise in the history of present illness section if OLDCAARTS doesn't apply? |
logic-- cough, temp, nausea, etc.
-ROS--in appropriate associated areas |
|
|
in the past medical history section, for any female over the age of 10 you want to get? |
menstrual history, and pregnancy history |
|
|
the family history section includes? |
-expoloration of a families health, past medical experiences, illnesses, social experiences, deaths, and genetic and environmental circumstnces -those with illness similar to patients? -those with history of major disease -those with hereditary disease |
|
|
the family history includes what relatives? |
-parents -siblings -grandparents (if useful) -for all family members: alive or deceased, age, state of health or cause of death -may diagram the family if there is a genetic condition |
|
|
with the family history section, you may diagram the family if there is? |
a genetic condition |
|
|
personal and social history includes? |
-home envrionment/living arrangements -marital/significant other status -occupation(even if retired)/ hobbies -tobacco use -alcohol use -toxic/chemical exposure -diet and exercise habits |
|
|
things to do when approaching sensitive issues? |
-ensure privacy -be direct and firm -dont apologize -dont preach -use language that is understandable -dont push too hard |
|
|
what are the sensitive issues that you need to approach? |
-alcohol and recreational drug use -religion -sexual history and orientation |
|
|
review of systems is easiest to remember if? |
if it is done in a head-to-toe manner |
|
|
with the review of systems list each ___finding, ONLY if you think? |
each negative and positive finding
-ONLY if you think they relate to the problem |
|
|
with the review of systems DO NOT simply write negative for___? |
for the organ system
|
|
|
for the review of symptoms DO NOT ___on a symptom if you have not? |
do not comment on a symptom if you have not asked the question |
|
|
examples of concluding questions for obtaining a medical history? |
-is there anything else that you think would be important for me to know? -what problem concerns you most? -what do you think is the matter with you? -what worries you the most about how you are feeling? |
|
|
in the obtaining a medical history what are the areas of "relatively less importance"? |
-PMH: ex. DM, hypertension, MI -FH: ex. history of rare or common disorders present -SH: ex. depression, alcoholism, drugs -rest of ROS: ex. syndromes |
