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109 Cards in this Set
- Front
- Back
WHAT IS THE FIRST STEP OF
MEDICAL HISTORY INTERVIEW? |
Determining the content of
the visit. |
|
WHAT ARE SOME EXAMPLES OF
A PATIENT'S POINT OF VIEW? |
1. We all have unique
perceptions of the external world. 2. Unique experiences. 3. Unique base of information. 4. Make every effort to sense the world of the individual patient (as the pt senses it). |
|
LIST THE CONSIDERATIONS
DURING ACQUIRING PATIENT'S INFO. |
1. Pt's point of view.
2. You need to understand the POWER you have and the VULNERABILITY of the patient. 3. Central objective of interacting with a pt. 4. Understand PT'S EXPECTATION OF YOU. 5. Help define what it is to be expected of the patient. |
|
DEFINE CENTRAL OBJECTIVES
OF INTERACTING WITH A PATIENT? |
1. Find out what is at the
root of pt's concern. 2. Try to deal with underlying worries. 3. Believe the patient. 4. Do not be judgmental of the pt. |
|
WHAT ARE THE ETHICAL
CONSIDERATIONS? |
1. The patient interview
forms a partnership with the patient based on: honesty, empathy, respect. 2. Goals of the patient interview. 3. Each interaction must be oriented to the pt. 4. Listen carefully. 5. Constantly hone your interviewing skills. |
|
WHAT ARE THE GOALS OF THE
PATIENT INTERVIEW? |
1. Dicovering information
leading to Dx and management. 2. Providing information to the patient concerning Dx. 3. Negotiating with the patient concerning management. 4. Counseling about disease prevention. |
|
DON'T CONCENTRATE SOLELY
TO A SPECIFIC PROBLEM OR DISEASE IS WHAT EHICAL CONSIDERATION? |
Each interaction must be
oriented to the patient. |
|
WHAT IS ETHICS?
|
Does not provide answers,
but offers guidelines to determine ultimate behavior. |
|
WHAT ARE THE 6 ETHICAL
CONCEPTS FOR BE CONSIDERED? |
1. Autonomy
2. Beneficence 3. Nonmalficence 4. Utilitarianism 5. Fairness and Justice 6. Deontologic imperatives |
|
DEFINE AUTONOMY.
|
Pt's need for self-
determination. |
|
DEFINE BENEFICENCE.
|
The care provider's need
to do good for the patient. |
|
DEFINE NONMALFICENCE.
|
Do no harm to the patient.
|
|
DEFINE UTILITARIANISM.
|
Consider the appropriate
use if resources for the greater good of the larger community. |
|
WHAT AFFECTS FAIRNESS AND
JUSTICE? |
Managed care and limited
resources. |
|
DEFINE DEONTOLOGICAL
IMPERATIVES. |
The duties of care
providers established by tradition and in cultural contexts. |
|
IN OTHER WORDS, WHAT DOES
PT'S POINT OF VIEW MEAN? |
Make every effort to sense
the world of the individual pt... * as the PATIENT senses it. |
|
WHAT DOES BELIEVE THE
PATIENT MEAN? |
Do not be judgmental of
the patient. |
|
DURING THE PATIENT'S
INTERVIEW, WHAT IS THE PARTNERSHIP WITH THE PT BASED ON? |
1. Honesty
2. Empathy 3. Respect |
|
WHAT ARE THE GOALS OF
PATIENT INTERVIEW? |
1. Discovering information
leading to Dx and management. 2. Providing information to the pt concerning Dx. 3. Negotiating with the pt concerning management. 4. Counseling about disease prevention. |
|
WHAT ARE THE ETHICAL
GUIDELINES? |
1. Make sure the problem
at hand is truly one of ethics. 2. Ensure that the facts are as clearly stated as possible. 3. Attitudes of pts should be clearly communicated. 4. Pt's point of view should prevail unless compelling argument otherwise. |
|
MAKE SURE THE PROBLEM AT
HAND IS TRULY ONE OF ETHICS AND NOT A RESULT OF...? |
1. Poor communication
2. Legal confusion 3. Personality conflict |
|
WHAT'S LISTEN TO THE
PT'S STORY? |
The H&P begins and is at
the heart of the Dx and Tx process. |
|
WHAT IS BEST SUITED FOR
GETTING PT INFO? |
COMPULSIVENESS
"It's okay to be COMPULSIVE as you compile and record info, but remain sensitive to the less obvious "soft" clues. |
|
WHAT ARE THE PRINCIPLES OF
HX TAKING? |
1. Communicating with the
pt. 2. Asking questions |
|
WHAT ARE CONSIDERED AS
COMMUNICATING WITH THE PT? |
1. Personal objectives.
2. Factors that influence communication. 3. Factors that enhance Communication: VEGA 4. Flexibility 5. Clarity |
|
WHAT ARE THE PERSONAL
OBJECTIVES OF HX TAKING? |
1. Identify those matters
the pt defines as problems. 2. Develop a sense of pt reliability as an interpreter and reporter of events. 3. Keep an attitude of friendliness and obvious respect. |
|
WHAT DOES VEGA MEAN?
|
1. V - voice
2. E - Eye contact 3. G - Gestures 4. A - Attitude |
|
WHAT FACTORS INFLUENCES
VOICE COMMUNICATIONS? |
1. Tone
2. Inflection 3. Volume 4. speed 5. Avoid being careless with words |
|
WHAT FACTORS INFLUENCES
EYE CONTACT? |
1. Appropriate eye contact
conveys interest and concern. 2. Avoid too much eye contact which can be uncomfortable. |
|
WHAT FACTORS INFLUENCES
GESTURES? |
1. Avoid a stiff, formal
demeanor. 2. Avoid extremes of reaction as the pt provides info. 3. Nonverbal demeanor matters just as much as your words. |
|
GIVE EXAMPLES OF EXTREME
REACTION? |
1. Startle
2. Surprise 3. Laughter 4. Grimacing |
|
WHAT FACTORS INFLUENCES
ATTITUDE? |
1. Avoid too much casual.
laid back attitude. 2. A friendly attitude can go a long way in your pursuit of info for the hx. |
|
WHAT ATTITUDE CAN GO A
LONG WAY IN YOUR PURSUIT OF INFO FOR THE HX? |
Friendly Attitude
|
|
WHAT ARE OTHER ADDITIONAL
FACTORS THAT ENHANCE COMMUNICATION? |
1. Maintain professional
dress and grooming. 2. If you do not speak the pt's language, get an interpreter. 3. Avoid slang 4. Listen intently 5. The "art of intelligent repose". 6. Every behavior should convey empathy and build trust. |
|
IN OTHER WORDS, DEFINE
THE "ART OF INTELLIGENT REPOSE"? |
1. Summarizes a positive
listening and observatory role of the provider. 2. Provider should be calm, still and attentive. |
|
WHAT DOES FLEXIBILITY MEAN?
|
You must allow freedom for
the pt to pursue his associations. |
|
WHAT DOES ALLOWING FREEDOM
FOR THE PATIENT TO PURSUE HIS ASSOCIATIONS MEAN? |
1. Ask open-ended
questions from the beginning. 2. Initially, let the pt describe the experience in their own words. 3. Later as info accumulates, it will be necessary to know precise, measurable details. |
|
WHAT ARE THE THREE TYPES
OF QUESTIONS? |
1. Open-ended questions
2. Direct questions 3. Leading question |
|
DEFINE OPEN-ENDED
QUESTIONS? |
Leaves discretion to the
pt about the extent of the answer. |
|
WHAT IS THE PURPOSE OF
DIRECT QUESTIONS? |
Seeks specific information.
|
|
DEFINE LEADING QUESTIONS?
|
Most risky, it may limit
the info provided to only that what the pt thinks you want to know. |
|
WHAT ARE THE FUNCTIONS TO
PERFORM DURING QUESTIONING? |
1. Facilitate
2. Reflect 3. Empathize 4. Confront 5. Interpret 6. Clarify 7. Encourage 8. Subtlety 9. Value Judgment 10. Jargon |
|
DEFINE FACILITATE?
|
Encourage your pt to say
more. |
|
DEFINE REFLECT?
|
Repeat what you have heard
to encourage more detail and confirm an accurate understanding. |
|
DEFINE EMPATHIZE?
|
Show your understanding
and acceptance. |
|
WHAT DOES CONFRONT MEAN?
|
Do not hesitate to discuss
a pt's disturbing behavior. |
|
WHAT DO YOU DO TO
INTERPRET? |
Repeat what you have heard
to confirm the meaning with the patient. |
|
WHAT DO YOU ASK TO CLARIFY?
|
"What do you mean?"
|
|
TO CLARIFY IS TO...?
|
1. Ask, "What do you mean?"
2. Ask often what the pt thinks and feels about an issue. 3. Make sure you know chief concern, it may change. 4. Inquire about issues at home and the workplace that may be influencing the major complaint. |
|
ENCOURAGE MEANS...
|
1. Suggest at appropriate
times that you have the "feeling" that there is more to say or that things may not be as well as they are reported. 2. Suggest at appropriate times that it is okay to be angry, sad, or nervous. 3. Make sure that the pt's expectations in the visit are met and that there are no other questions. |
|
WHAT DOES SUBTLETY MEAN?
|
1. Some apparent
irrelevancies may provide background information. 2. Be sensitive to the extent of an answer that is being sought. |
|
WHAT SHOULD YOU DO TO
VALUE JUDGMENT? |
1. Avoid the trap of being
too directive on certain issues. 2. Allow the pt to come to a decision as free as possible from the imposition of your value judgment. 3. Remain a health professional and not a preacher. |
|
WHAT ARE CONSIDERED AS
MOMENTS OF TENSION IN PATIENT MANAGEMENT? |
1. Curiosity
2. Anxiety 3. Silence 4. Depression 5. Crying 6. Manipulation 7. Intemacy issues 8. Suicidal 9. Affection 10. Anger 11. Dissemblance 12. Financial Stress 13. Intoxication |
|
WHAT DO YOU DO WHEN
PATIENT STARTS TO ASK CURIOUS QUESTIONS ABOUT YOU? |
A short answer followed
by "Why do you ask?... |
|
DEFINE ANXIETY?
|
Painful uneasiness or
possibly feeling of impending doom. |
|
WHAT DOES SUBTLETY MEAN?
|
1. Some apparent
irrelevancies may provide background information. 2. Be sensitive to the extent of an answer that is being sought. |
|
WHAT SHOULD YOU DO TO
VALUE JUDGMENT? |
1. Avoid the trap of being
too directive on certain issues. 2. Allow the pt to come to a decision as free as possible from the imposition of your value judgment. 3. Remain a health professional and not a preacher. |
|
WHAT ARE CONSIDERED AS
MOMENTS OF TENSION IN PATIENT MANAGEMENT? |
1. Curiosity
2. Anxiety 3. Silence 4. Depression 5. Crying 6. Manipulation 7. Intemacy issues 8. Suicidal 9. Affection 10. Anger 11. Dissemblance 12. Financial Stress 13. Intoxication |
|
WHAT DO YOU DO WHEN
PATIENT STARTS TO ASK CURIOUS QUESTIONS ABOUT YOU? |
A short answer followed
by "Why do you ask?... |
|
DEFINE ANXIETY?
|
Painful uneasiness or
possibly feeling of impending doom. |
|
HOW DO YOU DEAL WITH PT'S
ANXIETY? |
1. Avoid an overload of
info. 2. Pace the conversation. Do not hurry. 3. Do not allow the anxiety to be contagious. 4. Calm demeanor/ intelligent repose from you. |
|
WHAT SHOULD YOU DO WHEN PT
BECOMES SILENT? |
1. Be patient and do not
force. 2. Edge the pt along with an open-ended question. |
|
WHAT CAN YOU DO WHEN
PATIENT CRIES? |
1. Let the pt cry
2. Wait 3. Offer a tissue 4. Say "I know you're feeling bad. It's all right to cry." |
|
WHY DOES PATIENT USE
MANIPULATION? |
To get extra-special
attention. |
|
HOW DO YOU APPROACH
MANIPULATION? |
Do not depart from
professional standard of care. |
|
HOW SHOULD YOU APPROACH
INTIMACY ISSUES? |
1. Always protect the pt's
modesty, using covers appropriately. 2. Be careful about the ways in which you use words or frame questions. 3. Do not shock the pt. 4. Develop a sensitive, empathic relationship. 5. Zero tolerance sexual misconduct with pt. 6. There are bounderies to professional behavior that should not be crossed. 7. Take note of pt vulnerability, dependency and seductive behavior. |
|
HOW SHOULD YOU APPROACH
SUICIDAL PATIENTS? |
1. Talking about it is
essential. 2. Common error: failure to ask about suicidal ideation directly. |
|
HOW DO YOU DEAL WITH
AFFECTION OF THE SEDUCTIVE PATIENT? |
1. Maintain professional
behavior. 2. Be courteous, calm and firm from the start. 3. Maintain the pt's dignity. 4. Seek understanding of the behvaior. |
|
WHAT ARE THE CAUSES OF
AFFECTION OF THE SEDUCTIVE PATIENT? |
1. Results from patient
insecurity. 2. Pt may have dependency issues. |
|
HOW DO YOU DEAL WITH PT'S
ANGER? |
1. Confront it.
2. Acknowledge it, and apologize, if appropriate. 3. Pt should be given the opportunity to express the feeling, and find that you will not shrink away. 4. Accept their feelings without getting angry in return. |
|
WHAT OCCURS DURING
DISSEMBLANCE? |
Patients may be hiding
something. |
|
WHAT SHOULD YOU DO DURING
DISSEMBLANCE? |
1. Do not push too hard,
but do not neglect. 2. Allow the interview to go on. |
|
WHAT FACTOR INFLUENCES
PATIENT'S FINANCIAL STRESS? |
1. Money issues are real.
2. Impact patient's mind set. |
|
WHAT SHOULD YOU DO IF
PATIENT IS INTOXICATED? |
1. Alert security.
2. Approach and greet the pt in an accepting manner. 3. Avoid confrontation. 4. Do not give them orders. 5. Keep relaxed and non- threatening posture. |
|
WHAT ARE THE
CHARACTERISTICS OF AN INTOXICATED PATIENT? |
1. Angry
2. Belligerent 3. Uncontrolled |
|
SETTING THE STAGE FOR AN
INTERVIEW INCLUDE... |
1. Knowing yourself.
2. You may respond differently to different people. 3. Knowing your idiosyncrasies. 4. Proper setting. |
|
WHAT CAN YOU AVOID WHEN
YOU KNOW YOURSELF? |
Inappopriate Behavior
|
|
PROPER SETTING INCLUDE?
|
1. Must be as comfortable
as possible 2. You as the focal point of warmth and attention. 3. No bulky desks or tables between you and the pt. 4. Sitting comfortably at ease. 5. Placing a clock where you can see without obviously looking at your watch. 6. Giving the interview primacy in your life. 7. Providing good lighting. 8. Maintaining privacy. 9. Providing relative quiet. |
|
LIST FACTORS INCLUDED IN
SITTING COMFORTABLY AND AT EASE? |
1. Conversational tone of
voice. 2. Your manner can assure the pt that you care. 3. At eye level with the pt if possible. |
|
BE COURTEOUS WHEN GREETING
THE PATIENT INCLUDE...? |
1. Using pt's appropriate
title. 2. Introducing yourself by name and title. 3. Explaining your relation to the pt's care. 4. Notifying pt that you are a student, if applicable. |
|
HOW DO YOU SET THE
PATIENT'S COMFORT? |
1. Have suitable place for
coats and belongings. 2. Be alert to pt's comfort, as well as your own. 3. Let pt know that you have enough time. 4. Avoid interrupting unless necessary. |
|
HOW DO YOU SET THE STAGE
FOR AN INTERVIEW BEFORE TAKING THE HX? |
1. Be courteous when
greeting the pt. 2. The pt's comfort. 3. Begin with open-ended questions. 4. Follow the pt's leads. 5. You need to take notes however... 6. Make notes sparingly. 7. Give structure to present problem, chronological/ sequential framework. |
|
WHAT ARE THE COMMON SENSE
GUIDELINES WHEN TAKING A HX ON SENSITIVE TOPICS? |
1. Privacy
2. Be direct and firm 3. Do not apologize for asking 4. Do not preach 5. Use language that is understandable, but not patronizing. 6. Don't push too hard if pt is defensive. |
|
WHAT ARE CONSIDERED AS
SENSITIVE TOPICS? |
1. Alcohol and drugs
2. Religion/Spirituality 3. The sexual hx |
|
WHAT DOES "CAGE" MEAN IN
ALCOHOL AND DRUGS SCREENING QUESTIONNAIRE? |
C - cut down
A - annoyed by criticism G - guilty feelings E - Eye-opener |
|
WHAT DOES "TACE" MEAN IN
ALCOHOL AND DRUGS SCREENING QUESTIONNAIRE? |
T - # of drinks it takes
to make you feel high? A - annoyed by criticism C - cut down E - eye-opener |
|
WHERE DO YOU DOCUMENT
RELIGIOUS HERITAGE? |
Social Hx
|
|
WHAT ARE THE ACCEPTABLE
QUESTIONS TO ASK CONCERNING PT'S RELIGION? |
1. How would you
characterize your religious or spiritual heritage? 2. Do you belong to a formally organized congregation? 3. Are the Bible or any associated writings important to you? |
|
HOW DO YOU CONDUCT SEXUAL
HX? |
1. Best initiated in a
matter-of-fact manner. 2. If complaint is genitourinary ask about sexual hx and use the GU review of systems to ask sexual questions. 3. Frequency of intercourse. 4. Variety and number of partners. 5. Possibility of exposure to HIV, STD. 6. Risk of unwanted pregnancy. 7. Issues achieving orgasm |
|
WHAT ARE THE FOUR KINDS OF
HISTORY? |
1. Complete
2. Inventory 3. Focused 4. Interim |
|
WHAT IS COMPLETE HISTORY?
|
Designed to make you as
thoroughly familiar with the pt as possible. |
|
WHEN DO YOU CONDUCT
COMPLETE HISTORY? |
1. The first time you the
pt. 2. Preface to the head to toe exam (5 yr PE). |
|
WHAT IS INVENTORY HISTORY?
|
Touches on the major
points without going into detail. |
|
WHAT IS FOCUSED HISTORY?
|
For acute problem which is
possibly life threatening and requires IMMEDIATE attention. |
|
WHAT IS INTERIM HISTORY?
|
Designed to chronicle
events that have occurred since your last meeting with the pt. |
|
WHAT ARE THE COMPONENTS OF
THE COMPLETE MEDICAL HX? |
CC = Chief Complaint
HPI = Hx of Presnt Illness PMH = Past Medical Hx FH = Family Hx SH = Personal and Social Hx CHS = Current Health Status ROS = Review of Systems |
|
DEFINE COMPONENTS OF THE
COMPLETE MEDICAL HISTORY? |
1. Structure of Hx -
process has organization/ structure that is widely accepted in medical community. 2. Makes it standardized and easy to read if you follow this structure. 3. Structure for physical Dx class is the Long Form H&P or Focused H&P. |
|
WHAT IS CHIEF COMPLAINT?
|
1. Brief statement of why
pt is seeking care. 2. May include duration of problem. 3. Quoting the pt may be helpful. |
|
WHAT DOES HPI ACCOMPLISH?
|
1. Amplifies the chief
complaint. 2. Full, clear, chronological account. 3. Step by step eval of circumstances surrounding pt's visit. 4. State of health just before onset of problem. 5. Complete description of 1st Sx. 6. Possible exposure to infection/toxic agents. 7. Ask pt to describe a typical "attack" if Sx intemittent. 8. Is it getting better, worse, or staying the same? 9. Immediate reason that prompted seeking of attention. 10. complete ROS when there is a conspicuous disturbance of a particular organ/system. 11. Include pt's responses to their own Sx. 12. Include effects on the pt's life. 13. Tx already attempted and their success or failure. 14. Previous occurrences and Tx used for that occurrence. |
|
STATE THE METHOD OF
DETERMINING THE CONTEXT OF A VISIT. |
1. Acquiring Info
2. Ethical Considerations 3. Ethical Guidelines |
|
STATE THE PRINCIPLES OF HX
TAKING. |
1. Communicating with the
patient. 2. Askiing questions. |
|
STATE THE METHODS OF
MANAGING PTS, DURING A MEDICAL HX REVIEW, WHO PRESENT WITH THE FOLLOWING BEHAVIORS OR ISSUES. |
1.CURIOSITY - provide a
direct answer, unvar- nished by detail, to satisfy a pt's curiosity and prevent great inva- sion into your personal life. -A short answer followed by "Why do you ask?..." 2. ANXIETY - answer ques- tions forthrightly, never dissembling/diguising. 3. SILENCE - be pt and do not force. -Edge the pt along with an open-ended question. 4. DEPRESSION - Approach pt with specific ques- tions. -Pt cannot be hurried and will not be relieved by superficial reassurance. 5. CRYING - let the pt cry Wait, offer a tissue, and say "I know you're feel- ing bad. It's all right to cry. 6. MANIPULATION - do not depart from professional standard of care. 7. INTIMACY ISSUES - Always protect the pt's modesty, using covers appropriate- ly. -Be care ful aboout the ways in which you use words of frame questions -Do not shock the pt. -Develop a sensitive, empathic relationship. -Zero tolerance sexual misconduct with pt. -Take note of pt vulnera- bility, dependency and seductive behavior. 8. SUICIDAL - talking about it is essential. 9. AFFECTION - maintain professional behavior. -Maintain the pt's dig- nity. -Seek understanding of the behavior. 10. ANGER - confront it. -Acknowledge it, and apologize, if appropriate -Pt should be given the opportunity to express the feeling, and find that you will not shrink away. -Accept their feelings without getting angry in return. 11. DISSEMBLANCE - do not push too hard, but do not neglect. -Allow the interview to go on 12. FINANCIAL STRESS - drains on pt's resources are often sources of stress. 13. INTOXICATION - alert security. -Approach and greet pt in an accepting manner. -Avoid confrontation. -Keep relaxed and non- threatening posture. |
|
STATE THE FACTORS TO
CONSIDER IN SETTING THE STAGE FOR AN INTERVIEW. |
1. Know yourself
2. Know your idiosyncracies |
|
STATE THE COMPONENTS OF THE
COMPLETE MEDICAL HISTORY. |
1. CC - chief complaint
2. HPI - Hx of present ill- ness 3. PMH - Past Medical Hx 4. FH - Family Hx 5. SH - Personal and social Hx 6. ROS - Review of systems |
|
DESCRIBE THE CHARACTERISTIC
OF A SX THAT MUST BE IDEN- TIFIED WHEN OBTAINING A COMPLETE MEDICAL HX. |
1. Use the mnemonic:
"OLDCARTS" to make sure all characteristics of a problem are described in HPI. ONSET - how di it come about? LOCATION - where on body? DURATION - how long have the Sx been present? CHARACTER - quality of the symptom. AGGREVATING OR ASSOCIATED FACTORS - what makes it worse? RELIEVING FACTORS - what makes it better? TEMPORAL FACTORS(Timing) - timing issues you haven't explored. SEVERITY - tells intensity. |
|
LIST THE COMPONENTS OF THE
REVIEW OF SYSTEMS. |
1. Ask at least 3 questions
per system for a com- plete ROS. 2. Catch anything you may have missed in the HPI. 3. You must learn to trans- late the pt's observa- tions into medical ter- minology. 4. Ask questions pertaining to each system from head to toe. |
|
STATE THE PURPOSE OF THE
SUMMARY OF CARE FORM. |
1. Problem list
2. Kept in the beginning of the health record. 3. Running log. 4. Firmly established Dx. 5. New Sx or physical find- ing. 6. New findings revealed by lab result. 7. Personal and social difficulties. 8. Risk factors for serious conditions. 9. Factors crucial to re- member long-term. 10. Anything that will re- quire further eval and attention. 11. Assessment/Plan for each problem on the list |
|
STATE THE PURPOSE OF THE
PROBLEM ORIENTED MEDICAL RECORD (POMR) |
1. Format used to organize
pt data for long-term health care management. 2. Identfying problems. 3. Making Dx. 4. Planning appropriate care. 5. Monitoring the pt's res- ponses to care. 6. Record is a legal doc, thus info can be used in court and other legal proceedings. |
|
EXPLAIN THE COMPONENTS OF A
SOAP NOTE. |
1. Subjective - what the
pt tells you. 2. Objective - what you see 3. Assessment - Dx 4. Plan |