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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