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50 Cards in this Set
- Front
- Back
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The ___________ is the beginning and at the heart of the diagnostic and treatment process.
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The HISTORY AND PHYSICAL EXAMINATION is the beginning and at the heart of the diagnostic and treatment process.
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Health Interview
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The interview is the basis for forming a therapeutic partnership.
Make a Good First Impression |
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Goals of the health interview include:
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-Discover information leading to diagnosis and management
-Provide information about diagnosis -Negotiate health care management -Counsel about disease prevention |
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Autonomy
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Need for self determination
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Beneficence
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Do good for the patient
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Nonmaleficence
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Do no harm
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Utilitarianism
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Consider appropriate use of resources for the greater good of the community
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Fairness and justice
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Balance between autonomy and competing interests
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Deontologic imperative
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Duties of care providers established by tradition and in cultural contexts.
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Factors that Enhance Communication
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Flexibility
Adapt to the situation Clarity What you say What you hear Subtlety Response to the question Value judgment Avoid judgment Exploration of feelings Understand pts feelings |
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Communication Tensions
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Curiosity about you
Anxiety Silence Depression Crying Manipulations Intimacy Compassion Seduction Anger Dissembling Dissembling: hiding things either consciously or unconsciously. Money |
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Interviewing Children
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Pay attention to them (equal emphasis on the child as on the accompanying adult)
Play with them Start distally work centrally Be sensitive to their needs Glean clues about family dynamics Start your interaction by looking at the shoes or pants, etc. Build trust. |
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Children Explore following issues during Interview
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Mother’s gestational history, pregnancy, and birth
Child’s neonatal period, feeding, and developmental milestones Child’s school adjustment, habits, and home conditions Review systems for child-specific conditions |
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Interviewing Adolescents
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Respect need for confidentiality
Respect impending adult status May need to perform some of the interview without parents in the room. Privacy laws regarding Gynecological or Psychiatric Issues. Don’t force conversation Establish an alliance Be flexible in approach Factors impacting history taking: self-esteem, acceptance by peers, tension with parents Cover issues of special concern |
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Interviewing Pregnant Women
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View health needs of mother and fetus
Explore effects of pregnancy on health status Use interview as time for teaching health care practices Explore the following: Current pregnancy and obstetrical history Exposure to environmental/occupational hazards Family genetic conditions/congenital abnormalities Personal/social issues of pregnancy/parenting Reproductive, cardiovascular, endocrine, respiratory system focus Risk factors that threaten mother/fetus |
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Interviewing Older Adults
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Watch for age-related changes that may impede interview (e.g., sensory loss, visual impairment, cognitive impairment, or memory loss)
Draw on person’s cumulative lifetime experience, wisdom, and perspective Multiple overlapping health problems Chronic symptoms may not be reported Complete drug assessment essential Assessment of functional capacity is key |
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Interviewing Disabled Persons
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Adapt interview approach to fit needs
Involve persons to limits of their ability |
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History-taking Setting
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Comfort for all involved
Removal of physical barriers Good lighting Privacy Relative quiet |
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Structure of the History
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Introduction/Patient Identification
Chief complaint/History of Present Illness Past medical/surgical history, medications, allergies Family history Personal/Social history Review of Systems |
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Taking the History
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Introduce yourself
Address patient properly Be courteous Make eye contact Don’t overtire patient Don’t be judgmental Be flexible Avoid medical jargon Take notes sparingly Avoid leading questions Start with general concerns then move to specific descriptions Clarify responses with where,when, what, how, why questions Verify and summarize what you have heard |
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Describe Chief Compliant
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Brief statement of reason the patient is seeking health care
Note all significant complaints. Seek answer to the question, “What problems or symptoms brought you here today?” |
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Describe Histoy of Present Illness
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Determine duration of the current illness. “How long has this problem been present?” or, “When did these symptoms begin?”
A step-by-step evaluation of the circumstances that surround the primary reason for the patient’s visit |
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Present Problem or Illness- Explore the following:
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Chronology of events
Health state prior to present problem First symptoms Exposure to infection or toxic agents History of previous symptoms Illness impact on lifestyle Stability of problem Immediate reason for visit Review of involved system Problem list |
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Describe Past Medical/Surgical History
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Exploration of the person’s overall health before the present problem, including all past medical and surgical experiences
What current medications are they taking What Allergies do they have and how does it manifest |
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Past Medical History- Explore the following:
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General health
Childhood illnesses Major adult illnesses Immunizations Surgery Serious injuries and resulting disability Functional ability limitations Past medications Past transfusions Emotional status Use of complementary and alternative health and medical systems |
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Desribe Family history
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Exploration of a family’s health, past medical experiences, illnesses, social experiences, deaths, and genetic and environmental circumstances
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Family History- explore the following
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Explore following about blood relations (grandparents, parents, siblings):
Family with illness similar to patient’s Family members’ ethnicity, health, and/or cause and age of death Family with history of major disease Family with hereditary disease |
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Describe Personal/Social History
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Exploration of a person's work habits and relationships at work, school, and home
Diet Exercise |
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Personal and Social History- Explore the following:
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Habits
Sexual history Home conditions Occupation Environment Military record Religious preference Insurance/financial |
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Describe Review of Systems
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Detailed review of complaints for each body system
Systematic start Head to Toe Your chance to catch something that you overlooked |
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Review of Systems: Categories
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General constitutional symptoms
Diet Skin, hair, and nails Musculoskeletal Head and neck Endocrine Chest and lungs Heart and blood vessels Hematologic Gastrointestinal Genitourinary Neurologic Psychiatric |
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ROS: General Constitutional Symptoms
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Fever
Chills Malaise Fatigability Night sweats Weight change |
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ROS: Skin, Hair, and Nails
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Rash, eruption, itching
Pigmentation or texture change Excessive sweating Abnormal nail or hair growth Wounds/Bruising |
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ROS: Musculoskeletal
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Joint stiffness, pain
Restriction of motion Swelling, redness, heat Bony deformity Functional Limitations |
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ROS: Head and Neck: General
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Headaches
Dizziness Syncope Head injuries Loss of consciousness |
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ROS: Head and Neck: Eyes
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Acuity
Blurring Diplopia Photophobia Pain Vision changes Glaucoma Eye medications Trauma |
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ROS: Head and Neck: Ears
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Hearing loss
Pain Discharge Tinnitus Vertigo |
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ROS: Head and Neck: Nose
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Sense of smell
Colds Obstruction Epistaxis Postnasal discharge Sinus pain |
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ROS: Head and Neck: Throat and Mouth
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Hoarseness or change in voice
Sore throats Bleeding gums Tooth abscesses, extractions Soreness or ulcers of tongue/mucosa Taste changes |
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ROS: Endocrine: General
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Thyroid enlargement or tenderness
Heat/cold intolerance Weight change Diabetes Polydipsia Polyuria Changes in facial or body hair Increased hat or glove size |
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ROS:Endocrine: Female
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Females:
-Menses -Intercourse -Birth control -Pregnancy -Menopause -Breasts |
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ROS:Endocrine: Male
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Males:
-Puberty onset -Erections, emissions -Testicular pain -Libido -Infertility |
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ROS:Chest and Lungs
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Pain
Dyspnea Cyanosis Wheezing Cough Sputum Hemoptysis Night sweats Exposure to TB Last chest x-ray |
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ROS:Heart and Blood Vessels
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Chest pain
Palpitations Dyspnea Orthopnea Edema Hypertension Previous MI Exercise tolerance Date last ECG Other cardiac tests |
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ROS:Hematologic
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Anemia
Tendency to bruise/bleed easily Thromboses Thrombophlebitis Blood cell abnormalities Past transfusions |
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ROS:Gastrointestinal
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Appetite
Food intolerances Dysphagia Heartburn Nausea/vomiting Hematemesis Regularity of bowels Changes in stool Flatulence Hemorrhoids Jaundice Dark urine Previous x-rays |
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ROS:Genitourinary
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Dysuria
Pain Urgency Frequency Nocturia Hematuria Polyuria Hesitancy Dribbling Loss in force of stream Passage of stone Edema of face Stress incontinence Hernias STDs |
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ROS:Neurologic
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Syncope
Seizures Weakness or paralysis Abnormalities of sensation or coordination Tremors Loss of memory |
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ROS:Psychiatric
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Depression
Mood changes Difficulty concentrating Nervousness Tension Suicidal thoughts Irritability Sleep disturbances |
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Concluding History Questions
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“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?” |
