The Medical Interview

Front 1

What is a Disease?

Back 1

The medical condition that afflicts the patient

Front 2

What is a Illness?

Back 2

How the patient responds to the medical condition in a physical, emotional, social and spiritual context.

*illness takes into consideration how disease affects all aspects of a pts life.

Front 3

What do open-ended questions do?

Back 3

Allow pts to direct the flow of information. The interview should always begin w/ open-ended questions.

Front 4

What do close-ended questions do?

Back 4

Answered w/ a single word. These should be used to clarify information. Necessary for ultimately characterizing the Pt's Sx.

Front 5

What is the chief concern?

Back 5

What troubles the pt. most, even if it is not what you believe to be the pts main problem. Often it reflects the pt's attitude toward their own illness.

Front 6

How do you obtain the pt's chief concern?

Back 6

By asking open-ended questions.

Front 7

What are examples of open-ended questions?

Back 7

"Tell me more about that..."
"What do you mean by that...?"
*open-ended questions cannot be answered w/ a simple yes or no.

Front 8

What mnemonic is helpful in exploring the pt's perspective of their illness?

Back 8

"FIFE"
Pt's Feelings, including fears/concerns
Pt's Ideas about the nature and cause of the problem
the effect of the problem on the pt's life and Freedom
Pt's Expectations of the disease, the clinician, or of healthcare - often based on personal or past family experiences.

Front 9

What is the most important part of the medical interview?

Back 9

Remember: The pt. is ALWAYS more important than the dx.

Front 10

Why is setting important in the medical interview? How can you change the setting to optimize the pt. interaction

Back 10

It sets the tone for everything that follows.
1. establish a sense of privacy (close door or pull curtain)
2. position yourself at eye level (close but not too close!)
3. introduce yourself w/ your LAST name and explain your role "Hi my name is Dr. Damazo and I will be your doctor today and I would love to talk to you about what brought you into the hospital today Mr. Smith"
4. EVERY INTERACTION W/ A Pt. IS A PRIVILEGE!

Front 11

Why is note taking necessary but dangerous in the medical interview?

Back 11

Notes are necessary to remember important details, but keep it to a minimum, but make sure you make frequent eye contact, especially when discussing sensitive topics.

Front 12

What should the pt. interview ALWAYS begin with?

Back 12

Open-ended questions

Front 13

What is the Iatrotropic stimulus?

Back 13

"what prompted you to seek care now Mr. Smith?"

Front 14

What nonverbal aids facilitate communication b/e you and the pt?

Back 14

1. minimal facilitators like: "Yes?" "Uh huh", "Go on"
2. Nodding or shaking the head in agreement
3. eye contact
4. Sitting w/ an open posture (arms uncrossed, facing the pt. directly, upright and attentive)
5. position yourself in a non-threatening location (don't stand b/e the pt. and door, do not stand above the pt. looking down, minimize barriers (move a desk or computer screen)
6. remain silent for up to 3 seconds when the pt. stops talking
7. nod and smile (because you are going to be a DOCTOR!!!! :-)

Front 15

What does clinical reasoning include?

Back 15

1. Identifying problem symptoms and abnormal findings
2. linking findings to an underlying process of pathophysiology or psychopathology
3. establishing and testing a set of explanatory hypotheses
4. asking questions to confirm or reject hypothesis.

Front 16

What seven characteristics of each symptom should be obtained in taking a hx?

Back 16

1. Where is it? "please point to the pain"
2. Quality? "what was it like? sharp, squeezing dull...?"
3. Quantity? "frequency, size, amount severity 1-10?"
4. Chronology? "when did it start?" use specific dates
5. Setting/context? "What were you doing when it hurt?"
6. Aggravaging/alleviating factors? "does anything make the Sx better or worse?
7. Associated manifestations? "Anything happen when the Sx occurs?

Front 17

What is the most important part of the seven characteristics of Sx Hx taking?

Back 17

Chronology! It is so important to establish a specific timeline!

Front 18

How can you use facilitators to obtain a Hx?

Back 18

By using open ended questions that are followed up w/ more directed questions, until the area is fully clarified.

Do not interrupt the pt's train of though unless the conversation becomes tangential.

Summary! Summarize what the Pt just said by re-explaining what point you believe the pt. was trying to make.

Echoing! Keeps the pt. on track and encourages the pt. to continue w/ what they were saying. i.e. Pt: "i feel really terrible" Me: "you feel terrible?" Pt: "yes, i mean i have no energy what so ever. and I..."

Checking! a quick review of what you just heard them say to clarify unclear points.

Front 19

What additional components of the Hx of Present Illness (HPI) are essential to include?

Back 19

1. MEDICATIONS!!! Always inquire regarding prescription, over the counter and supplemental medications and herbs.
2. Allergies!!! ask about allergies to medications, reactions to any tests, environmental agents (especially food)
3. Tobacco, alcohol or illicit drug use
4. risk factors for dx (like risk factors. i.e. chest pain should be followed up w/ questions about HTN, DMII, diet, SHx of Cardiac disease)
5. pertinent positives, abdominal pain should be followed up w/ questions about fever, vomiting, diarrhea etc.
6. THE PT'S RESPONSE TO HOW THIS DISEASE HAS AFFECTED THEIR LIFE.

Front 20

What is a Pt's Gravidity?

Back 20

The number of total pregnancies regardless of outcome

Front 21

What is a Pt's Parity?

Back 21

The number of pregnancies that terminated after the 20th week, regardless of whether the infant lived or died.

Front 22

What is a Pt's Aborta?

Back 22

The number of pregnancies that terminated before the 20th week.

Front 23

What should be included in the menstrual history?

Back 23

1. menarche (Age of onset of menses)
2. normal interval b/e periods
3. how many tampons, how heavy is the flow and how long does it last? (in days)
4. If they're older, when menopause occurred.
5. date of last menstrual period (LMP) and period before the last menstrual period (PMP)
6. Gyn Hx should include info about infections, procedures and any symptoms related to the GU tract.
7. If sexually active if contraception is used
8. record dates of last mammogram and PAP smear.

Front 24

What topics are included in a Pt's Past Medical Hx?

Back 24

1. Past surgical operations
2. Childhood illnesses
3. Psychiatric illness, (have you ever had a problem w/ emotional or mental illness?)
4. OBGyn hx including: (pregnancy hx, menstrual hx, sexual hx
5. any serious accidents

Front 25

What should the family Hx include?

Back 25

presence/absence of illness in the pt's family such as true hereditary diseases, familila illnesses, current illnesses.

Front 26

What topics should be covered in a Patients profile?

Back 26

1. Social history ("married? who do you live w/? what is your social support system?")
2. Occupational exposure hx. (any exposure to fumes, dusts, chemicals?
3. spirituality
4. culture
5. diet
6. recreational drugs, alcohol, tobacco
7. sexual history

Front 27

What is cultural competency?

Back 27

Consceintiously understanding your Pt's culture, w/o imposing yoru own attitudes/beliefs.

Front 28

What is the CAGE screening method for alcohol/substance abuse?

Back 28

"have you felt the need to Cut down on your drinking?"
"have you been Annoyed by criticism of your drinking?"
"have you felt Guilty about your drinking?"
"have you ever had to take a drink first thing in the morning to get going?" (an eye-opener)

Front 29

How should you quantify the number of cigarrettes smoked per year?

Back 29

By estimating the number of pack-years.

pack years = (number of packs smoked per day) x (number of years that number of packs was smoked)

example: 2 packs per day for 10 years and 1 pack per day for thirty years equals 50 pack years.

Front 30

How are screening questions for sexual problems and concerns best approached?

Back 30

W/ a combination of closed and open-ended questions:
a. are you sexually active? when was the last time you had intimate contact w/ someone?
b. have you noticed any changes or problems in your sexual function?
c. do you have any concerns about your sexuality?
If yes to any of the above then proceed with:
For men:
a. do you have any problems maintaining an erection?
b. do you have any trouble having an orgasm?
For women:
a. Do you have any pain during intercourse?
b. Do you have problems w/ lubrication or getting excited?
c. Have you had an orgasm?
d. Do you have difficulty having an orgasm?

Front 31

How can you assess a pt. for domestic violence?

Back 31

1. Start with a normalizing question: "Because abuse is common in many women's lives, I've begun to ask about it routinely."
2. Then use "SAFE"

Front 32

What are the SAFE questions for uncovering domestic violence?

Back 32

1. Stress/Safety: "what stress do you experience in your relationship?"; "do you feel safe in your relationships?"
2. Afraid/Abused: "Has your partner ever threatened or abused you?"; "Have you been physically hurt?"
3. Friends/Family: "Are your friends aware you have been hurt?"; "Could you tell your friends?"
4. Emergency plan: "Do you have a safe place to go and the resources you need in an emergency?"

Front 33

What does a positive response to almost every review of systems question asked indicate?

Back 33

1. Identifies pts w/ psychosomatic disease and emotional difficulties
2. That the physician failed to obtain information in an empathetic manner.

Front 34

What are good ways to close the interview?

Back 34

1. Summarize what you believe to be the Pt's problem
2. Give pt's one last chance to bring up anything they would like to talk about "before i go is there anything else you think i should know?"
3. thank the pt. for their cooperation and time
4. document your interaction AFTER the pt has left.
5. confirm that the pt. understands and is agreeable w/ the plan for care

Front 35

What are exceptions to a teenagers confidentiality?

Back 35

1. Plans to harm self
2. Plans to harm others
3. Someone is hurting you
4. Reportable diseases

Front 36

What is the HEEADSSS mnemonic for adolescent issues?

Back 36

1. Home environment
2. Education, Employment
3. Eating
4. Activities, affect, ambitions, anger
5. Drugs
6. Sexuality
7. Suicide/depression
8. Safety from injury and violence

Front 37

What problems are geriatric pt's particularly prone to?

Back 37

1. Issues related to competency. Is the pt. able to comprehend and make decisions regarding their health care?
2. Iatrogenic disorders - older pt's are particularly susceptible to medication interactions and side-effects
3. Pain - Pain is a huge part of geriatric pts and should always be addressed.

Front 38

What are activities of daily living (ADLs)?

Back 38

Basic self-care abilities of geriatric pt's:
*Bathing, dressing, toileting, feeding, transferring, managing money.

Front 39

What are the instrumental activities of Daily Living (IADLs)?

Back 39

Activities requiring higher level functioning:
* Using the telephone, shopping, preparing food, taking medications, transportation

Front 40

What is the most important relational skill the physician can have?

Back 40

The ability to communicate empathy for the patient's predicament.

*note just because you are empathetic does not mean you have to agree with the patient.

Front 41

What verbal aids can the physician use to communicate empathy?

Back 41

1. reflect the pt's emotion: "You seem sad"
2. legitimize the pt's feelings: "It is understandable you would feel that way"
3. Express respect for the pt's coping efforts: "you are doing a remarkable job w/ your illness"
4. Express support: "I am here to help you through this"
5. Express partnership: "We'll work together to solve this problem"

Front 42

What nonverbal aids can be used by the physician to establish trust w/ the pt?

Back 42

1. Touching: shaking hands, check blood pressure, pulse, supporting hand on the back
2. Pay close attention to the pt's EYES: "the mouth lies but the eyes tell the truth"
3. Pt. posture: notice protective postures which may express anxiety about a topic.
4. Pt. breathing
5. Pt. Gestures

Front 43

How do anxious pts breathe?

Back 43

Anxious pts gasp for air and speak from the height of inspiration

Front 44

How do depressed pts breathe?

Back 44

Depressed pt's sigh when they breathe and speak from the end of expiration

Front 45

What does a rub of the nose indicate?

Back 45

Displeasure/disagreement w/ the topic being discussed

Front 46

What does clearing the through signify?

Back 46

Displeasure/disagreement w/ the topic being discussed

Front 47

What does hand wringing indicate?

Back 47

Sign of despair

Front 48

What does steepling of the hands indicate?

Back 48

Confidence

Front 49

What do hands held tightly around the arms of a chair causing "white knuckles" indicate?

Back 49

Fear and anxiety

Front 50

What are subjective observations?

Back 50

What the pt. actually says to the physician "that doesn't really bother me."

Front 51

What are objective observations?

Back 51

What the dr actually observes about the pt. "the pt. averts his eyes and rubs his nose while saying "That really doesn't bother me"