Physical Diagnosis Exam 1 Part 1 - Building A History

What are the 3 primary objectives to build rapport & trust?

1) Understand patients concerns

2) Explore patient's expectations

3) Show genuine interest, concerns, and collaboration

A positive patietn relationship requires communication build on what 5 things?

1) Courtesy

2) Comfort

3) Connection

4) Confirmation

5) Confidentiality

What type of effective communication allows the patient to choose the extent to which they answer?

Open ended questions

Ex: tell me about your issue?

What type of effective communication is used when seeking specific information from a patient?

Direct Questions

Ex: When did this issue start?

What type of communication when used, can limit information patients provide, and what they thing YOU want to know?

Leading Questions

Ex: How much pain are you in? (assuming they have pain and it limits their answer)

What are the 6 features of effective communication?

1) Facilitate (encourage patient to say more)

2) Reflect (repeat what you have heard)

3) Clarify (ask, what do you mean?)

4) Empathize (show understanding and acceptacnce)

5) Confront (address disturbing patient behavior)

6) Interpret (explain what you have heart to confirm meaning)

What are some ideas to set the best stage possible for building a history with your patient? (6)

1) comfort for all involved

2) removal of physical barriers

3) good lighting

4) privacy

5) relative quiet

6) easy access to clock

Before the 18 questions, what is the first question to ask after the introduction during the history/clinical interview?

Gather the chief complaint(s) first by asking:

"What brings you in today?" or "How can I help you?"

What is the first question for the History/Clinical Interview?

When did it start?

What is the second question for the History/Clinical Interview?

Did it begin gradually or suddenly?

If the answer to the second question for the History/Clinical Interview is that the chief complaint came about GRADUALLY, what 2 things should you ask?

1) "Over what period of time?"

2) "How long did the symptoms take to develop?"

What is the third question for the History/Clinical Interview?

Did anything cause or contribute to the onset?

What is the fourth question for the History/Clinical Interview?

Have you ever experienced anything like this before?

If the answer to the fourth question question for the History/Clinical Interview is YES, what 2 things should you ask?

1) "How is it similar and different from the last occurrences?"

2) "What was the outcome?"

What is the fifth question for the History/Clinical Interview?

Can you point to the exact location of your symptom(s)? Describe.

What is the sixth question for the History/Clinical Interview?

Does it travel (radiate) to any other part of your body? Describe.

What is the seventh question for the History/Clinical Interview?

Do you have symptoms in any other part of your body?

What is the eighth question for the History/Clinical Interview?

Can you describe the sensation?

(dull, sharp, burning, aching, gnawing, throbbing, shooting, constricting, other)

What is the ninth question for the History/Clinical Interview?

How would you describe the intensity? (VAS scale 0-10)

What was the tenth question for the History/Clinical Interview?

Has it been constant or does it come and go? (Explain)

Depending on the answer to the tenth question for the History/Clinical Interview, if the chief complaint is present 75% of the day or more what is it called? If its tied to a particular event or time of day (ex: every time patient drives)? If its not tied to a particular event or time of day (often unpredictable)?

Constant

Episodic

Intermittent

What was the eleventh question for the History/Clinical Interview?

Has it been getting better, worse, or staying about the same since its onset?

What was the twelfth question for the History/Clinical Interview?

Have you found anything that makes it better? (Ex: Rest, morning, evening, certain positions, other)

What was the thirteenth question for the History/Clinical Interview?

Have you found anything that makes it worse? (Ex: positions, activities, morning, evening, coughing, sneezing, straining, other)

What was the fourteenth question for the History/Clinical Interview?

Has there been a change in any bodily functions? (Ex: urination, defecation, respiration, digestion, vision, sexual, other)

What was the fifteenth question for the History/Clinical Interview?

Has it affected your daily activities in any way?

What was the sixteenth question for the History/Clinical Interview?

Have you tried any over the counter or prescription medications, or any home remedies?

If the answer to the sixteenth question for the History/Clinical Interview is YES, what follow up question should you ask?

What was the effectiveness?

What is the seventeenth question for the History/Clinical Interview?

Have you sought other professional care for this condition?

If the answer to the seventeenth question for the History/Clinical Interview is YES, what follow up question should you ask?

What was the effectiveness?

What is the eighteenth and final question for the History/Clinical Interview?

Is there anything else you would like to discuss or you think would be important for me to know?

SUMMARY of the 18 Questions & Pneumonic

Know the 18 questions & be able to write out completely by memory (NOT multiple choice)

1) When arise?

2) Gradual or Sudden

3) Cause/Correlation?

4) Experienced before?

5) Location?

6) Radiate?

7) Other body symptoms

8) Sensation (describe)

9) Intensity (describe 1-10)

10) Constant, episodic, or intermitent?

11) Better, worse, same?

12) What makes Better?

13) What makes Worse?

14) Body function changes

15) Daily activities

16) Medications/Remedies

17) Professional Care

18) Anything else Important

WinGardian (leviosa) Carries Everything.

Levitating Right Behind Snape Is (a) Crystal Ball, But When Busted, (it) Drops, Making Punishment Inevitable

What two questions are asked during the past health history (PHH)?

1) How would you rate overall health (0-10 VAS)

2) Have you gained or lost weight in the last year? (Amount and why?)

What are the 4 categories of MIST (which is part of PHH)?

1) Medications

2) Illnesses

3) Surgeries

4) Traumas

What 2 questions do you ask about for the Medication part of MIST?

1) Do you CURRENTLY take any medications or supplements? (Over counter, prescription, other?)

2) Have you completed a course of medication/treatments for any condition?

What 3 questions do you ask about for the Illnesses part of MIST?

1) Do you CURRENTLY suffer from any diseases, diagnoses, allergies?

2) Have you suffered from any significant diseases, diagnoses, allergies IN THE PAST

3) Have you had measles, mumps, chicken pox, or other COMMON CHILDHOOD ILLNESSES

NOTE: Ask about CURRENT, PAST, and CHILDHOOD illnesses

What question do you ask for the Surgery part of MIST?

Have you had any surgeries?

(ex: tonsils, appendix, hernia, joint replacement, childbirth)

What 2 questions do you as for the Trauma part of MIST?

1) Have you had any injuries, accidents, broken bones, bad falls, or blows to head/body?

2) Do you CURRENTLY use any supports, braces, wraps, heel lifts?

What are the 2 major questions to ask when going through the Occupational History (OH)?

1) Describe the demands of your job

- primarily sit, stand, walk, other

- lifting and/or twisting

- jarring, jolting, vibrating forces to spine/extremities

- head/body to be bent forward, backward, to side, or twisted repeatedly or for extended periods

2) Have you ever worked/lived somewhere where exposed to toxic metals, gases, fumes, dust, radioactive material, or chemicals?

What 3 questions are asked in the Social History (SH)?

1) What are stress levels at HOME? (rate 0-10)

2) what are your stress levels at WORK? (rate 0-10)

3) How do you spend spare time? (ex: sports, reading, hobbies)

What are the 5 questions asked in the Marital History (MH)?

1) Married, single, divorced, partnered?

2) Is your partner in poor, fair, good, excellent health?

3) Do you have children?

4) Children health poor, fair, good, excellent?

5) Anyone in family w/ diagnosed conditions?

What 4 questions are asked in the Family History (FH)?

1) Father's health (poor, fair, good, excellent); If deceased, why?

2) Mother health (poor, fair, good, excellent); If deceased, why?

3) Sibling health (poor, fair, good, excellent); If deceased, why?

4) Anyone in family w/ diagnosed conditions?

(NOTE: Same as last question for marital status)

When going through the HABITS questionnaire, what are the 4 major areas of focus to ask questions on?

BRED

1) Beverages

-- type, amount (typical day)

2) Rest

-- quality, hours, surface, position, before bed routine, posture

3) Exercise

-- daily/weekly exercise program, aerobic amoutn, weightlifting amount, any trainer utilization

4) Diet

-- amount of fruits, veggies, meat, fish, foul, diary, and are sugars/oils/fats/salt a main part of diet

Review of Symptoms:

Fever, chills, malaise, fatigability, night sweats, sleep patterns, & weight (average, preferred, present, change) symptoms of what system?

General Constitution

Review of Symptoms:

Rash, eruption, itching, pigmentation/texture change, and excessive sweating are symptoms of what system?

Abnormal nail/hair growth?

Skin

Hair/Nails

Review of Symptoms:

Headaches, Dizziness, Syncope, head injuries, & loss of consciousness are symptoms of what system?

General Head & Neck

Review of Symptoms:

Vision changes (Acuity/blurring), diplopia, photophobia, pain, glaucoma, trauma, and medications are symptoms of what system?

Eyes (Head & Neck)

Review of Symptoms:

Hearing loss, pain, discharge, tinnitus, and vertigo are symptoms of what system?

Ears (Head & Neck)

Review of Symptoms:

Sense of smell, colds , obstruction, epitaxies, postnasal discharge, and sinus pain are symptoms of what system?

Nose (Head & Neck)

Review of Symptoms:

Sore throat, hoarseness, and voice changes are symptoms of what system?

Throat (Head & Neck)

Review of Symptoms:

Bleeding gums, tooth abscess/extractions, soreness/ulcers of tongue/mucosa, & taste changes are symptoms of what system?

Mouth (Head & Neck)

Review of Symptoms:

Enlargement, tenderness, and suppuration are symptoms of what system?

Lymph Nodes

Review of Symptoms:

Appetite, Likes/Dislikes, Dietary Restrictions, Vitamins/Supplements, Caffeine/alcohol, and dietary recall are symptoms of what system?

Diet

Review of Symptoms:

Syncope, seizures, weakness/paralysis, abnormalities of sensation/coordination, tremors, & loss of memory are symptoms of what system?

Neurological

Review of Symptoms:

Difficulty concentration, mood changes, irritability, depression/anxiety, sleep disturbances, & suicidal thoughts are symptoms of what system?

All of these symptoms are yellow flags EXCEPT which symptoms (which is a red flag)?

Psychiatric/Psychological

Suicidal thoughts = Red flag (not just yellow)

What type of history is most often recorded the FIRST time you see the patient?

Complete history

What type of history touches on major points without complete detail?

Inventory History

What type of history is for acute problems, where only the need of the moment is given full attention?

Focused History

What type of history is events since the last appointment, determined by the type of problem and situational factors?

Interim history

What are the 4 major categories of special considerations for building a history?

1) Age (Children, adolescents, older adults)

2) Gender (pregnancy, transgender)

3) Disability

4) Sensitive Topics (alcohol/drug use, childhood trauma, intimate partner violence, sexuality, spirituality)

What are suggested as adaptations for children? (4)

1) Pay attention to them (equal emphasis on child/adult)

2) Play w/ them

3) Be sensitive to their needs

4) Observe family dynamics

What 4 questions should be asked in order to understand the developmental history of a child?

1) Mothers gestational history, pregnancy, and birth

2) Child's neonatal period, feeding, and developmental milestones

3) Child's school adjustment, habits, and home conditions

4) Review systems for child-specific conditions

What are suggested as adaptations for adolescents? (5)

1) Respect need for confidentiality

2) Respect impending adult status

3) Do not force conversations

4) Establish alliance

5) Flexible approach

NOTE: can be impacted by self-esteem, acceptance by peers, and tension w/ parents

What are the 2 acronyms to cover issues of special concern with adolescents?

HEEAADDSSS

(Home life, Education, Eating, Activities/ambitions, Affect/anger, Drugs, Depression, Suicide, Sexuality, Safety)

SPAACES

(School, Parents/peers, Accidents, Alcohol/drugs, Cigarettes, Emotional issues, Sexuality)

What are suggested adaptations for Older adults?(6)

1) Age related changes that may impede interview (ex: sensory loss, visual/cognitive impairment, memory loss)

2) Draw on persons cumulative life experience, wisdom, perspective

3) Multiple health problems/comorbidities

4) Chronic symptoms

5) Complete drug assessment

6) Assessment of functional capacity

What are suggested adaptations for pregnancy (gender)? (5)

1) health of mother AND fetus

2) pregnancy effects on health status

3) risk factors (ex: exposure to hazards, family genetics/congenital abnormalities, personal/social issues w/ pregnancy/parenting)

4) Current pregnancy & obstetric history

5) reproductive, cardiovascular, endocrine, respiratory system focus (ROS)

What are suggested adaptations for transgender patients (gender)? (4)

1) Be informed on best practices for transgender patient care

2) Ask patients what they hope to achieve

3) take inclusive health history

4) Be aware of reproductive/health concerns/disease presentations

What are suggested adaptations for disabled patients? (3)

1) adapt interview to fit needs (ex: doctor sit)

2) Involve patient to the limit of emotional, mental, and physical abilities

3) Family members are often available to make patient more comfortable/provide further information

What are some recommendations for approaching sensitive topics?

1) Ensure privacy

2) be direct & firm

3) do not apologize for broaching issue

4) do not preach

5) use understandable language

6) DO NOT PUSH TOO HARD

What identifies IF a problem exists? What investigates the extent of the problem?

Screening

Assessment

What screening is for substance abuse in adolescents?

CRAFFT

Car

Relax

Alone

Forget

Friends

Trouble

What 2 screenings are to diagnose alcoholism?

1) CAGE

-- C = Cutting down

-- A = Annoyance by criticism

-- G = Guilty feeling

-- E = Eye-opening

2) TACE

-- T = How many drinks does it TAKE to make you feel high?

-- A = Have people ANNOYED you by criticizing your drinking?

-- C = Have you felt you ought to CUT down on your drinking?

-- E = Have you ever had an EYE-opening drink first thing in the morning to steady your nerves or get rid of a hangover

What screening is for childhood trauma which assesses types of childhood abuse and household trauma, with 3-5 being high risk?

Adverse Childhood Experience (ACE) screening

What is abuse (physical or verbal) done by someone involved in an intimate relationship with the victim (past/present), affecting primarily women, children, and dependent elderly?

Intimate Partner Violence (IPV)

T/F: After a positive (yes) response to physical abuse, it requires follow-up (afraid to go home; guns/knives at home; alcohol/drugs part of problem; gotten worse; children involved?), and if concerns still exist, documentation is needed even after a negative (no) response

TRUE

What screening asks if an individual has ever been hit/kicked/punched/hurt by someone within the past year; if they feel safe in their current relationship; and if there is a partner from a previous relationship who is making you feel unsafe now?

Partner Violence Screening (PVS)

What screening is for domestic violence and asks if in the last year, how often has your partner: Hurt you physically? Insult/talk down to you? Threaten w/ physical harm? Scream/curse at you?

HITS Screening

Hurt

Insult

Threaten

Scream

What are some recommendation on how to approach sexuality?

1) Ask questions in "gender neutral" ways (partner, NOT husband/wife)

2) Tell me about your living situation

3) Are you sexually active & in what way?

What is an approach for spirituality?

FICA

F = faith/belief/meaning

I = importance/influence

C = community

A = address/action in care