PE Chapters 1, 2, 3

Why is gathering a history so important?

-70% of your diagnosis can be based on history alone

-90% of your diagnosis can be made when you add the appropriate physical exam

Clinician Centered Encounter:

You will take charge of the interaction to meet his/her own need to acquire the symptoms, details and other data that will help you identify a disease

Patient-centered Encounter:

Recognize the importance of the patients' concerns, feelings, and emotions; the personal context of the symptoms and disease; the patient is in the driver's seat

Integrating both ______ _____ _____ and ______ ______ _____ will lead to a more complete picture of your clinical encounter

Clinician-centered encounter and patient-centered encounter

Example of clinician-centered encounter

Develop of thorough history to help differentiate between a streptococcal pharyngitis from other etiologies

Example of patient-centered encounter

Worried only about pain and missing work, but also concerned as a friend died of throat cancer

Steps of an encounter

1. Initiating the session

2. Gathering information

3. Physical Examination

4. Explanation and Planning

5. Closing the session

Step 1: Initiating the session

-Set the stage

-Adjust the environment

-Review the clinical record

-Set your agenda

-Greet the patient and establish initial rapport

-Identify the patient's title, name, preferred pronoun

Set the stage

-Prepare it for the interview

-How do you look as the clinician?

-Is the room ready?

-Leave your bias at the door

Adjust the environment

-Make the interview setting private and comfortable as you can

-Adjust the room in the best way possible for patient's comfort

-Allow good eye contact, be at eye level if possible

Review the clinical record

-Always look at all available information

-Problem list, allergies, medications, history

Set your agenda

-Clarify with the patient what you are there to do

a. Checklists: I am here to do a pulmonary exam today

b. Site visits: I am here to do a comprehensive history and physical exam today

Greet the patient and establish rapport

-Always introduce yourself with your NAME and ROLE

-If appropriate, shake hands

Building rapport

-Show empathy, minimize interruptions, engage in listening, nonverbal cues, offer feedback; be culturally responsive

-Listen>Speak

a. You should talk less than 50% of the time

Special Populations:

Newborns/Infants <1 year of age

Encourage caregivers to feed baby while talking or right before exam; focus on caregiver first, then baby

Special Populations:

Young/School Aged Children (1-4 years old)

Try to play with the patient; use fun "games" to assess (jumping, throwing, drawing); brush up on kid culture

Special Populations:

Adolescents

Give respect and choices; direct questions to adolescent; time alone with patient; insure confidentiality

Special Populations:

Older Adults

You will likely be younger; use proper name; provide comfortable space and lighting; allow extra time if able to

Special Populations:

Blind/low vision

Verbally introduce self and announce when you are leaving. Explain what is going to happen before you do it

Special Populations:

Hard of Hearing

Ask how they prefer to communicate; give written materials; try to get sign language interpreter if possible; do not speak rapidly

Special Populations:

Deaf

Ask how they prefer to communicate; get interpreter if possible; always address the patient, not interpreter; give written materials

Special Populations:

Wheelchairs

-Access to exam room; do not help with wheelchair unless you ask first

Special Populations:

LGBTQ

Leave your bias at the door!

Step 2: Gathering Information

Discover Information: Leading to diagnosis and management

Provide Information: Diagnosis and management

FIFE (to get patient's perspective)

Feelings - Fears/concerns about problem

Ideas - Nature or cause of the problem

Function - Effects of the problem on patient's life

Expectations - of problem, clinician, healthcare....

Identify to the patient's emotional cues

-30-40% of patients have anxiety and depression in primary care practices

-Continue to respect, support, and explore with the patient

Gather history

-Past medical history

-Family history

-Personal/social history

-Review of symptoms

The pinnacle of patient centered care

1. Introduce choices and describe options

2. Explore patient references

3. Make a decision

Self reflection

-Did I ask effective questions?

-Did I get patient participation?

-Check for understanding

Disparities in Healthcare

1. Social determinants of health

2. Racism and bias

3. Cultural humility

Social determinants of health

-economic stability

-education

-social and community context

-health and health care (access to healthcare)

-neighborhood and built environment

Cultural Humility

1. Self-awareness: Learn about your own biases; we all have them

2. Respectful communication: Work to eliminate assumptions about what is "normal". Learn from your patients

3. Collaborative partnerships: Build your patient relationships on mutually acceptable plans

Nonmaleficence

First, do no harm

Beneficence

Act for patients' good by by preventing/treating disease

Respect for Autonomy

Accept patients choices, including rejecting treatment

Decisional Capacity

Ability to make a choice clinicians respect

Confidentiality

Prevent disclosure of patient's information to those not authorized

Informed consent

Must acquire patient's authorization to test or treat

Truth telling

Disclose information that may be relevant to patient (how many times have you done this?)

Justice

Patients with similar medical needs should receive similar medical treatment and treated fairly

Subjective vs objective data

Subjective: Symptoms the patient tells you

Objective: Signs you find on your physical exam; test data

Delivering bad news (SPIKE)

S: Set up the interview: Privacy, significant others, connect, manage time/interruptions

P: Perception - What are your thoughts since you have had the biopsy?

I: Invite the patient to be active in how much they know (every detail or minimum?)

K: Knowledge given should be at the patient's level

E: Emotions/empathy

Types of health history

Comprehensive: Typical with new patients

Problem-oriented: Patients seeking care for a specific reason

Follow-up: Patients continuing care for an ongoing/chronic problem

Maintenance: Screening, preventative

Specialist: Depends, but usually comprehensive

CHLORIDE PP

CHaracter

Location

Onset

Radiation

Intensity

Duration

Events surrounding chief complaint

Provocative (what makes it worse)

Palliative (what makes it better)

General health:

-Fever

-Chills

-Malaise

-Easily fatigued

-Night sweats

-Weight changes

-Diaphoresis

Skin

Rash

Lumps

Lesions

Pruritis

Xerosis

Color change

Changes in hair or nails

Last term screen date and results

Hair

-Change in hair-unusual loss or growth

-Texture

Nails

Change in nail texture

Color or thickness change

Head

Headache

Dizziness

Trauma

Eye

Use of eyeglasses or contact lenses

Visual changes

Diplopia

Pain

Discharge

Dry eyes

Blurring

Last eye exam and results

Ears

Change in hearing

Hearing impairment

Otorrhea

Otalgia

Tinnitus

Last hearing test and results

Nose and Sinuses

Rhinorrhea

Pain

Trauma

Obstruction

Infections

Sense of smell

Mouth and throat

Condition of teeth and gums

Sore throat

Hoarseness

Voice changes

Disturbance of taste

Last dental exam date and results

Neck

Lumps

Pain

Tenderness

Breast

Lumps

Discharge-galactorrhea

Pain

Tenderness

Self exams

Last mammograms and results

Respiratory

Cough

Pleuritic pain

Shortness of breath

Wheezing

Sputum production

Infections

Last CXR and results

Last TB test

Cardiac

Chest Pain

Palpitations

Dyspnea

Dyspnea with position change

Paroxysmal nocturnal dyspnea (PND)

Orthopnea

Last EKG date and results

Gastrointestinal

Appetite change

Nausea

Vomiting

Dysphagia

Constipation

Diarrhea

Heartburn

Abdominal pain

Food intolerance

Change in color, caliber, or consistency of stool

Frequency of bowel movements

Hematemesis

Malena

Last EGD

Urinary

Frequency

Urgency

Difficulty in starting stream

Change in stream caliber

Incontinence

Nocturia

Change in color of urine

Hematuria

Infections

Change in color

Flank pain

Dysuria

Genitoreproductive (Female)

Lesions on external genitalia

Itching

Discharge

Dyspareunia

Abnormal bleeding

Last Pap test/gyn results

Genitourinary (male)

Lesions on penis

Discharge

Impotence

Pain

Scrotal masses

Changes in quality or ability to have erection or ejaculation, condom use

Self testicular exam

Last rectal exam/prostate check

Musculoskeletal

Weakness

Muscle stiffness

Cramps

Limitation of movement

Joint pain, swelling

Deformities

Back or neck pain

Peripheral Vascular

Claudication

Edema

Varicose veins

Coolness of an extremity

Loss of hair on legs

Discoloration of extremity

Ulcers

Neurologic

Syncope

Dizziness

Paralysis

Numbness

Parasthesias

Tremors

Memory impairment

Hallucinations

Speech impartment

Gait dysfunction

Behavior or mood change

Disorientation

Endocrine

Heat or cold intolerance

Excessive sweating

Excessive sweating

Excessive thirst or hunger

Polyuria

Thyroid enlargement and tenderness

Unexplained weight change

Increased hat and glove size

Skin striae

Hematologic

Easy bruising

Bleeding

Past transfusions and reactions

Abnormal blood clotting