PCCR I: The Clinical Encounter, Interviewing Process, Health History, and Physical Exam

5 Major Steps of PT Encounter

1: Initiation - initial rapport w/ pt and family members

2: Information Gathering: exploring both pt perspective of illness and biomedical perspective of disease (bkgd and context)

3: Physical Examination:appropriate components of physical exam

4: Explanation & Planning: appropriate amount and type of information, next steps/plan of action, shared decision making

5: Closing the Session: answer questions, reiterate plan, and assure commitment to health. Self reflect

Initiate Encounter

Set Stage/Adjust Env (appearance, setting private and comfortable)

Greet Pt and establish rapport (include family)

• explain role and involvement

• Id title, preferred name, gender pronouns

• Newborns and Infants:

  • Greet parents, encourage keeping baby happy/comfortable, ask how parents are (recognition!!)

  • Young/School-aged children: intro to child then family/caregiver. Beg w/ play → ask age appropriate Q

  • Adolescent: they are main focus (ensure caregivers feel heard). Spend time w/ pt alone (awk confidentiality and trust)

  • Older Adults: space for maneuvers, lower bkgd noise, warm temp, time to answer/talk

  • Physical & Sensory Disabilities: “people-first” language. Directly to pt, not caregivers; avoid need to provide assistant (how can I help)

    • Wheelchairs: path of access, keep in wheelchair, respect space

    • Blind/low vision: announce yourself and others, notify when leaving, explain next actions

    • Deaf/Hard of Hearing: sign language interp? (Never use family); mouth is not covered and look at pt when speaking; minimize bkgd noise

  • LGBTQIA+: higher anxiety and fear → higher distrust = no trust, not hx; have barriers to healthcare

Information Gathering

Esta. Agenda:

• CC/Presenting Problems?

• Open ended Q.

Invite story → esta what is most important to pt

• active listening! Once done ask specific q to garner additional info

• Pt perspective? FIFE (feelings, ideas, effect onf Function, expectatios)

• ID and respond to emotional cues: NURSE (name/understand/legitimize/respect/support/explore)

Explore biomedical perspective (important bkgd info and context)

• Health Hx; PMH; FH; SH; RoS

Physical Examination

Head→Toe!! Maintaining comfort (Avoid embarassing)

Physical findings? Presence/absence of disease/illness?

Explanation & Planning

Provide useful info and verify understanding

• elab CC and how it relates to disease/illness (no medical jargon)

• “Teach-back” method/ “show-me” method

Negotiate Plan via Shared Decision Making

• intro choices and describe process → explore pt pref → move toward decision of pt choosing

Closing Encounter

Inform closing time. Any Q?

• new concern/topic assures them of interest and make plans for FU

Summarize plan and plan for further evaluation/tx/FU

Self reflect

• mindfulness? “Purposefully and nonjudgementally attentive to [one’s] own experience, thoughts, and feelings”

• Reflect on behavior w/ own biases, values, assumptions

Skilled Interviewing - Guided Questioning

Open → Focused Q

• elicits graded response

• Series of Q at a time. Mult choices?

• Clarify pt meaning

• Encourage clarification

  • Use echoing/reptition

Skilled Interviewing - Active/attentive listening & Empathetic Response

Attention to verbal and nonverbal language

Empathy “capacity to ID w/ pt and feel pt’s pain as own, then respond in supportive manner”

• don’t assume!! Ask elaboration

Skilled Interviewing - summarization & transitions & Partnering

Review what pt said and allow them to correct/fill-in any additional details

Skilled Interviewing - validation, empowering, reassurance

Allows pt to feel as though response if legitimate and understandable

Empower to ask Q, express concerns, to q/probe recommendations (makes them likely to follow plan)

Skilled Interviewing - Appropriate verbal/non-verbal communication

Simple, recog words (no medial jargon)

Non-stigmatizing language

Posture/gesture/facial expressions (nodding)

Eye contact

Tone of voice/use of silence

Mirror!!

Stig vs Non-stig language

Ex-con → person who was/is incarcerated

Parolee/probationer → person on parole/probation

Drug abuser/junkie/addict- → person who uses/injects drugs

Schizo/depressive → person w/ …

AIDS/HIV pt → person living w/…

Prostitute/hooker → sex workers/ person involved w…

Rape victim → sexual assault survivor

Handicapped/Disabled → people w/ diabilities

Normal/healthy/whole/typical → people w/o diabilities

Dwarf/midget → person of short stature/ little person

Confined to wheelchair/wheelchair bound → person who uses…

Symptoms vs Signs

Subjective (pt tells you) vs Objective (physical exam findings and diag)

Comprehensive Medical History

For new pt: fund/personalized knowledge abt pt; strengthens clincial-pt relationship; id/ r/o physical cause related to pt concerns; baseline for future assessments; platform for health promotion (edu and counseling); dev proficiency in essential skills of physical exam

Initial Info & ID Details

CC

HX of Present Illness (HPI)

PMH

FH

Personal and SH

RoS

Comprehensive Medical History - Initial Information and Identifying Details

Date and Time of Eval

Pt ID: Name (initials), Age, Gender

Source of Info: Pt/Parent/Spouse/caregiver/EMS

• unreliable/unable - docu reason (pt vague…spouse is reliable historian)

Comprehensive Medical History - Chief Complaint

Primary Sx/ concern causing pt to seek care

Document: [Chief Complaint] x duration (I have crushing chest pain x 3hrs)

Mult? Primary sx as CC and addition as HPI (under positive asso sx)

Comprehensive Medical History - History of Present Illness

Clear, Concise, chronological description of pt’s complaint

OP5QRS2T

Onset: when began?

• if vague ask clarifying to better quantify (Guided Q)

• When__ start? What does time mean to you? Yrs or mths

Precipitating: What cause Sx?

• what doing when __ began; anything unusal? →risk factors? Relevant PMH/SH

Palliative: factors that make sx better

• anything make sx better? → anything for pain? → better w/ __

Provocative: factors that make sx worse

Progression: how sx changed since onset

• focused has __ changed since began? →ep longer/freq/severe?

Prior episodes: focused - exp b4? → if y what was cause?

Quality: Description of sx

• can you describe? → dizziness to you..? → aching/burning/sharp…

Radiation: sx anywhere else? (PREDOM for pain)

• pain move/travel? →CP to neck/jaw/arm; ABD →back (straight or wrap around?)

Site: location

• where? →point w/ finger? →same both or worse?

Severity: Bad

• PAIN scale 1-10 can clarify w/ palliative/provocative factors)

• NONPAIN: mild, moderate, severe (how affecting ability…)

Timing: often/long sx affect pt

• time of day w/ worse sx; how often exp; how long ep; pain wax/wane or intermittent/constant

Comprehensive Medical History - HPI (associated sx)

Other symptoms present (aside from CC)

OPQRST each positive sx (any RoS pt says yes to)

List all negative (any ROS pt says no to)

Comprehensive Medical History - Past Medical History

Adult Illnesses (dates and yrs since diagnosis)

• medical (High BP, Heart attack, Hep, asthma, COPD, seizures cancer)

• surgery (type and date/yr, surgeon’s name) directed to r/o appendicitis…

• Hospitalizations (date, hospital, diag, tx, studies done, outcomes)

• Trauma/serous injury (age @t time of injury, tx, causes, complications, outcome

• OBGYN (obstetric hx, menstrual hx, methods of contraception, sexual function)

• Psychiatric (hx of depression, anxiety, suicidal ideation/attempts, homicidal ideation. Y to any ask abt prior psych hospitalization (date, duration, tx)

Childhood illness

• acute illness: MMR, Chicken pox, Whoopting cough (pertussis, Rheumatic fecer, scarlet fever, polio (ALL MANIFEST LTR IN LIFE)

  • Consistent strep (tonsillectomy)

• Chronic illness: asthma, DTM (either PMH or childhood (if resolved then))

Health Maintenance: immunizations (name, yrs admin), vaccines; screening tests (colonoscopy, mammogram, PAP smear…)

Mediations (name, dose, route, frequency, indication (esp w/ PRN) why/what diag)

Allergies: allegen and reaction (date/yr). Foods, medicatios, env and insect

Comprehensive Medical History - Family History

Outlines ages and health OR age and cause of death of family members (2 generations above and below)

• Age or age of death of each relative

• Health and any known medical probs (why die?)

  • Docu alive and well (A&W) w/ no MH

• Ask abt chronic disease (DOCU if neg/pos)

  • HTN, coronary artery disease, elev cholesterol lvls, stroke, DTM, thyroid/renal disease, arthritis, TB, asthma/lung disease, headache, seizure disorder, mental illness, suicide, substance abuse

  • Cancer hx (breast, ovarian colon, prostate)

Comprehensive Medical History - Personal and Social History

Pt’s personality and interests, coping mech, strengths, and concerns

• non-judgmental!!

• Sensitive topics (explain why you need to know)

• Influence from societal, cultural, and family constraints

• Opening q and specific q to garner info

• Ackow own discomfort

Tobacco use/ illicit, recreational drug use/ alc use (specific!!)

Occupation & highest level of education

Marital Status

Lifestyle Habits (diets, exercise, supplements, caffeine intake)

Safety measures (seatbelt, bike helmet. Sunscreen, smoke detectors, firearms in home)

• mainly comprehensive; firearms w/ psych

Sexual orientation/ gender ID

Birthplace

Person environmental map (sig relationships? Healthy? Home environment, life exp, leisure act, sexuality, spirituality, social support syst)

Baseline level of function (ADLs/iADLs aka basic vs instrumental)

• consider w/discharge

Comprehensive Medical History - SH (Tobacco/Illicit/Alc)

Tobacco use

• Using: what kind? How many? How long (pack yrs = PPD x yrs smoking)

• If not using: Have you ever? How long? When quit?

Recreational/Illicit Drug Use

• National Institute on Drug Abuse recc: “how many times in the past year have you used an illegal drug or used a prescription medication for nonclinical reasons?”

  • what used? Last used? How much? How often?

Alcohol Use

• how often? How many drinks (men 4/day or 14/wk; women 3/day or 7/wk)? When last drink?

• Misuse → blackouts, withdrawal seizures, accident/injuries secondary to drinking, diff at work/relationships due to alcohol abuse

• CAGE questionnaire; AUDIT-C

Comprehensive Medical History - SH (Sexual Orientation & Gender ID-SOGI)

Do NOT assume - asking allows relevant and compassionate care

• appropriate/DIRECT questioning, specific language (gender neutral; ask pt how they refer to genetalia), consider generalized approach (specific concerns/q to start regarding sex health/practice?)

• Then go to 5p+

• Consider asking as pt of ROS/HPI (genitourinary syst)

5 Ps+

• Partners: last time w/ intimate contact? Sexual intercourse? Genders? Partners in last 6mth/5yrs/lifetime? New partners in last 6mth?

• Practices: have sex? What kinds (oral,vaginal,anal)? Using/sharing sex toys? Pts of body used for sex?

• Protection from STIs: what done to protect? When use condoms (if N then why?) Any concerns abt HIV/AIDS?

• Past HX of STIs: ever had one? Y kind, when, tx, meds? Ever tested? Y when, what, results?

• Pregnancy Prevention: plans desire for children?

  • Opp sex partners: concen abt preg/getting partner preg? Doing anything to prevent? Want info on birth control? Any Q or concerns abt preg prevention?

• Other: assessment of trauma/violence/sex satis/ sex heal concerns/probs and support for SOGI

Comprehensive Medical History - SH (Spiritual History)

Asking - express compassion and increase feeling of being understood

FICA Screening tool

• Faith/belief: what is it?

• Importance and Influence: does it influence healthcare decision making?

• Community: any community? Is this a support? (Y how?)

• Address: how address issues in healthcare?

Comprehensive Medical History - SH (Familial and Social Relationships)

Both short and long term effects (mental/health behavior/physcial)

Abuse? DO NOT ask in presence of others, ask them to leave

• resistance? Don’t force situ

• Begin q with normalizing statement (b/c abuse is common in many of my pt’s lives, I’ve begun to ask about it regularly)

  • Relationship where hit/threatened?

  • Anyone treated badly? Made them do things you don’t want to?

  • Anyone you’re afraid of?

Comprehensive Medical History - Review of Systems

Inquiry method to uncover any prob/sx you or pt may have overlooked (particularly in areas unrelated HPI)

• can uncover sx supporting different diagnosis

• Y/N head-toe format

• Always ask at end of interview, when clinal reasoning GONE

• Helpful to ask general Q

• ANY ADDITION MAJOR SX RELATED TO CC, MOVE TO HPI W/ OTHER POSITIVE ASSO SX

The Physical Examination - Preparation

Hand hygiene (soap&water/ hand sanitizer)

Observe sign for contact precautions and don appropriate PPE

• Contact: contracted thru touching (MRSA, C.Difficile)

  • Gloves, gown

• Droplet: spread thru contact w/ secretions from mouth, nose, lung (esp w/ coughing and sneezing) typ ~3ft, COVID ~6ft

  • Gloves, gown, mask

• Airborne: spread thru air over long distances (TB, Chickenpox)

  • Place in neg pressure room

  • Gloves, gown, respirator mask

• Reverse Isolation: protect pt from staff/visitors (immunocompromised typ chemo)

  • Gloves, gown, mask

The Physical Examination - Positioning

Standing/Sitting

Supine/Prone

Lithotomy/Dorsal Recumbent/Lateral Recumbent

Trendelenburg/Reverse Trendelenburg

Semi-Fowler’s/Standard Fowler’s/High Fowler’s

The Physical Examination - Head to Toe

Vitals → General Survey → Skin (can be incorp into inspection of each body syst) →HEENT-N → lungs/thorax → cardiovascular → breasts/axilla → abdomen → peripheral vascular/lymphatics → neurologic → musculoskeletal → genital/rectal

The Physical Examination - Cardinal Techniques (IPPA)

Exception: abd (IAPP)

Inspection: observation of details of pt appearance, behavior, mvmt

Palpation: Tactile pressure form the palmar fingers/finger pads to assess areas of body

Percussion: striking finger against digit from other hand lying flat against surface of chest/abd to evoke sound wave

Auscultation: using stethoscope to detect chara of heat, lungs, bowels, vasculature