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How many diagnoses are made by history alone?
2/3
What does a good history do?
Provides focus to the physical examination and helps with relationship development
What are the 6 elements of a patient-centered approach?
1. Seeking care (patient context of a symptom)
2. >1 concern (1st concern mentioned may not be pertinent)
3. Patient must have a voice (empathic communication)
4. Patient tells the story
5. Story telling is therapeutic (patients unburden themselves and feel heard)
6. Don't want a "fix" (sharing stories and having it responded to is often enough)
What does active listening allow you to do?
Achieve objectivity and precision in the interview and is the first step in connecting with your patient.
A clinical relationship embodies these 6 attributes
1. Non-judgmental attitude
2. Respect
3. Genuineness
4. Objectivity and active listening
5. Empathy
6. Acceptance of patient
6 keys to being respectful as a provider
1. Introduction
2. Eye contact
3. Proper address (Mr. / Mrs. / Etc.)
4. Last name
5. Explain role
6. Address comfort
What type of questions should you start with in an interview?
Open-ended
What parts of a medical interview should be open-ended questions?
Opening the interview, exploring present symptoms, understanding patient perspectives, assessing severity, encouraging patient input
What parts of a medical interview should be closed-ended questions?
Gathering background information, confirming information, reviewing medical history, assessing severity, concluding the interview
What is the core to the "Art of Medicine"
1. Listen
2. Look
What describes the nuances of language outside of the spoken word?
Paralanguage
What is objective information?
Clinical finding that is observed - sign
What is subjective information?
That which is perceived by the patient - symptom
Sign vs symptom
Sign = objective finding (what I see)
Symptom = subjective indication (what the patient tells me)
What are the parts of a SOAP note?
1. Subjective
2. Objective
3. Assessment
4. Plan
What is a latrotrophic stimulus?
A stimulus or event that prompts patients to seek or receive medical attention
How is the CC usually written?
In quotation marks because its in the patients own words
What do you ask when taking an HPI?
ChLORIDEPPP
What technique is used if a patients story is complicated?
Summarization
How should the review of systems be documented?
Separated by body system in list fashion
What is the benefit of holistic patient assessment?
Allows us to assess the patient's health comprehensively, beyond the specific reason they came in for
What are the benefits for collecting the ROS?
1. Holistic patient assessment
2. Identification of asymptomatic conditions
3. baseline for future comparisons
4. Screening for risk factors
What is polypharmacy?
the simultaneous use of multiple drugs to treat a single ailment or condition
Why is family history important?
1. Contains health conditions that are passed down through generations
2. Can help educate the patient on lifestyle decisions
3. Can help recommend certain screening tests
4. Can identify patients with a high-than-usual chance of having a common disorder
What is a pedigree?
An analysis chart that is a tool to study the inheritance of genes and the family history of traits and disorders
What is the "patient" considered on a pedigree?
Proband
Why is social history important?
Identify factors outside of a patients past or current medical condition that may influence the patients overall health or behavior
What are factors that might reveal and unreliable social history?
1. Can be awkward
2. Communication
3. Shame/fear
4. Questions too personal
What do you document if you don't have a diagnosis yet?
The symptom (ex. Sore throat)
What are differential diagnosis?
Conditions that are being considered that may require further work up
What elements are in the "plan" section of a SOAP note?
1. Diagnostic studies
2. Referrals
3. Therapeutic interventions
4. Education
5. Disposition
What is an ICD-10 code?
ICD-10 codes classify diagnoses and diseases for billing
What do ICD-10 codes go?
In the assessment next to the diagnosis
