Foundation of Health Assessment 📝

what is the definition of clinical skills?

any discrete act within the overall process of patient care

-*history taking*

-*performing physical examination*

what do you need to become a skilled clinician?

be able to gather information and establishing trust

what are the five components of an encounter?

1. initiating the encounter

2. gathering information aka health history

3. performing the physical examination

4. explaining and planning

5. closing the encounter

what is a professional appearance?

neat hair, clean nails, no body odor

what is important to consider when setting the stage for a patient encounter?

is the patient comfortable?

what is important to do before initiating patient encounter?

review the record *before* seeing the patient

what should you review in the pt record before seeing them?

- age, gender

- problem list - past medical/surgical history

- medications

- allergies

how do you set your agenda for a patient encounter?

determine your goal before the encounter

what examples of possible goals to have for a pt encounter?

- obtaining info

- attempting to diagnose

- delivering diagnosis, or bad news

why is it important to set your agenda before the encounter?

- *patients priorities may be different from ours

- time is limited, 1 hour for initial encounter, 15 min for follow up

how should you greet the patient and establish initial rapport?

- *provide your name

- *explain your role

- if possible, shake hands

how should you identify a patient when setting the stage?

- *avoid using first name until you get permission

- avoid "dear", "sweety," etc

- *ask what pronouns he or she prefers

how do you verify the patients understanding of the condition?

"teach back"

why do we use shared decision making?

this process promotes optimal therapy, adherence to treatment, and patient satisfaction

what is subjective vs objective data when collecting healthy history?

subjective: what the pt tells you

objective: PE + all lab and diagnostic testing results

what should comprehensive health history contain?

1. Initial information

2. Chief complaints or CC

3. History of present illness (HPI)

4. Past medical history

5. Family history

6. Personal and social history

7. Review of systems

what is initial information?

- date and time of encounter

- pt identifiers

- source/liability (pt, family, bystander, facility)

what is the chief complaint/concern?

the primary reason why the pt is seeking care, usually one or two

how do you document CC?

quote the pt, "my back has been bothering me"

what are tips for taking health history?

- take notes

- keep eye contact

- *use open ended questions

- *let your pt tell their own story in their own words

what is the HPI describing?

details and characteristics of CC

what is included in HPI?

1. Location

2. Quality

3. Quantity/severity

4. Timing-Onset, duration, frequency

5. Modifying factors

6. Associated manifestations pertinent positives and negatives

if for ex pt comes in complaining of back pain but associated manifestations mentioned include tingling in left thigh and foot, no incontinence, no weakness of lower extremities, what should you consider?

think about differential diagnosis and use review of systems (ROS)

what are pertinent positives?

symptoms and signs that you would expect to find if the pts possible diagnosis were true

what are pertinent negatives?

symptoms and signs that are not present which then weakens the possibility of potential diagnosis

what must be taken into consideration for past medical history?

1. childhood illness

2. adult illness

3. surgical

4. psychiatric

5. OBGYN illness

6. health maintenance

7. allergy and meds

what are ex of childhood illnesses?

asthma, diabetes, measles, chicken pox

what are ex of adult illnesses?

DM, HTN, heart disease

what is health maintenance?

vaccines, screening tests

what are important aspects of the personal and social history of our patient?

- sexual orientation and gender identity

- living environment

- education

- employment

- religion

- activities of daily living (ADL)

- substance use

how do we asses alcohol dependance?

What do you drink? quantity, CAGE question

how do we asses tobacco use?

# of pack smoked/days x years = *pack year history*

what is ROS?

head to toe screening tool to uncover symptoms and problems patient may be experiencing that can contribute to making a diagnosis

what should be done if new symptoms are uncovered during ROS?

they should be added to HPI in write-up

what are common findings in the HEENT exam?

rhinorrhea, rhinitis, pruritus, epistaxis

what are common findings in neck exam?

lymphadenopathy, goiter

what are common findings in respiratory exam?

sputum (color, blood), pleuritic chest pain

what is a significant question in CVS exam?

can you lay flat while sleeping

what are common findings in GI exam?

dysphagia, odynophagia (painful swallowing), bowel movement (color, size, quality, frequency), rectal bleeding, tarry stool

what is a significant finding in peripheral vascular exam?

claudication

what are significant findings in urinary exam?

frequency, dysuria, polyuria, nocturia

what are significant finding in exam of female genitalia?

dysmenorrhea, menorrhagia, metrorrhagia, dyspareunia

what is a significant finding in musculoskeletal exam?

limited range of motion (ROM)

in what order should you document HPI?

age

CC

time frame

pain scale and description

pain alleviation

additional complaints

what is important to remember for HPI?

- time anchors

- pain scale

- use of generic medication name

what is a fundamental of skilled interviewing?

active listening

how do you begin guided questioning?

move from open ended questions to more specific questions while avoiding leading (yes/no) q's

what type of answers should be elicited in guided questioning?

graded answer: quantity rather than yes/no

in what style should you ask guided questions?

*one at a time

do you have HTN, DM...?

and you can offer multiple choice to help

is pain dull, sharp, throbbing, pressure...?

what does an empathetic response consist of?

ones ability to recognize the others feelings/pain then respond in a supportive manner

***ask what they think and feel rather than assuming

what is summarization?

summarize to communicate what you have heard, organize your thoughts

what should follow summarization?

*transition* to explain what you are doing next to put the pt at ease

"let me ask you about allergies"

"im going to examine you next"

what should follow your transition?

*partnering* : build a rapport with pts and express your commitment to an ongoing relationship

what should follow partnering?

*validation* of the legitimacy of their emotional experience

"your accident must have been terrifying"

how can you *empower the patient*?

****

- Know that the clinician-patient relationship is unequal

- Patients have many reasons to be vulnerable

- Ultimately patients are responsible for their care

- By asking questions, expressing their concerns, and making

recommendations, they are more likely to adopt to your advice.

what do you do after empowering the pt?

*reassurance*

"dont worry, everything will be okay"

*dont give premature reassurance!!*

how do you use appropriate verbal communication?

1. use understandable language

2. use non stigmatizing language

how can you use understandable language?

use simple, recognizable and clear words and avoid medical jargon

"where does that pain *radiate* or move?"

pause and ask for *"teach back"*

what is the nonstigmatizing language for each of the following?

drug addict

wheelchair bound

schizophrenic

prostitute

rape victim

handicapped/disabled

midget/dwarf

Drug addict (person with dependence)

Wheelchair bound (person who uses wheelchair)

Schizophrenic (person with schizophrenia)

Prostitute (sex worker)

Rape victim (sexual assault survivor)

Handicapped/disabled (person with disabilities)

Midget/Dwarf (person with little statue)

what is appropriate nonverbal communication?

- stay calm and unhurried

- be aware of your facial expression

- body language - open arm placement

what is informed consent?

communication process in which a clinician educate a patient about risks, benefits, and alternatives of a given procedure or intervention

1. Nature of the procedure or treatment

2. Risks and benefits of the procedure or treatment

3. Reasonable alternatives

4. Risks and benefits of alternatives

5. *Assessment of the patient's understanding of the above*

what are advance directives?

*A written document of a person's wishes regarding medical

treatment, to ensure those wishes are carried out should the

person becomes unable to communicate them with a healthcare provider*

*Healthcare Proxy*

*Healthcare power of attorney*

*POLST/MOLST*

*DNR/DNI*

*Living Will*

what are the factors influencing health of individuals and populations?

*SDOH*

what is cultural humility?

lifelong process as individuals continually engaging in

self-reflection and self-critique to understand one's own

biases and limitations in understanding and respecting

cultural differences.

what are the 5 R's of humility?

reflection

respect

regard

relevance

resiliency

how may religion have an affect on health?

Jehovas witness, diet, birth control

what is another major consideration during the clinical encounter?

understanding medical ethics and upholding the principles

what is nonmaleficence?

first do no harm

what is beneficence?

clinicians are to act for the patient's good

what is respect for autonomy?

accept the choices the patient makes

what is decision making capacity?

respect patient's ability to make decisions

what is confidentiality?

duty to prevent disclosure of pt info

what is informed consent?

authorization from the patients to test and perform procedures

what is justice?

treat everyone equally