Week 3
Fundamentals of Skilled Interviewing:
Practice Active Listening- Verbal communication, non-verbal communication
Empathetic Responses - Recognizes patient’s feelings
Ask Open-Ended Questions - Allows patient to explain their chief complaint in their own words first. “Tell me about your leg.”
Ask Questions that Elicit a Graded Response - Specific questions that give you more incite into the issue. “Does your leg hurt when you walk?”
Validation/affirmation - Reassurance, Acknowledge their Chief Complaint
Partnering with patient - support them & make them feel heard, so they are more comfortable going through with at home instructions
Summarization - capsule overview: “Let me make sure I have the full story”…”Did I miss anything?”
Transitions - Puts Patient at ease as you change directions, ie. Chief Complaint to Medical History, Interview to Exam, etc.
Empower the patient- so they follow instructions at home as well; so they follow through with the treatment plan.
Patient-centered questions: try to get the patient to talk, open-ended
Doctor-centered questions: Specific questions, typically yes/no answers
Doctor- centered questions fill in the holes that patient-centered didn’t answer
Ask yourself- Did I develop a rapport? Am I helping the patient provide an accurate and unbiased report of their illness? Did I collect enough information to make an accurate Diagnosis?
General Survey:
Apparent State of Health: general judgment, acutely ill, fit, robust
Level of Consciousness: alert, responsiveness
Signs of Distress: Shortness of breath, pain, cough, depression, wincing, antalgia, grimacing
Skin Color/ Lesions: Jaundice, cyanosis, rashes, bruises, scars, neck
Dress, Grooming, Hygiene: attire, shoes, copper bracelets, unkempt
Facial Expressions: affect, eye contact, stare
Body Odor, Breath: alcohol, diabetes, liver, kidney
Posture, Gait, and Motion Activity: tremors, agitation, lean, shorter leg, toe out, Multiple Sclerosis, etc.
Height/Weight: unusually tall/short, symmetry, generally proportional
Chest Pain could signify Heart Attack, Anxiety, Indigestion, etc.
Pallor: pale skin
Clubbed finger tips/fingernails typically signify a Cardiac issue due to decreased blood flow to the fingers
Paralysis/limited function on one side of the face could signify Stroke or Bell’s Palsy
Dowager’s Hump: Lump at the base of the neck/top of the back. Advanced Osteoporosis, a person sometimes develops Vertebral fractures and Kyphosis, or a spinal hump often occurs.
Normal Osteoarthritis (Wear & Tear/ old age) causes joint swelling in the fingers.
Ulnar deviation: Fingers move towards the pinky side (ie. Rheumatoid Arthritis)
“Butterfly Rash” is typically a sign of Lupus.
Goiter in neck is caused by an enlarged/inflamed Hypothyroid (low functioning) (Hashimoto’s Disease)
One limb noticeably smaller than the other could signify a nerve compression in the spine, lading to muscle atrophy. Could take a year to notice
Bulging eyes is caused by Hyperthyroid (overactive) (Graves Disease)
Vital Abbreviations:
HR=Heart Rate (pulse)
BP= Blood Pressure
RR= Respiration Rate
BT= Body Temperature
BMI= Body Mass Index- American system= calculated by Weight in lbs divided by Height in in² then Multiplied by 703. (Weight lbs/height in²)X703=BMI
Why do Vitals? identify acute problems, quantifies the magnitude of an illness and how the body is coping, marker of chronic disease states.
Blood Pressure:
Systolic Pressure: Top number, amount of pressure your heart generates when pumping blood through your arteries.
Diastolic Pressure: Bottom number, amount of pressure in your arteries when your heart is at rest between beats.
Pulse Pressure: the difference between Systole and Diastole
Normal BP: less than 120/80
Elevated BP: 120-129 and less than 80
Stage 1 HTN: 130-139 and 80-89
Stage 2 HTN: >140 and >90
HTN Crisis: >180 and >120
BP varies throughout the day due to- Stress, activity, pain, noise, caffeine, smoking, etc.
Arrhythmias: irregular, extra beats. Effects BP
HTN: Hypertension, High BP
Hypotension: low BP
White Coat Hypertension: BP high in the office but otherwise normal
Masked Hypertension: BP normal in office but is usually high
Cuff size matters! Too small of cuff increases Systolic. Too large cuff decreases Systolic
Complications of HTN- Brian Stroke, Vision loss, blood vessel damage, heat attack, kidney failure, bone loss. Prolonged HTN causes organ failure over time
Primary prevention: treatment of HTN prior to end organ damage
Secondary prevention: Treatment of HTN to prevent of slow progression of end organ damage
What causes HTN? Cardiac output increase, blood volume increase, resistance (flexibility and diameter of artery walls, blood viscosity).
Plaque blocks are caused by cholesterol particles building up in arteries, typically entering through a small tear.
Orthostatic Hypotension: When Systole drops 20mmHG of Diastole drops 10mmHG within 3 minutes of standing up. Causes dizziness upon standing. Usually self resolves
Normal RR: 12-20/minute
Inhale=inspiration, Exhale=expiration
Bradypnea=slow breathing, Tachypnea=Rapid Shallow breathing, Hyperpnea/Hyperventilation=Rapid Deep breathing
Cheyenne-Stokes Breathing: Dysrhythmia alternates between hyperpnea and apnea (when someone is dying)
Obstructive breathing: prolonged expiration, COPD