Transcript EO_002.03 part 1 Obtain Health Hx

Obtain a Health History
Ref(s):
C1 - Bates “A Guide to Physical
Examination”, eighth Edition
Obtaining a health history
• The Health History Interview
• Techniques of skilled interviewing
• Components of the Comprehensive Adult History
Health History Interview
Health History:
– A structured framework for organizing patient
information in a written or verbal form.
– Focuses the clinician’s attention on specific
pieces of information that must be obtained
from the patient.
The interviewing process:
– Generates the pieces of information in a fluid
manner.
Health History Interview
Conversation with a purpose
– To improve the well-being of the patient:
1. Establish a trusting and supportive
relationship
2. Gather information.
3. Offer information.
Health History Interview
You need to focus your energy on gathering
information while:
– Letting the patient’s story “unfold”
– Generating a series of hypotheses about the cause
of the patient’s concerns and
– Still find a way to explore the patient’s “feelings
and beliefs about their problem(s)”.
Health History Interview
The challenge:
“Every man is
….like all other men
…like some other men,
…like no other man.”
(Barbara Bates)
Remember that few patients are “competent” story or
history tellers…in the way that you want them to
be.
Health History Interview
Who are we talking with?
Why has the patient come?
What do we want to know?
What does the patient expect of us?
What more information do we need to solve the
problem?
Health History Interview
Before you begin:
1. Taking time for Self-reflection
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How can you remain or become consistently open
and respectful to individual differences?
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Everyone brings their own beliefs, values, and
experiences to each patient encounter…how will that
affect what you are about to hear and how will you
respond to it?
Health History Interview
2. Reviewing the Chart
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Problem list
Medications
Allergies
Past diagnoses and treatments
The chart or ER triage sheet does not, “capture the
essence of the person that you are about to meet”
Health History Interview
3. Setting Goals for the interview
Provider centered goals:
– Write-up for your supervisor
– Insurance form
Patient centered goals:
– Relieve the pain
– Note for work
There has to be a balance between the above as well as the
institutional needs.
Health History Interview
4. Reviewing Clinician Appearance and Behavior
What do patients look for in appearance?
Posture, gestures, eye contact, and tone of voice can all
express interest, attention, acceptance and understanding.
But they all have the potential to express the opposite!
Health History Interview
5. Improving the environment
– How do you make a room(s) more private or more
comfortable?
6. To take notes or not to take notes?
– If you need to use short phrases, specific dates, or
words not the final version of what a patient said?
– How do you respond to, “your note taking is making
me uncomfortable?”
Health History Interview
The sequence of the interview:
1. Greeting the patient and establishing rapport.
2.
Inviting the patient’s story.
3.
Establishing the agenda for the interview.
4.
Expanding and clarifying the patient’s story: generating
and testing diagnostic hypotheses…Q and Q!!!
5.
Creating a shared understanding of the problem(s).
6.
Negotiating a plan. (further evaluation, treatment and
patient education)
7.
Planning for follow-up and closing the interview.
Greeting the patient and establishing rapport
Introduce yourself.
• Great patient appropriately in a friendly relaxed way.
– Shake hands (if possible).
– Explain your role in the patient’s care and status (as a student)
• Note – never forget patient names and use titles.
• Confidentiality is paramount
– Know who is in the room, their relationship to the patient and whether or
not he or she should stay in the room.
• Be sensitive to the comfort of the patient:
– Bedpan vs. pain vs. other tests taking place
• Arrange the room appropriately:
– Do not have objects between you and the patient when avoidable.
– Avoid arrangements that connotate disrespect or inequality of power
• Consider the need for a chaperone nurse/ Med Tech
Inviting the patient’s story
Open ended questions to elicit the Chief Complaint:
– “What concerns bring you in today?”
– “How can I help you”
– “You have had this problem for seven weeks, what
made you decide to seek medical treatment for it today?
What has changed?”
Listen without interrupting!
Inviting the patient’s story
Following the patient’s lead:
• Initially - “continuers”
• Try to hone in on the most significant things using “Direct
questions”.
• Consider asking questions that require a graded response.
• Consider offering Multiple Choice answers.
• Ask one question at a time.
• Use language that is understandable and appropriate?
• Clarify what the patient means but in terms they can
understand.
Expanding and clarifying the patient’s story
Language is important:
– Shortness of breath vs. dyspnea
– Bright red blood in your stools vs. hematochezia
Establishing the sequence and time course of the presenting
problem is also important.
– It is now 1200, to the best of your knowledge when exactly did the
pain start?
Establishing the agenda for the interview.
Both the patient and the clinician have goals in
mind…they are not always the same.
As a student you usually have more time per patient;
this changes as you become a clinician.
Agree upon the goals at the beginning of the
encounter and then you can move forward.
Expanding and clarifying the patient’s story
Each symptom has attributes that must be clarified, including
context, associations, and chronology…the most obvious
and ( very common) being that of “pain”.
Remember: the “seven attributes of a symptom”.
Symptom attributes
1. Location: Where is it? Can you point to it? Does
it radiate?
2. Quality: What is it like?
3. Quantity or severity: How bad is it?
4. Timing: When, how long, how often?
5. Setting in which it occurs: environmental and
personal activities.
6. Remitting or exacerbating factors.
7. Associated manifestations.
Essentially, by asking the right questions you are
generating and testing diagnostic hypotheses
through engaging the patient’s perspective.
To do this well you must understand the
pathophysiology of disease and the patterns of
disease. How do you gain this knowledge?
Studying, seeing real patients, studying, seeing real
patients, reviewing and studying, and SEEING
REAL PATIENTS!!!!!!
Creating a shared understanding of the problem(s).
The seven attributes gives you the details but you also need to
explore the following terms to consider a dual view of
reality for the interview to be successful… disease vs.
illness:
– Disease: explanation that the clinician brings to the
symptoms.
– Illness: how the patient experiences symptoms. What
factors may shape this experience?
Creating a shared understanding of the problem(s).
Exploring the patient’s perspective:
1.
Pt’s thoughts about the nature and cause of the problem.
2.
Pt’s feelings, esp. fears about the problem.
3. Pt’s expectations of the clinician and healthcare.
4.
The effect of the problem on the patients life.
5.
Prior personal or family experiences that are similar.
6.
Therapeutic responses that the patient has previously
tried.
Creating a shared understanding of the problem(s).
IFFE:
• What do you think is causing the problem ( Patient’s best Idea of what
is causing the problem?
• What is your worst Fear that the problem could be?
• How is the problem affecting your Functioning?
• What are your Expectations of this visit?
Negotiating a plan
Create a plan that is feasible for you and the
patient…not just you!
e.g. The case of the patient that does not get sick
leave or is self-employed with few or no benefits.
Planning for Follow-up and Closing
Maybe difficult…if you are doing well so far the
patient likes talking to you and chances are they
would like to continue.
Ensure that the plan has been agreed upon and
summarize the plan…or better yet have them
summarize it.
Do not get into discussion of new topics as you are
leaving if you can avoid it. Reassurance is
adequate if it is not a life or limb threatening
concern.
Techniques of Skilled interviewing
Active listening:
– Fully attend to what the patient is communicating being
aware of the pt’s emotional state.
Adaptive Questioning:
– Directed questioning from general to specific.
– Questioning to elicit a graded response.
– Asking a series of questions, one at a time.
– Offering multiple choices for answers.
Techniques of Skilled interviewing
Non-verbal communication
– Eye contact, gestures, facial expression, posture, head
position and nodding or shaking, personal distance,
crossed arms or legs.
– Matching your position to the patient: eye to eye, or
reasonable physical contact with the patient.
Techniques of Skilled interviewing
Facilitation:
– using posture, actions or words to encourage the pt to
say more. I.e. “mmm go on”, “I’m listening”,
maintaining eye contact, or leaning forward in the chair.
Reflection/echoing:
– a simple repetition of the patients words, I.e. Pt “The
pain got worse and started to spread”? Clinician
“Spread”?
Techniques of Skilled interviewing
Clarification:
– Some patients words are ambiguous and require further
discussion, I.e. What do you mean when you stated “I
have a cold”, “I don’t feel like my usual self”.
Empathy:
– Offering some one a tissue during a moment of distress
or simply stating “I understand”, “you seem sad.”, or
“That sounds upsetting.”, “ This is a very difficult
challenge for you”
Techniques of Skilled interviewing
Validation:
– Legitimize their emotional experience. “That must have
quite terrifying.”
Reassurance…in a proper manner.
– You need to identify and accept the patient’s feelings
without offering reassurance at that moment and allow
the reassurance to come later…once you have all the
necessary information and concerns can be openly
addressed.
Techniques of Skilled interviewing
*Summarization:
– Lets the patient know that you have been listening.
– Picks up any missed information or misinterpretation of
information.
– Organizes your clinical reasoning, conveys your
thinking to the patient and makes the relationship less
one sided and more collaborative.
Techniques of Skilled interviewing
Highlighting transitions
– “Now I would like to ask you some questions
concerning your past health.”
Taking a History on Sensitive Topics
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Drug / Etoh abuse
Sexual orientation or habits
Death and dying
Financial concerns
Racial and ethnic experiences
Family interactions
Domestic violence
Psychiatric illness
Physical deformities
Functioning of the Urinary Tract / Bowels, etc..
Basic principles
• Maintain a non-judgemental approach.
• Explaining to a patient why you need to know the
information and putting it into context is very
helpful.
• Use ”specific language”!
Other ways to become more comfortable
• Reading about these topics.
• Talk to selected colleagues.
• Talk to teachers about your concerns.
• Listen to experienced clinicians when they
have to discuss certain topics with a patient.
• Be aware of Bias and cultural difference!
Culture
• A system of shared ideas, rules, and meanings
which individual inherit or acquire that tells them
how to view the world, how to experience it
emotionally, and how to behave in relation to
other people and to the environment.
The Goal
• Become aware of your own biases and values.
• Develop communication skills that transcend
cultural differences.
• Build therapeutic partnership based on respect for
the patient’s life experiences.
Self-awareness
How do you define yourself by:
• Ethnicity
• Class
• Region
• Religion
• Political affiliation
• How are you the same or different than your
family of origin?
Values vs. Bias
Values - standards we use to measure beliefs and
behaviors…which may appear to be absolute.
Biases - the attitudes or feelings that we attach to the
awareness of differences.
Learning about others
Can you be an expert on every person’s culture?
• Patients are experts on their own unique cultural
perspective.
• Be ready to acknowledge your own ignorance or
bias.
• Learn about ethnic or racial groups in your region
or if you are going to work in a different region as
a start.
Adapting Interview Techniques
The Silent Patient
• Silence: collecting thoughts, remembering details, deciding
on trusting you with info.
• Non-verbal clues: emotion, unable to sit still.
• Are you asking too many questions in sequence?
• Have you offended them in any way?
• Are they too short of breath to answer your questions?
Adapting Interview Techniques
The Talkative patient
• Do you give them “free reign for 5-10 mins”?
• Focus on what is important for the patient, you may need
to interrupt but be courteous.
• A brief summary may help you change the subject yet
validate any concerns.
• It is important to not show your impatience.
Adapting Interview Techniques
The Anxious Patient
• It is a frequent reaction to sickness, treatment, and the
healthcare system itself.
• It is also maybe part of their illness.
• Watch for verbal and non-verbal clues.
• If you detect anxiety, reflect your impressions back to the
patient and encourage them to talk about any underlying
concerns.
Adapting Interview Techniques
The Crying Patient
• Emotions: sadness to anger to frustration.
• Maybe therapeutic for the patient.
• Most patients will recompose themselves and continue
with their story…as opposed to escalating or becoming
uncontrollable.
• Does a crying patient make you uncomfortable?
Adapting Interview Techniques
The Confusing Patient
• “ a positive review of symptoms”
• Focus on the meaning or function of the sx as part of a
psychological assessment.
• You may become baffled, confused, or, as is usually the
case, frustrated yourself.
• “my fingernails feel too heavy”
• Be aware of any neurological, psychiatric, or intoxication
in patients like this as well as any language barriers…get
more info from loved ones with permission from the
patient.
Adapting Interview Techniques
The Angry or Disruptive patient
• Reasons: ill, suffered a loss, felt powerless within the
healthcare system…they may direct this anger towards
you.
• Did you do anything wrong? Can you correct it or at least
apologize so you can move on.
• You can validate their feelings without agreeing with their
reasons.
Adapting Interview Techniques
• What do you do when patients become hostile or
disruptive?
– Inform security, hear what they have to say, do not
appear challenging in posture, and suggest moving to
another location that is not upsetting to other patients
and offers more privacy or less privacy given the
situation.
Adapting Interview Techniques
The Patient with a language Barrier
• “Nothing will convince you of the importance of a history
then having to do without one.”
• Make every effort to find an interpreter.
• A neutral objective person who is familiar with both
languages and cultures.
• Family members may: speed things up, violate
confidentiality, distort meanings, transmit incomplete
information, and may have their own agenda.
Global Competency
Overall technique of applying the knowledge of the skill
Greeting patient & Introduction
Establishing Rapport:
• Look confident & professional approach.
• Non verbal communication- looks & talk friendly manner,
show interest & seriousness regarding patient’s problem.
Logical sequence of questioning.
• If a procedure is required explain the procedure & obtain
informed consent.
• Assurance of the procedure & confidentiality.
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Follow cues & proper interaction with the patient.
Use open & direct question appropriately; avoid
medical jargon & ensure patient understand, also
ask the patient to explain any vague terms that
they use.
Avoid unnecessary repetition.
Comprehensive Adult History
Demographic Data
Chief complaint.
History of present illness (HPI).
– Medication/Allergies.
Past Medical History.
Personal and Social History.
Family History
Review of Systems.
Comprehensive Adult History
• Comprehensive vs. focused (problem oriented)
interview
• Components structure the patient’s interview and
the format of the written record…but do not
dictate the sequence of the interview!
Comprehensive Adult History
Demographic (identifying) Data
– name
– age
– gender
– occupation
– marital status
– (years of service)
– Source of the history
– Include date and time of the hx being taken
– Consider if the hx is being given from a reliable source
Comprehensive Adult History
Chief Complaint
– use the patient’s own words.
• “ I can’t breathe properly.”
– more than one chief complaint (C/C) let the patient (Pt) put them
inorder of importance, as they see it.
– Might be as simple as” I need a note for work.”
Comprehensive Adult History
History of Present illness (HPI)
– Complete, clear, and chronologic account of the
problems that the patient is trying to obtain care for.
– Sx’s need to be well characterized with descriptions
focusing on the common seven attributes for
understanding all patient sx’s:
Comprehensive Adult History - HPI
1. Location: Where is it? Can you point to it? Does
it radiate?
2. Quality: What is it like?
3. Quantity or severity: How bad is it?
4. Timing: When, how long, how often?
5. Setting in which it occurs: environmental and
personal activities.
6. Remitting or exacerbating factors.
7. Associated manifestations.
Principal Symptoms Description
Pain
– CHLORIDE PPPS
– OLDCART
– OPQRST
Other presenting sx’s i.e fatigue, SOB, vertigo, unwell,
vomiting, diarrhea, etc…
– OLDCART
– OPQRST
DDx list
CHLORIDE PPPS
Ch –Character
L – Location
O – Onset, gradual vs sudden
R – Radiating
I – Intensity
D - Duration
E – Events surrounding cc
P – Palliative
P – Provoking
P – Previous episode
S – Sx’s associated
Chloride PPP…s
•Most Basic H&P taught on the PA course
•Designed as an effective approach for someone presenting with
a complaint of “Pain” e.g. chest, abdominal, leg, etc…
•Completely appropriate for the junior clinician.
–Minimizes risk of missing questions when you don’t know
what is wrong or which are the most crucial questions to ask
Chloride PPP…s
Is the testing framework for some but not all
of the phase one Practical EC’s…regardless
all P-EC’s require Q&Q of sx’s…so will
every future patient encounter in your
clinical practice.
Chloride PPP…s
• It is one of several methods used to “qualify and
quantify” the patient’s complaint of pain
• “Sudden onset of mid-sternal crushing chest pain
radiating to the left shoulder and jaw occurring
with exertion lasting 15 mins made worse with
activity and improved with rest, with no previous
episodes and no association with trauma... initially
was 9/10 and now is 4/10.”
Chloride PPP…s
• The “s” component stands for “symptoms associated”…it
is the most important part and a challenge for the junior
clinician to pick out what are most important associated
sx’s to ask about to rule in a Dx and rule out other vital
differential diagnoses
– E.g. Sob, palpitations, cough, LOC, nausea, vomiting,
PND, Orthopnea, edema, fever,etc…
– To help in differentiating cardiac and non-cardiac
causes of chest pain
Chloride PPP…s: Disadvantages
• Design is not good for other presenting complaints:
“SOB”, “Fatigue”, “don’t feel well”
• Can be very inefficient for most experienced clinicians
• Can be difficult to present in an orderly fashion to most
physicians without them losing interest…particularly
specialist consultants.
• Why do you use it…because you do not know which of the
questions are most important yet.
Studying, seeing real patients, studying, seeing real patients,
reviewing and studying, and SEEING REAL
PATIENTS!!!!!!
Essentially building a clinical data base that you are going to
selectively access information from on an as needed
basis…to formulate a clinical plan.
Chloride PPP…s: Disadvantages
• Difficult to sort through for a final disposition for
the patient (lose the forest for the trees) unless
combined with some of the following techniques.
– E.g.“VINDICATE” or using an anatomic
approach - is a way to fill in the “S” part of
chlorideppps
• Also the short list, systems approach, diagnostic
template among others
OLDCART
O – Onset
L – Location
D – Duration
C – Characteristics
A – Aggravating Factors
R – Relieving Factors
T – Time it occurred
OPQRST
Onset of disease
Position/site
Quality, nature, character – burning sharp, stabbing, crushing;
also explain depth of pain – superficial or deep.
Relationship to anything or other bodily function/position.
Radiation: where moved to
Relieving or aggravating factors – any activities or position
Severity – how it affects daily work/physical activities.
Wakes him up at night, cannot sleep/do any work.
Timing – mode of onset (abrupt or gradual), progression
(continuous or intermittent – if intermittent ask frequency
and nature.)
Treatment received or/and outcome.
Are there any associated symptoms? Check with R.O.S.
VINDICHATEM
V - Vascular
I - Infectious/Inflammatory
N - Neoplastic
D - degenerative
I - Idiopathic, Iatrogenic
C – Congenital
H - Hematological
A – Autoimmune
T – Trauma
E - Endocrine
M - Metabolic
Current Health Status
Medications taken
– to include home remedies, herbal supplements
– prescription and non-prescription
Allergies
– environmental
– medications
– foods
Comprehensive Adult History
Past Medical History (PHx)
Purpose to identify all major health issues of the Pt.
– A. Childhood diseases:
• Measles, rubella, mumps, chicken pox, polio, rheumatic fever,
scarlet fever
– B. Adult illnesses (divided in four categories):
1. Medical ( DM, HTN, CAD, Asthma)
2. Surgical and/or injuries ( dates, indications)
3. Obstetrical / Gynecological
4. Psychiatric
C. Health Maintenance
• Immunizations, Screening Tests i.e CXR, PSA, mammograms
Comprehensive Adult History
Personal and Social hx
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Occupation and last year of schooling
Home situation and significant others
Stressors: recent and long-term
Leisure activities
Exercise and dietary habits
Drug, alcohol, and tobacco usage
Religious affiliation and spiritual beliefs
Activities of Daily Living
Safety Measures
Alternate Health Care Practices
Comprehensive Adult History
Family History (FHx)
Pertinent health of patients blood relatives to include all immediate
relatives:
– Parents
– Siblings
– Grandparents
– Children
– Grand children
Comprehensive Adult History
Determine the occurrence of the following:
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diabetes
tuberculosis
Asthma
heart disease
high blood pressure
kidney disease
Cancer
arthritis
anemia
- headaches
- mental illness
- COPD
- Elevated Cholesterol
- stroke
- Seizure disorder
- Alcohol or drug addiction
– When doing a focused Hx you should concentrate on the disease
processes that are related to the Symptoms / disease that the Pt is
presenting with!!!!
Comprehensive Adult History
Review of Systems (ROS)
– Or Functional Inquiry
– Consider it to be a “head to toe assessment”
– Remember to use layperson’s language
ROS
General or Usual state of health
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Episodes of chills, weakness or malaise
Fatigue
Sweats
Usual weight including gain or loss of weight
R.O.S
EO 001.01
Skin
Any changes in skin color, nails or hair
– brittle hair, alopecia, clubbing, or paronychia
Any of the following:
- rashes, sores, lumps, moles, infections, lesions,
masses, eruptions, general or localized
pruritis
EO 001.01
HEENT
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Head
Eyes
Ears
Noses & Sinuses
Throat / Mouth & Neck
Head:
– Any hx of head trauma or headache.
EO 001.01
Eyes
Determine the fol:
– vision changes with most recent eye test results
– Visual field changes
– ocular pain
– pain with eye movement
– redness
– irritation
EO 001.01
Ears
Ascertain the fol:
– tinnitus
– hearing loss (acuity)
– earache
– Infection with or without drainage/discharge
– vertigo
EO 001.01
Nose & Sinuses
Sense of smell
– cranial nerve I
Common ailments:
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stuffiness/congestion
bleeding
discharge
sinus pain
EO 001.01
Mouth, Throat, &Neck
Common ailments:
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bleeding
sores
lumps
frequent sore throat
voice change/hoarseness
difficulty swallowing - dysphagia
EO 001.01
Breasts
Signs / Symptoms
– Lumps / nodules
– Pain / tenderness
– Discharge
Is self-examination performed?
Last Clinical Breast Exam (CBE)?
Mammograms in the past?
EO 001.01
Respiratory
• Cough(productive/dry)
• Increased RR
• Sputum (color, amount,
smell)
• Wheezing
• Haemoptysis
• Chest pain
• SOB
• Chest X-Ray
– Date and result
EO 001.01
Cardiac
• Chest pain, Palpitations, claudication
• SOB, Cough
• PND, Orthopnea, Edema
• Syncope or pre-syncope
• Base-line or previous EKG/Stress Test
EO 001.01
Gastrointestinal
Common ailments:
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appetite < or >
dysphagia / odynophagia
n&v
heartburn
reflux
jaundice
indigestion
abd pain
EO 001.01
Gastrointestinal
Bowel movements?
– What is normal for them? Daily or not.
– constipation/diarrhea
– hematochezia
– Melena
– hemorrhoids
EO 001.01
Urinary System
Is the patient suffering from:
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Dysuria
Frequency
Urgency
Nocturia
Hematuria
Hesitancy
Decreased stream
Dribbling post voiding
EO 001.01
Genito-Reproductive Male
Penile discharge
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how often
color
blood
odor
Pain and/or lesions
– occurrence
– location
– frequency
EO 001.01
Genito-Reproductive Male
Hx of STD’s
– # of exposures
Testicular pain
– location
– Swelling
– Self-examination
Sexual problems or concerns
EO 001.01
Genito-Reproductive Female
Menstruation
– age of menarche
– regularity
– frequency and duration
– last menstrual cycle (LMP)
– abnormal menses (discharge/pruritus)
– amount of bleeding
last gyne exam and PAP smear results
Hx of STD’s
Dyspareunia
Ovarian cysts
Menopause
libido
EO 001.01
Obstetrical Hx
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Number of pregnancies
Full term deliveries (vaginal or C/S)
Abortions (spontaneous and/or therapeutic)
Complications of pregnancy
Infertility
Method(s) of contraception used
Familial obstetrical hx (if relevant)
EO 001.01
Musculoskeletal
Extremities
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joint or muscle
location
severity
aggravating/relieving factors
with movement
swelling
ROM
temp sensitive
EO 001.01
Neurologic - CNS/PNS
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Syncope
- Abnormalities in sensation
Seizures
- Abnormalities in coordination
Weakness
and balance
Numbness/Tingling
Tremors
CVA/TIA sx’s
Memory loss
Involuntary movements
Headaches, visual sx’s
EO 001.01
Psychiatric Hx
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Humor, Anxiety, Depression, Mood changes
Nervousness, Irritability
Sleep disturbances, Memory changes
Attention, concentration
Hallucinations, delusions
Suicidal / homicidal ideation
EO 001.01
Endocrine System
Common ailments
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polyuria
polydipsia (thirst)
intolerance to temp change
excessive sweating
weight changes/problems
Hair/skin changes
GU related problems
EO 001.01
Hematologic
Bleeding
– hx of abnormal/excessive bleeding
– duration
– any transfusions
Bruising
– ecchymosis
SOAP FORMAT
SOAP
Subjective- how patient feels/thinks about him. How does he
look. Includes CC and general appearance/condition of
patient
Objective - relevant points of patient complaints/vital sings,
physical examination/daily weight, fluid balance,
diet/laboratory investigation and interpretation
Assessment – address each active problem after
making a problem list. Make differential
diagnosis.
Plan – about management, treatment, further
investigation, follow up and rehabilitation
ANY
QUESTIONS???