Exam 1 H&P

Clinical Narrative and Complete History

• The clinical narrative serves as a stimulus to jog a clinician's memory, and is a critical tool for communication among healthcare professionals.
• It also serves as a data source for case control studies and other clinical research protocols, and is used by hospital quality assurance and utilization review committees to monitor performance.

Functions of the Clinical Record

• The clinical record is legally discoverable and can be used as evidence in court.
• It serves as a memory aid, allowing clinicians to recall details about a patient's life and experiences.
• It is used by healthcare insurers to verify diagnoses and to establish that claimed services were actually provided.

Recording Information

• When recording personal data about a patient, avoid including judgmental remarks or wrong diagnoses, as they can be difficult to eradicate and may lead to misinformation.
• Be cautious about recording the patient's attitude, lifestyle, expectations, and health belief system.
• Avoid recording certain types of personal information, such as explicit descriptions of sexual habits, problematic relationships, or criminal convictions.
• Include the patient's own words whenever possible, and use behavioral or functional descriptions to convey personal information.
• Minimize distortion by avoiding language that "pathologizes" the patient.

Presenting the Patient

• Effective presenters communicate rapidly and effectively by sharing well-organized vignettes that "capture" the patient and their clinical problem.
• Know your patient and know your listener, and tailor your presentation accordingly.
• Understand the power and limitations of the spoken word, and prioritize clarity and organization in your presentation.
• "Sell the story" by constructing a narrative that brings the clinical data together in a convincing way.

Effective Case Presentation

• The format of the case should include an opening statement, a history of present illness, past medical history, review of systems, family history, and laboratory and exam results.
• The presentation should be concise and well-structured, with a clear and targeted statement of physical findings and relevant lab data.
• The plan should be clearly explained and targeted to the patient's needs.

Establishing a Therapeutic Relationship

• The primary goal of clinical history taking is to create an environment where patients feel comfortable sharing uncensored data vital to the diagnostic process.
• Empathetic listening is therapeutic, even if it doesn't repair physical damage, as it makes patients feel better.

Precision in Communication

• Precision requires obtaining detailed and unambiguous information to aid in diagnosis and treatment.
• Imprecision can lead to random, unsystematic errors due to vagueness, poor listening, or lack of attention to detail.

The Patient's Theory

• Patients have their own beliefs about their illnesses, which can influence what they share and how they present their symptoms.
• It's essential to differentiate between the patient's theory and their actual symptoms.
• Examples: patients may attribute symptoms to a specific condition, like gallstones, when they're actually caused by something else, like reflux.

Barriers to Effective Communication

• Patients may have different versions of their story, which can lead to crucial differences in diagnosis.
• Patients may learn to tell a good story based on the interviewer's questions and responses.
• Patients may recall new information or change their story due to various factors, including their beliefs and previous experiences.
• Skillful clinicians can minimize these barriers by creating a non-threatening atmosphere and actively listening to the patient.

Student Concerns

• Students may feel they lack sufficient knowledge or experience to conduct effective interviews.
• Students may feel like they're an interloper or that patients are "fed up" with multiple interviews.
• It's essential to remember that students are still interacting with patients in a professional manner, and the information they gather is valuable.

Good Communication

• Good communication with patients involves listening and asking good questions to understand their needs and concerns.
• Patients appreciate good communication, which helps them feel heard and cared for.
• Good communication with families, when appropriate, can also help build trust and respect.
• Effective communication is essential in establishing relationships with patients, their families, and other healthcare providers.

Objectives

• Recall the components of a family history
• Elicit an accurate family history
• Accurately document a family history

Importance of Family History

• Holds important information about an individual's past and future life
• Used as a diagnostic tool and guides decisions about genetic testing for the patient and at-risk family members
• Emotionally charged due to strong feelings about family members

Who is "Family"?

• Grandparents
• Parents
• Siblings
• Patient
• Children

Components of a Family History

• Health status
• General information:
  • Family's origin or racial/ethnic background
  • Names and dates of birth
• Medical conditions and ages at diagnosis
• Age of death and cause of death
• Pregnancy outcomes

Relevant Illnesses and Conditions

• Hereditary diseases (e.g. sickle cell anemia, osteogenesis imperfecta)
• Familial illnesses (e.g. coronary artery disease, diabetes, breast cancer)
• Illnesses that may not only be familial but also affect the patient's psychosocial environment (e.g. bipolar disorder, alcoholism)

Eliciting a Family History

• Ask about illnesses that seem to run in the family
• Inquire about parents' health (e.g. heart attacks)

Past Medical History

• The past medical history is a bridge between the HPI (History of Present Illness) and the patient's overall health.
• OAPs (Other Active Problems) are medical problems that may contribute to the current syndrome or must be considered in responding to it.

Eliciting an Accurate Past Medical History

• Ask open-ended questions to avoid missing important events.
• Check medications, emotional or psychiatric problems, surgical procedures, and allergies.
• Transition to the past medical history by asking about the patient's overall health.

Components of a Past Medical History

• Allergies: clarify symptoms and reactions.
• Accidents or injuries: include dates and details.
• Immunizations: include dates and types.
• Illnesses: start from childhood, including dates and details.
• Current medications: include dosages and frequency.
• Hospitalizations: include dates and reasons.
• Surgical procedures: include dates and details.
• Screening procedures: include dates and results.

Gynecological and Obstetrical History

• GYN history: include age at menarche, last menstrual period, menstrual pattern, and any pain.
• Obstetrical history: include the number of pregnancies, term births, preterm births, abortions, and living children.
• Use expanded obstetric notation (G, T-P-A-L) to give more detail.

Respect

• Respect is being nonjudgmental, valuing an individual's traits and beliefs despite personal feelings.
• Showing respect to patients:
  • Introduce yourself clearly and explain your role.
  • Clarify patients' names and ask before calling them by their first name.
  • Consider patients' comfort during the visit and warn them before doing unexpected or painful things.
  • Respond to patients in a way that shows you have heard what they said.

Genuineness

• Genuineness is being yourself, both as a person and as a professional.
• Expressing genuineness to patients:
  • Introduce yourself as a student and acknowledge your limited knowledge and responsibility.
  • Demonstrate interest in patients as people.
  • Be honest and transparent, but maintain professional boundaries.
• Professionalism in genuineness:
  • Avoid oversharing or "hogging" the conversation.
  • Do not share personal feelings that may not be helpful to patients.

Empathy

• Empathy is a type of understanding that differs from sympathy or compassion.
• Empathy in patient care:
  • Demonstrate understanding by listening to patients' total communication (words, feelings, and gestures).
  • Acknowledge patients' feelings and concerns to get an accurate idea about what is going on.
  • Put yourself in patients' shoes to understand their feelings about symptoms.

Levels of Responding

• Ignoring Response: No response to patients' cognitive or emotional content.
• Minimizing Response: Respond to feelings and symptoms at a lesser level than patients' expressed concern.
• Interchangeable Response: Recognize and accurately assess patients' feelings and symptoms, and feed back that awareness at the same level of intensity.
• Additive Response: Recognize openly expressed feelings and symptoms, as well as those not expressed, and provide reassurance.

Communication

• Using words precisely:
  • "Translate" medical terms into words patients can understand.
  • Identify not only symptoms but also feelings, and use descriptive words for levels of feeling.
• Nonverbal communication:
  • Body language: transmitting information through physical behavior.
  • Paralinguistics: verbal qualities such as tone, rhythm, and pace.
  • Kinesics: the use of personal space and physical behavior.
  • Self-awareness: awareness of personal behavior and appearance during interactions.

Review of Systems (ROS)

• A comprehensive inventory of specific body systems designed to document any symptoms a patient may be experiencing or has experienced.
• ROS is a series of directed questions, helping to identify additional symptoms that may be related to the symptoms for which the patient is seeking help.
• It's appropriate to limit the ROS to a specific timeframe instead of "Have you ever had…".

Objectives of ROS

• Identify additional symptoms that may be related to the symptoms for which the patient is seeking help.
• Document an accurate review of systems, including both positive and negative symptoms.

Types of Symptoms

• Positive symptoms: those the patient has experienced.
• Negative symptoms: those the patient denies having.
• Pertinent positives and negatives should be documented.

Conducting ROS

• Avoid asking detailed questions about every organ system; use more broad questions.
• Focus on symptoms related to the chief complaint (CC) initially.
• Use ambiguous terms (e.g., indigestion, fatigue) and clarify if the patient responds with a positive answer.
• Abbreviate or eliminate the ROS in emergency situations.
• With each positive response, obtain enough detail to indicate whether the symptom is significant or trivial.

ROS Tips

• Start with general questions, then focus on specific symptoms.
• Make the questions broad and open-ended.
• Encourage the patient to filter out unnecessary details.
• Remind the patient of the time limitations and ask them to pick out the most important symptoms.

The 14 Systems of ROS

• Constitutional: symptoms that affect general well-being or overall status.
• Eyes
• Ears, Nose, and Throat (ENT)
• Cardiovascular
• Respiratory
• Gastrointestinal
• Genitourinary (Males & Females)
• Musculoskeletal
• Integumentary
• Neurological
• Psychiatric
• Endocrine
• Hematologic/lymphatic
• Allergic/immunologic

Examples of Questions for Each System

• Constitutional: weight loss, weight gain, fatigue, weakness.
• Eyes: change in vision, date of last visual examination, glasses or contact lenses.
• Ears, Nose, and Throat (ENT): change in or loss of hearing, date of last auditory evaluation, ear pain, tinnitus.
• Cardiovascular: chest pain, orthopnea, murmurs, palpitations.
• Respiratory: dyspnea, cough, amount and color of sputum.
• Gastrointestinal: abdominal pain, dysphagia, heartburn, nausea, vomiting.
• Genitourinary (Males & Females): frequency, urgency, dysuria, hematuria.
• Musculoskeletal: arthralgia, arthritis, gout, joint swelling.
• Integumentary: rashes, pruritus, bruising, dryness.
• Neurological: syncope, seizures, numbness, tingling.
• Psychiatric: emotional disturbances, sleep disturbances, substance abuse disorders.
• Endocrine: polyuria, polydipsia, polyphagia, temperature intolerance.
• Hematologic/lymphatic: easy bruising, bleeding tendency, anemia.
• Allergic/immunologic: allergic rhinitis, asthma, atopy, food allergies.

SOAP Note Structure

• SOAP note consists of four main sections: Subjective, Objective, Assessment, and Plan

Subjective Section

• Information provided by the patient or corresponding historian
• Includes Chief Complaint (CC), History of Present Illness (HPI), Past Medical History (PMH), Family History (FH), Social History (SH), and Review of Systems (ROS)

Chief Complaint (CC)

• Main reason the patient is seeking medical help
• Documented in the patient's own words in quotations
• Examples of correct CC questions: "How can I help you today?", "Can you tell me about your problem?", "Tell me why you came in today?"

History of Present Illness (HPI)

• Thorough elaboration of the chief complaint and other current symptoms
• 8 components recognized by CMS guidelines: Location, Quality, Severity, Duration, Timing, Context, Modifying Factors, and Associated Signs and Symptoms

Components of HPI

Location

• Where is the pain or symptom?
• Specific area or regional?
• Does it radiate?
• Unilateral or bilateral?

Quality

• Description of the character of the pain or symptom
• Is it sharp, dull, aching, throbbing, burning, constant, acute, or chronic?

Severity

• How bothersome is this problem?
• Does it interfere with daily activities?
• Does it keep you up at night?
• Rate the problem on a scale of 1 to 10

Objective Section

• Includes Patient Vital Signs, Physical Exam Findings, and Laboratory and Diagnostic Results

Assessment Section

• Diagnosis (Problem List) and Differential Diagnosis

Plan Section

• Additional Lab and Diagnostic Tests Planned
• Consults and Referrals
• Therapeutic Modalities (Pharmacological and Non-Pharmacological Management)
• Health Promotion
• Patient Education
• Disposition/Follow-up Instructions

Importance of Patient Profiles

• A complete patient profile includes information on daily activities, exercise, eating habits, food intolerance, and allergies
• Patients may not always provide accurate information, so it's essential to ask specific questions to assess their habits and health risks

Daily Activities and Exercise

• Ask specific questions to assess the patient's daily activities and exercise habits
• Vague answers like "I like to play tennis" are not sufficient; ask about frequency, duration, and type of exercise
• A sedentary lifestyle is a risk factor for certain diseases

Nutrition and Eating Habits

• Assess the patient's eating habits, including food intolerance and allergies
• Income can affect dietary habits, so it's essential to consider this factor

Substance Abuse

• Assessing truthfulness can be a challenge when eliciting alcohol, smoking, and drug histories
• Ask specific questions about the amount, frequency, and context of the patient's substance use
• Use standardized screening tools like the CAGE questionnaire to assess alcohol abuse

Spirituality and Religion

• Spirituality and religion are not necessarily the same thing
• Some patients may express loose affiliation with a religion or be hostile towards organized religion
• Religious and cultural beliefs can be a driving force in a person's life and affect their health care decisions

Relationships and Support Systems

• Assess the patient's relationships, including their support system and potential for domestic violence
• Ask about household members, nearby family, and willingness to help in times of crisis
• Consider the patient's relationships when developing their care plan

Sexual Functioning

• Sexual functioning is an essential part of life experience and affected by various factors, including STIs, depression, and anxiety
• Use transparent and non-judgmental language when asking about sexual problems
• Start with open-ended questions and progress to more intimate and specific questions to assess the patient's sexual health

Medical History

• Key aspects to cover:
  • Chest pain, orthopnea, murmurs, palpitations, arrhythmias, dyspnea, and exertion
  • Date of last EKG or other CV studies
  • Respiratory:
    • Dyspnea, cough, and amount and color of sputum
    • Hemoptysis, history of PNA, and date of last chest X-ray
    • Date and result of last TB testing
  • Gastrointestinal:
    • Abdominal pain, dysphagia, heartburn, nausea, and vomiting
    • Usual bowel habit and changes in bowel habits
    • Use of aids such as fiber, laxatives, or stool softeners
    • Melena, hematochezia, hematemesis, hemorrhoids, and jaundice
  • Genitourinary:
    • Frequency, urgency, dysuria, and hematuria
    • Polyuria, incontinence, and number of partners
    • Hx of STI, infertility, and other symptoms (e.g., hesitancy, nocturia)
  • Musculoskeletal:
    • Arthralgia, arthritis, gout, joint swelling, and trauma
  • Integumentary:
    • Rashes, pruritus, bruising, and skin cancer or lesions
  • Neurological:
    • Referrals to specialists, therapists, counselors, or other professionals

History of Present Illness (HPI)

• Key facts:
  • 61% of final diagnoses were made based on HPI in one study
  • 76% of encounters were diagnosed correctly using HPI
  • Document subjective information from someone other than the patient
  • Do not label patients with an unproven diagnosis
  • CMC guidelines recognize 8 features in an HPI
  • Patients' thoughts on their condition can be helpful to note
• How to elicit an HPI:
  • Let the patient talk for 2 minutes uninterrupted
  • Follow up with open-ended questions
  • Use Wh questions (Where, What, Who, When, and How)
  • Avoid leading, jargon, and rapid-fire questions

Social History

• Key aspects to cover:
  • Patient profile (social hx) to learn about the patient as a person
  • Making therapeutic decisions requires knowledge of the patient's profile
  • Object of the patient profile is to give a picture of the patient as a functioning person
  • Record health-related behavior
  • Going the extra mile:
    • Ask about specific challenges and needs
    • Consider factors affecting daily life (e.g., work, family, social support)
  • Start with general questions about the patient's recent life and experiences
  • Some information may emerge during the interview without specific questioning
  • Tailor questions to the situation at hand
  • Use interpreters when necessary
  • Ask about occupation, hobbies, and activities
  • Assess exercise, sports, and trauma risks
  • Ask about alcohol, drug, and tobacco use

Medical Abbreviations and Organizations

• Centers for Disease Control (CDC)
• Advisory Committee on Immunization Practices (ACIP)
• National Institutes of Health (NIH)
• American Heart Association (AHA)
• Drug Enforcement Agency (DEA)
• Centers for Medicare & Medicaid (CMS)
• Joint Commission on Accreditation of Healthcare Organizations (JACHO)
• Clinical Laboratory Improvement Amendments (CLIA)
• US Food & Drug Administration (FDA)
• Medical Association Abbreviations:
  • AAPA
  • HOD
  • TAPA
  • BOPA
  • AMA
  • TMA
  • BME
  • ARC-PA
  • PAEA
  • NCCPA

Terminology

• Key terms:
  • Fatigue
  • Photophobia
  • Diplopia
  • Tinnitus
  • Epistaxis
  • Polyp
  • Rhinorrhea
  • Gingivitis
  • Orthopnea
  • Palpitations
  • Arrhythmia
  • Paroxysmal
  • Nocturnal
  • Edema
  • Claudication
  • Dyspnea
  • Sputum
  • Hemoptysis
  • Dysphagia
  • Jaundice
  • Hematochezia
  • Hematemesis
  • Melena
  • Dysuria
  • Hematuria
  • Polyuria
  • Incontinence
  • Hesitancy (urine)
  • Nocturia
  • Dyspareunia
  • Arthralgia
  • Pruritis
  • Syncope
  • Polyuria
  • Polydipsia
  • Polyphagia
  • Lymphadenopathy
  • Atopy
  • Anemia
  • Thromboembolic