Interview & Health History PDF

Interview & Health History ADVANCED HEALTH ASSESSMENT N749 – Doctorate of Nx Anesthesia Program Dr. Jean-Marc J. Ndame, DNP, CRNA, FNP-C Patient’s Interview The Clinical Encounter 5 Phases: • Initializing the encounter • Preparation and setting the stage • Establish rapport (trust)/using therapeu...

Interview & Health History ADVANCED HEALTH ASSESSMENT N749 – Doctorate of Nx Anesthesia Program Dr. Jean-Marc J. Ndame, DNP, CRNA, FNP-C Patient’s Interview The Clinical Encounter 5 Phases: • Initializing the encounter • Preparation and setting the stage • Establish rapport (trust)/using therapeutic communication • Gathering information • Performing the physical exam • Explaining and planning • Closing the encounter Setting the Stage Clinical Encounter • Introduce yourself and your role • Assess Pt’s preferred method of address (preferred pronoun e.g., he/she…) • Address the patient respectfully • Listen to the patient’s responses (ACTIVE LISTENING) • Maintain respect, confidentiality, patient autonomy • Establish trust The Health History The Purpose • Gather sensitive and nuanced history • Deepen your relationship with the patient • Establish a diagnosis • Patient Education • Health Promotion and Disease Prevention The Health History Others • Identifying Data • age, gender, occupation, martial status, source • Reliability • Varies according to mood, memory, trust, sensory disabilities (deaf/HOH) • Chief Complaint • Often stated in the patient’s own words • The reason for seeking care Main Components of the Health History Subjective Data (from patient) • Subjective = What the patient tells you • CC (Chief Complaint) • HPI (History of Present Illness) • PMH (Past Medical History) • FH (Family History) • PSH (Past Surgical History) • ROS (Review of Systems) Main Components of the Health History Objective Data (from provider and studies) • Physical Examination • Denotes the presence or absence of disease • Presents deeper opportunity to assess pt’s outlook and condition • LABS and Imaging • Pt’s education • 40-80% of info received during visit is forgotten immediately • Useful technique: Assess pt’s understanding/Teach back Main Components of the Health History SOAP NOTE • Subjective data – what the patient tells you – the patient’s perspective • Objective data – what you observe – the physical appearance and exam • Assessment – differential diagnoses • Plan – what comes next – testing, treatment, referral, follow-up Subjective Data CC and HPI Describe how symptoms developed • OLD CARTS, PQRST, 7 descriptors of a symptom, common symptoms guide • Includes the patient’s thoughts, feelings • Pulls relevant portions of the ROS • May include meds, allergies, health related habits • Pertinent POSITIVE & NEGATIVE Subjective Data PMH • Past Medical History • Childhood illness, immunizations • Adult illness with dates • Medical, Surgical, Obstetric, Gynecologic, Psychiatric • Specifically ask about diabetes, CAD, HTN, Hepatitis, HIVD, Asthma, • Hospitalizations • Sexual History Subjective Data Medications and Allergies • Medications – list, why they are taken, for how long • Allergies to medications • 4 types of hypersensitivity • Distinguish between allergy and adverse drug reaction (ADRs) Subjective Data Health Maintenance • Immunizations, lifestyle, safety, screening, ppd • Medications – OTC, CAM, Rx • Allergies – drugs, food, allergens, tape, iodine, latex • Use/abuse of drugs, ETOH, smoking, cannabis • History of domestic violence Subjective Data Personal and Social History • Diet • Smoking/tobacco – pipe, cigars, chewing tobacco, e-cigs • Alcohol • Marijuana • Illicit drugs – cocaine, methamphetamine, heroin, others • Education level Subjective Data Family History • Outlines or diagrams age, health status, cause of death, presence or absence of specific diseases such as HTN, CAD, Diabetes, genetic problems, melanoma, colon/ovarian/breast cancer • Siblings, parents, grandparents, children Subjective Data Additional Components • Older Adult – disabilities • Deafness, blindness, mobility, depression, altered mental status • Pediatric – birth history, and r/t immunizations • GYN/Prenatal – menstrual hx, OB hx, STIs, and r/t immunizations Subjective Data Review of Systems (ROS) • General • Usual weight, recent weight changes, weakness, fatigue, fever • Head • Headaches, head injury, dizziness, lightheadedness, • Eyes • Vision changes, glasses, blurred vision, spots, specks, flashing lights, pain, eye problems such as glaucoma, cataracts, last examination Subjective Data ROS • Ears • Problems with hearing, tinnitus, vertigo, pain, infections, discharge, hearing aids • Nose and Sinuses • Frequent colds, nasal stuffiness, postnasal drip, pain, itching, hay fever, nose bleeds, sinus trouble, cough Subjective Data ROS • Throat • Conditions of teeth and gums, bleeding gums, dentures, last dental exam, sore tongue, dry mouth, frequent sore throats, hoarseness • Neck • Lumps, swollen glands, stiffness or pain, goiter • Breasts • Lumps, pain, discomfort, nipple discharge, self examinations practices, mammography Subjective Data ROS • Respiratory • Cough, sputum (color, quantity) Hemoptysis, dyspnea, wheezing, pleurisy, last CXR, asthma, bronchitis, pneumonia, TB, pain • Cardiovascular • Heart problems, HTN, Rheumatic Fever, Heart Murmurs, chest pain, palpitations, dyspnea, orthopnea, edema, past EKG, or other heart tests, paroxysmal nocturnal dyspnea • Previous MI Subjective Data ROS • Gastrointestinal • Trouble swallowing, heartburn, appetite, nausea, bowel movements, color, size, change in habit, rectal bleeding, black or tarry stools, hemorrhoids, constipation, diarrhea, abdominal pain, food intolerance, excessive belching or passing gas, jaundice, liver or gallbladder trouble, hepatitis • Urinary • Frequency of urination, polyuria, nocturia, urgency, burning, pain with urination, hematuria, urinary infections, kidney stones, incontinence, in males, reduced caliber or force of the urinary stream, hesitancy, dribbling Subjective Data ROS • Genital – Male • Hernias, discharge from penis, sores on penis, testicular pain or masses, hx STI & treatment, sexual habits, interest, function, satisfaction, birth control method, condom use, HIVD risk • Genital – Female • Age of menarche, regularity, frequency, duration of periods, amount of bleeding, bleeding between periods or after intercourse, last LMP, dysmenorrhea, premenstrual tension, age of menopause, menopausal symptoms, postmenopausal bleeding • Born before 1971 DES exposure from maternal use during pregnancy • Vaginal itching, discharge, sores, lumps, STI and treatments, number of pregnancies, (Gravida, Para, SAB, TAB, Live births), complications of pregnancy, birth control methods, sexual habits, interest, function, satisfaction, problems including dyspareunia, exposure to HIVD Subjective Data ROS • Peripheral Vascular • Intermittent claudication, leg cramps, varicose veins, past clots in the vein • Musculoskeletal • Muscle or joint pain, stiffness, arthritis, gout, backache, swelling, redness, pain, tenderness, weakness, limited ROM or activity, duration, history of trauma, repetitive motion injury, job related injuries Subjective Data ROS • Neurologic • Fainting, blackouts, seizures, weakness, paralysis, numbness or loss of sensation, tingling or “pins and needles”, tremors or other involuntary movements, changes in speech, difficultly with balance or walking • Hematologic • Anemia, easy bruising, bleeding, past transfusions, or transfusion reactions • Endocrine • Thyroid trouble, heat or cold intolerance, excessive sweating, excessive thirst or hunger, polyuria, change in glove or shoe size Subjective Data ROS • Psychiatric • Nervousness, tension, mood changes or swings, depression, memory change, thoughts of hurting oneself or suicide, use of drugs or ETOH to help mood, a positive ROS. Subjective Data: Useful Tools for CC &HPI OLDCART OLD • O - Onset • L – Location • D – Duration CARTS • C –Character • A – Aggravating & Associated Factors • R – Relieving Factors • T – Temporal factors • S – Severity Symptoms Subjective Data: Useful Tools for CC &HPI PQRST • P – Provocative/Palliative • Q – Quality • R – Region/Radiating • S – Severity • T - Temporal Subjective Data: Useful Tools for CC &HPI Eight Descriptors of a Symptom • 1. Timing (onset, duration, frequency) • Description of events coincident with onset. • Whether there have been similar episodes in the past. • Whether the onset was gradual or sudden. • Periodicity and frequency of symptom • Total duration of the symptom. • ***Has pt had the symptom before? Subjective Data: Useful Tools for CC &HPI Eight Descriptors of a Symptom • 2. Location of the symptom (if applicable). • The location should be anatomically precise. • Deep vs. superficial; specific vs. diffuse • Radiation of symptom • 3. Character/quality of the symptom (e.g., dull, sharp, or burning pain). • Try to use patient’s own words Subjective Data: Useful Tools for CC &HPI Eight Descriptors of a Symptom • 4. Quantify the symptom/severity. • Rate pain 1-10. • Ask how symptom affects daily activities. • 5. Precipitating or aggravating factors/relieving factors. • What makes it worse? Activity, food, position, etc • What makes it better? Same as above, heat, ice, medication • 6. Setting: Where was the person or what was the person doing to bring on the symptom? Subjective Data: Useful Tools for CC &HPI Eight Descriptors of a Symptom • 7. Associated factors. Is the primary symptom associated with any other symptoms? • 8. Patient’s perception. Effect on normal daily activities. Ask patient, “What do you think it is?” “What does it feel like to you?” “What concerns you the most/what are you worried that it is?” Basic H&P vs. Anesthesia H&P Basic H&P • Assess current state of wellness/illness • Gather historical data that could contribute to fuller understanding of current state • Diagnose and treat any physical and/or psychosocial issues • Labile HR, BP, carotid stenosis à cerebral perfusion Basic H&P vs. Anesthesia H&P Anesthesia H&P • status of health • status of illnesses – stable and optimized? Changes? New? (new à back to PCP) • Are changes such that they will affect CV, pulm, metabolic, renal/hepatic and fluid balance… • Is procedure/surgery elective, urgent or emergent? • Issues/conditions that would affect methods of anesthesia • Airway – neck masses, cervical motion, TMJ, nasal obstruction, trach • Spinal fusions/sclerosis • Labile HR, BP, carotid stenosis à cerebral perfusion The Health History Common Pitfalls • Asking one question after another without listening to the person’s answer • Standing body posture with clip board • Writing while talking • Using jargon • Not speaking loud enough or directly to pt • Asking a question while walking away • Asking questions with an implied answer • Continuing on despite the person’s needs • • For pain control, bathroom privileges, privacy Not listening to family and friends Perioperative Lab Testing and Imaging General • Related to surgery type & pt’s condition • Labs • BMP/CMP; Coag panel: INR/PT/PTT; CBC • Imaging • 12 leads EKG; CXR; CT/MRI Example of Health History Taking Youtube Video • https://www.youtube.com/watch?v=-TCbx6kS8B8 Reference • Bates Guide to physical Examination and History taking 3rd Edition HEENT & FOCUSED AIRWAY ASSESSMENTS ADVANCED HEALTH ASSESSMENT N749 – DOCTORATE OF NX ANESTHESIA PROGRAM DR. JEAN-MARC J. NDAME, DNP, CRNA, FNP-C HEAD ¡ Pain - Headaches ¡ Common ¡ Need to elicit full description ¡ Chronologic pattern, severity, changes over time ¡ Associated symptoms ¡ Changes with position, coughing ¡ Family history EARS ¡ Tinnitus ¡ New vs. continuing, uni vs. bilateral ¡ Associated w hearing loss ¡ Vertigo ¡ Differentiate from dizziness or syncope ¡ Cardiovascular vs central or peripheral lesion of CN VIII NOSE AND SINUSES ¡ Difficulty breathing/blockage ¡ History of nasal fracture ¡ Rhinorrhea ¡ Congestion, sneezing, itching, watery vs purulent ¡ Facial pain, headache, fever ¡ Epistaxis ¡ Source of bleeding MOUTH AND THROAT ¡ Sore throat ¡ Acuity of symptom; associated symptoms ¡ Hoarseness ¡ Associated with illness; chronicity ¡ Smoking ¡ Sore tongue ¡ Bleeding gums ¡ Dental caries ¡ Bleeding tendencies ¡ Buccal masses ¡ Chewing tobacco NECK ¡ Swollen glands ¡ Lymph vs salivary ¡ Enlarged thyroid gland ¡ Hyperthyroid – Grave’s disease ¡ Palpitations, weight loss, anxiety, tremors ¡ Hypothyroid – Hashimoto’s thyroiditis ¡ Fatigue, weight gain, cold intolerance, constipation ¡ Multinodular goiter ¡ Cancer PHYSICAL EXAM TECHNIQUES ORDER OF OPERATIONS ¡ Inspection ¡ Palpation ¡ Percussion ¡ Auscultation CRANIAL NERVES ¡ CN VII (Facial) ¡ Raise eyebrows ¡ Smile/frown ¡ Show teeth ¡ Puff cheeks HEAD ¡ Face ¡ Color, pigmentation ¡ Texture, thickness ¡ Hair distribution ¡ Lesions ¡ Palpate for texture, esp. lesions ¡ Basal cell carcinoma ¡ Squamous cell carcinoma – “rough skin” ¡ Face ¡ Palpate for tenderness (parasinuses) EARS ¡ Auricle ¡ Inspect for deformities, lumps, lesions, discharge ¡ Palpate for tenderness ¡ Tragal tenderness EAR CANAL ¡ Otoscopic exam ¡ Adult ear – pull auricle straight up, backward and slightly away from head. ¡ Pediatric ear – downward and back ¡ Insert gently, downward and forward ¡ Inspect canal – cerumen, exostoses EXTERNAL EAR CANAL AUDITORY ACUITY ¡ Weber test ¡ Test for lateralization of sound ¡ Place lightly vibrating tuning fork on top of pt’s head ¡ Ask where pt hears sound – one side or both ¡ In unilateral conductive hearing loss, sound is heard in impaired ear (mechanical) ¡ In unilateral sensorineural hearing loss, sound is heard in good ear (CN affected) AUDITORY ACUITY ¡ Weber test ¡ Test for lateralization of sound ¡ Place lightly vibrating tuning fork on top of pt’s head ¡ Ask where pt hears sound – one side or both WEBER RESULTS ¡ In unilateral conductive hearing loss, sound is heard in impaired ear (mechanical) ¡ In unilateral sensorineural hearing loss, sound is heard in unimpaired ear (CN affected) AUDITORY ACUITY ¡ Rinne Test ¡ Compares air conduction (AC) to bone conduction (BC) of sound ¡ Place lightly vibrating tuning fork on mastoid bone level with ear canal. When sound can no longer be heard, bring fork around in front of ear canal. RINNE RESULTS ¡ Air conduction (AC) should be greater than bone conduction (BC) ¡ In conductive hearing loss AC = BC or BC > AC ¡ In sensorineural hearing loss, normal pattern, AC > BC NOSE AND PARASINUSES ¡ Inspect nose ¡ Symmetry, deformity ¡ Test for obstruction ¡ Pressing on each nostril in turn and asking pt to breathe in. ¡ Inspect inside of nose – use otoscope ¡ Look posteriorly then superiorly in small increments to view turbinates NOSE AND PARASINUSES ¡ Palpate parasinuses ¡ Frontal – under bony brows ¡ Maxillary – under maxilla MOUTH ¡ Inspect AND PHARYNX ¡ Lips – color, moisture, lesions, ulcerations, cracking, scaling. ¡ Inspect ¡ Oral mucosa ¡ Use tongue blade ¡ Color, ulcerations, lesions, nodules MOUTH AND PHARYNX ¡ Inspect ¡ Gums and teeth ¡ Swelling, bleeding of gums ¡ Teeth – looseness, loss, chipping, fillings, position ¡ Roof of mouth ¡ Color, texture, lesions MOUTH AND PHARYNX ¡ Tongue and floor of mouth ¡ Check hypoglossal nerve (CN XII) – ¡ stick tongue out, note any asymmetry ¡ Use gloves and gauze to pull tongue out ¡ Note color and texture ¡ Note any lesions ¡ Cancer of tongue common in men > 50, smokers, ETOH ¡ Palpate checking for masses MOUTH AND PHARYNX ¡ Pharynx ¡ With mouth open but tongue not protruded, ask pt to say, “ah” ¡ Visualize posterior pharyx ¡ Assess CN X – vagal nerve – symmetrical rise of uvula/soft palate MOUTH AND PHARYNX ¡ Pharynx ¡ Inspect ¡ Soft palate, anterior and posterior tonsillar pillars, uvula, tonsils and pharyx ¡ Color, symmetry, exudate, swelling, ulceration ¡ Tonsils may have crypts (deep folds), contain exfoliated squamous cells as white spots or chunks. NECK ¡ Inspect neck ¡ Symmetry, masses, scars ¡ Enlargement of parotid or submandibular glands ¡ Visible lymph nodes TRACHEA ¡ Trachea ¡ Midline, feel for deviation. THYROID ¡ Inspect ¡ Tip head back, use tangential lighting ¡ Ask pt to swallow and look for upward movement of gland. THYROID GLAND ¡ Palpation ¡ Ask pt to flex neck slightly ¡ Stand behind patient ¡ Place your fingers of both hands on pt’s neck so that your index fingers are just below the cricoid cartilage ¡ Ask pt to swallow again ¡ Feel for thyroid isthmus rising up under your finger pads ¡ By displacing trachea with one hand, feel for lobe with opposite hand. ¡ Note size, shape, and consistency, also any nodules or tenderness GOITER ANESTHESIA AIRWAY ASSESSMENT FOCUSED AIRWAY ASSESSMENT HISTORY ¡ Any difficulty ¡ Surgery / burns ¡ Concurrent disease ¡ Dental, oropharyngeal, lymphatic, parotid, thyroid, vocal cord ¡ Reflux / recent meals GENERAL ASSESSMENT ¡ Dentition ¡ Distortion ¡ Edema, tumor, infection/inflammation ¡ Disproportion ¡ Large neck, large tongue, small mouth ¡ Dysmobility ¡ TMJ ¡ Cervical Spine ¡ Obesity ¡ Pregnancy FULL ANESTHESIA AIRWAY ASSESSMENT ¡ Tongue size/Visibility of uvula ¡ Nostril patency ¡ Mallampati ¡ Condition of the teeth ¡ Presence of heavy facial hairs ¡ Relationship of upper incisor to the ¡ Thyromental distance with the head lower incisor in maximum extension ¡ Ability to protrude the lower incisor in front of the upper incisor ¡ Circumference of neck ¡ Compliance of mandibular space ¡ Range of motion of head and neck ¡ Inter-incisor distance ¡ Atlanto-occipital joint extension NASAL PATENCY DEVIATED SEPTUM DENTITION ¡ Inquire re loose teeth, recent tooth loss ¡ Dentures or removable appliances MANDIBULAR MOVEMENT TMJ ASSESSMENT Upper lip bite / catch test 1. Class I: Lower incisor can bite upper lip above vermilion line 2. Class II: incisor can bite upper lip below vermilion line. 3. Class III: cannot bite upper lip. INTER-INCISOR GAP ¡ Inter-incisor distance with maximal mouth opening ¡ Minimal acceptable value > 4cm ¡ Measured in fingerbreadths (fbs) ¡ One fingerbreath = 3.38 cm in length ¡ Significance ¡ Positive results – easy insertion of a 3cm deep flange of laryngoscope blade ¡ < 3cm – difficult laryngoscopy ¡ < 2cm – difficult LMA insertion RELATIVE TONGUE/PHARYNGEAL SIZE FACIAL HAIR THYROMENTAL DISTANCE ¡ Distance from the mentum to the thyroid notch. ¡ Ideally done with the neck fully extended. ¡ Helps determine how readily the laryngeal axis will fall in line with the pharyngeal axis. THYROMENTAL DISTANCE ¡ If the thyromental distance is short, <3 finger widths, the laryngeal axis makes a more acute angle with the pharyngeal axis and it will be difficult to achieve alignment. ¡ Less space to displace the tongue. ¡ > 6.5 cm ; no problem with laryngoscopy intubation. ATLANTO-OCCIPITAL JOINT EXTENSION DELIKAN`S Sign ¡ Patient is asked to look straight ahead. The index finger of the left hand of the clinician is placed under the tip of the jaw while the index finger of the right hand is placed on the patient's occipital tuberosity. ¡ The patient is now asked to look at the ceiling. If the left index finger becomes higher than the right, extension is considered normal. ¡ If level of both fingers remains same or the chin finger remains lower, increased difficulty is anticipated CERVICAL SPINE MOVEMENT PRAYER SIGN DIFFICULT TO MASK VENTILATE: MOANS ¡ Mask Seal ¡ Obesity or obstruction (OSA) ¡ Age > 55 ¡ No teeth – “cave in” or facial “sink” ¡ Stiff MASK SEAL DIFFICULTY ¡ In one study of more than 1,500 patients, five criteria were recognized as independent factors for difficult mask ventilation: ¡ age older than 55 years ¡ body mass index (BMI) of more than 26 kg/m2 ¡ presence of a beard ¡ lack of teeth ¡ history of snoring. 1.LANGERON O, MASSO E, HURAUX C, ET AL. PREDICTION OF DIFFICULT MASK VENTILATION. ANESTHESIOLOGY. 2000; 92(5):1229–1236 OBESITY OR OBSTRUCTION ¡ Heavy chest ¡ Abdominal contents inhibit movement of the diaphragm ¡ Increased supraglottic airway resistance ¡ Difficult mask seal ¡ Quick desaturation AGE > 55 / NO TEETH ¡ Associated with difficult mask ventilation, possibly due to loss of tone in the upper airway. Face tends to “cave in” ¡ Consider leaving dentures in for mask ventilation and remove for intubation STIFF ¡ Refers to Poor Airway Compliance ¡ Reactive Airway Disease ¡ COPD ¡ Pulmonary Edema/Advance Pneumonia ¡ History of Snoring/Sleep Apnea AIRWAY TEMPLATE ¡ Mallampati: ¡ Thyromental distance (TMD): ¡ Inter-incisor distance: ¡ Mandibular protrusion/TMJ mobility: ¡ Teeth: ¡ Neck ROM: ¡ Neck circumference: ¡ Neck masses: