History Taking - PACA 1 - Module 1 PDF

History Taking Hannah Pruzinsky, PA-C Module Instructional Objectives Explain the value of the patient-provider bond and mechanisms for its development Explain the importance of a well-documented comprehensive history and physical exam Identify the components of a comprehensive history and physical exam Describe the difference between a comprehensive patient history and a focused patient history Identify the question categories associated with a history of present illness (HPI). Identify key components of history taking Review appropriate strategies to foster a positive patient-provider encounter Identify the components of the social and sexual history Describe the purpose for performing a review of systems (ROS). Explain the importance of the ROS as a component of the patient’s history. The Patient-Provider Relationship In short.. Today we History Taking (both long and short form) will be covering: ○ History of Present Illness ○ Review of Systems ○ Social and Sexual History Vital signs (expanded in lab) “Listen to your patient; they are telling you the diagnosis.” - Sir William Osler, MD “He who studies medicine without books sails an uncharted sea, but he who studies medicine without patients does not go to sea at all.” - Sir William Osler, MD History Taking - Why is it important? Why is it important? The interview and physical examination are essential for development of the clinician-patient bond. This bond is the beginning of a therapeutic partnership, which is a vital component of the holistic “healing process”. Fiduciary relationship. Why is it important? The medical history and the physical examination are inextricably woven together The physical exam may trigger additional history questions “A lot of the appeal of internal medicine is Sherlockian—solving the case from the clues. We are detectives; we revel in the process of figuring it all out. It’s what doctors most love to do.” Lisa Sanders MD It has been said that more than 80% of diagnoses are made Work the odds! from history-taking alone A further 5-10% on examination and the remainder on deeper investigation. 1. 3 Main Functions of 2. the Medical Interview 3. Building the Relationship Patient-Clinician Relationship Building rapport with a patient by employing: - - Empathy - Respect - Genuineness - Professionalism - SKILLS Empathy: identify emotionally with the patient but still keep one’s professional distance. Genuineness: be yourself, yet be professional Respect: value the patient’s beliefs/traits despite own personal feelings Professionalism: proper attire, conﬁdence, direct but not confrontational language, avoiding slang, speaking to not at your patient, use language and terms they can understand while employing proper medical language when needed. Professionalism also extends outside of the room (social media, how you carry yourself outside of work, etc.) Patient-Clinician Relationship: Introductions - Greeting the patient using their preferred pronouns and by their last name - If unsure how a patient would like to be referred to, verify with the patient ﬁrst. - Conﬁrm pronunciation of their name - Greet any additional parties/visitors and conﬁrm their relationship to the patient - Verify with the patient that visitors may be present (patient conﬁdentiality) Patient-Clinician Relationship: Introductions - Conﬁrm the patient’s comfort (seating, position, ambient temperature) - Level with the patient - Give the patient your undivided attention - Active listening - Appropriate tone and volume Patient-Clinician Relationship: Non-verbal Communication Non-Verbal Communication: Transmitting information without words (between the provider and patient) - Eye contact - Body positioning (posture, leaning forward) - Head gestures (nodding) - Appropriate use of touch (with permission) - Facial expressions - Appropriate use of silence - Smiling/Appropriate emotional responses Non-Verbal Communication - Non-verbal behavior of the physician contributes signiﬁcantly to the overall quality of the doctor-patient relationship - Quiet, attentive listening conveys interest and builds rapport more powerfully than virtually any other action or utterance the physician can make Non-Verbal Communication - Doctors who establish appropriate eye contact are more likely to detect emotional distress in their patients - Doctors who lean forward and have an open body posture have more satisﬁed patients What are the beneﬁts of developing a good patient-provider relationship? Establish mutual respect Establish trust Convey empathy and compassion Beneﬁts Higher job satisfaction Patients more likely to adhere to treatment recommendations There are many! More accurate physical exam ﬁndings / detailed histories and physicals! How are we gathering data within this relationship? Data Gathering Question Styles: Open Questions: invites the patient to tell their story: Contrasted with: “Are you having a problem? Not feeling well today?” Data Gathering Question Styles: Reﬂective Questions: type of open question that encourages a patient to elaborate on something they already said Closed Questions: these questions should be used only after open questions to get speciﬁc responses because they give the patient little choice in the way they answer (useful in the review of systems) Data Gathering Question Styles: Guided Questioning: This form of questioning allows you to obtain more information without changing the ﬂow of the patient’s story. - Open-ended focused questions - Offering multiple choices for answers - Clarifying what the patient means - Echoing encourages the patient to continue Question Styles to Avoid… Data Gathering Question Styles to AVOID: Complex Questions: several questions in one. Creates confusion as to what is a pertinent positive or negative Leading Questions: this question type encourages the patient to respond the way the provider wants them to Be careful with questions that start with why. In some instances it may be perceived as threatening or judgmental. Building a History 1. Subjective: history section** 2. Objective: values, PE, data SOAP note obtained 3. Assessment: diagnosis, 4 main sections of a SOAP note differentials that will help with data 4. Plan: action plan gathering/history taking and building a plan for your patient… Starting with the Subjective Information… Chief Complaint (CC) History of Present Illness Obtaining the (HPI) Family History (FHx) Fundamentals: Social History (SH) Review of Systems (ROS) Fundamentals Chief Complaint (CC): Verbatim, what the patient’s complaint is History of Present Illness (HPI): Past Medical History (PMH): Chronic problems, allergies, medications, immunizations, surgeries, hospitalizations, trauma, immunizations Family History (FHx): family history of medical illnesses, cancer, etc. Social History (SH): marital status, lifestyle risk factors, employment/retirement status, education, religion, beliefs, cultural history, support system, stressors Review of Systems (ROS): Primary problem or condition of the patient prompting a visit Chief Complaint Usually one primary complaint with other accompanying “CC” minor symptoms When documenting the CC, make every attempt to quote Reason for the visit or the patient’s own words “presenting problems” especially if it is descriptive, unusual, or unique L: Location History of Present O: Onset of complaint P: prior, palliative, provocative, Illness “HPI” progression Q: Quality of pain Concise, clear, and R: Radiation chronological description of the S: Severity problems prompting the T: Timing patient’s visit… including: Data Gathering: Subjective History Apart from the “LOPQRST”, there are several other parts of the subjective history to include: - PMH (past medical history): chronic conditions, trauma, hospitalizations - Allergies: medications, environmental, food, latex, etc. - Immunizations - FHx (Family History) - SHx (Surgical History) - SoHx (Social History) - Sexual History - Review of Systems Data Gathering: Subjective History Medical History (of the patient): - Includes all medical problems of the patient whether they are currently active or remote including: - Childhood illnesses - Adult Illnesses: DM, HTN, Heart attack, hepatitis, asthma, HIV, seizures, arthritis, cancer, etc - Psychiatric - OBGYN Data Gathering: Subjective History Family History (of the immediate family): - Age and health status of: parents, siblings, children. You can also include grandparents if history is known - If deceased family members, what was the cause of death? - Major focus of questions: does anyone in your family have a history of or currently have: diabetes, heart disease, stroke, cancer, arthritis, or any other disease/condition? - **If it appears an illness is genetic, you may need to ask questions outside of the immediate family Data Gathering: Subjective History Allergies: - Allergy status should be conﬁrmed for each patient, at each visit. - Conﬁrm before prescribing any medication - Medications: OTC, Rx, Herbs/Supplements - Latex - Environment: seasonal (hay fever), pet dander, dust, insects (bees), etc. - Foods: peanuts, shellﬁsh, strawberries, chocolate, etc. - If any allergies, what type of reaction? - Ex: hives, swelling, airway obstruction, etc. Data Gathering: Subjective History Other Illnesses/Conditions/Doctors: - Has any other physician cared for this present condition? - What other current diagnosed conditions does the patient have? - When was it diagnosed and is it currently being treated? - This will transition into asking about medications Data Gathering: Subjective History Medications: - Rx, OTCs, herbs, supplements, vitamins, minerals, immunizations - What is currently being taken? - Why is it being utilized? - Dosage: amount and frequency? - Are you taking it as prescribed? (compliance!) - How long? (when did you start taking the medication?) Data Gathering: Subjective History Immunizations: - List immunizations, date, and reaction if any - Best to use immunization card as a template if available. If not, document as “per patient recall” Data Gathering: Subjective History Accidents: - When did they occur? - How did they happen? - What were the injuries? - Was there medical attention or care? - Have injuries healed completely or still ongoing? Data Gathering: Subjective History Surgeries: - Which procedure? - When did they occur? - What was the reason? - Results? - Complications? Data Gathering: Subjective History Hospitalizations: - When? - Why? What was the reason/the discharge diagnosis? - Duration of admission? - What type of treatment received? - Procedures/Tests/Specialty consults (if known) - Residual problems? Continuing on to Social History… Data Gathering: Subjective History Social History: - Part of the history that allows the clinician to see the patient as a full person and to gain a deeper understanding of the patient’s outlook, background, and the conditions they are living in - A glimpse into the patient’s everyday life - This may give insight into the patient’s expectations and beliefs regarding health and well being Birthplace Residence Social History Education Occupation Marital Status Data gathering… Substance use history Sexual history Data Gathering: Subjective History Social History: - Demographics: birthplace, ethnic origin, religious preference (may also pertain to beliefs surrounding medical care) - Occupation: environment, ergonomics, work duties, exposures? - Lifestyle: habits, exercise, diet, hobbies, interests - Substance Use: tobacco, alcohol, drugs, caffeine - Home conditions Data Gathering: Subjective History Social History - Home Conditions: - Living in a home? Housing insecure? Homeless? - Living alone or with others (who?) - Type of structure? Private home, apartment, assisted living… - Location? - Accessibility? - Economics? - Pets? Data Gathering: Subjective History Social History - School Conditions: - Is the patient experiencing any bullying? - How are they doing in school? - Playing sports? Playing instruments? Involved in the arts? - Do they enjoy the activities? - Are they experiencing any difficulty learning? - Are they making new friends/socializing well with other children? Data Gathering: Subjective History Social History - Substance Use: - Smoking: (tobacco or drugs) - How much and how often - Pack years: #packs/day x # years (or # cigarettes/day/20 x # years smoked) - Desire to quit? - Alcohol: - How much and how often? - Desire to quit? - Blackouts? (if misuse) - Recreational Drugs: - What type? How much and how often? - Desire to quit? Previous attempts? Rehab admissions? What is an open ended question we could ask a patient to learn about their alcohol usage? Data Gathering: Subjective History Social History - Lifestyle and Diet: - Food: Tell me about your diet? - Types of food? Quantities/portions? Frequency of eating? Changes in weight? - 24 hour diet diary or 7 day diet history may be necessary depending on complaints - Lifestyle: - Exercise: type, duration, how often? - Hobbies: type? And now to sexual history… Data Gathering: Subjective History Sexual History - You want to make some type of statement to advise the patient that the next line of questioning may be a little more personal - Reassure the patient that this is a part of the routine evaluation process, and obtain their permission to proceed. Data Gathering: Subjective History Sexual History - Be aware of your own body language, facial expressions, and tone of voice so that you create an open environment for discussion - With adolescents, consider asking the parent to leave the room so the patient feels free to answer questions without fear of parental disapproval or repercussions, especially when discussing possible history of sexual abuse Data Gathering: Subjective History Sexual History - Sexuality is a core part of human existence and does contribute to quality of life - This part of the history can be an opportunity for patient education regarding: - STDs: history of, possible exposure to, protection/lack thereof - Primary sexual disorders/impotence - Sexual dysfunction secondary to chronic illness/injury - Sexual dysfunction secondary to meds/treatments - Birth control - Protection: may reveal sexual abuse - May uncover source of depression associated with sexual dysfunction Data Gathering: Subjective History Sexual History: 5 P’s (+ one?) - Partners? - S, M, W, D or…are you in a relationship? - Is the relationship monogamous or open/polyamorous? - Practices? - Protection (from STI)? - What type? How frequently? - Past History of STI? - Prevention of Pregnancy? - Plus? - Do you have any concerns about sexual function? - Is there any domestic or partner violence? - Sexual orientation? Data Gathering: Subjective History Sexual History: - How would you identify your sexual orientation? - Heterosexual, homosexual, lesbian, gay, women who have sex with women, men who have sex with men, bisexual, asexual - How would you describe your gender identity? - Male, female, non-binary, transexual, intersex, questioning, unsure/prefer not to answer Data Gathering: Subjective History Domestic Violence - The USPSTF (United States Preventive Services Task Force) and the American College of Obstetricians and Gynecologist recommend routine screening of all women of childbearing age for intimate partner violence and providing or referring those who screen positive for intervention services - If the patient has had multiple trips to the ER, this may be the underlying cause. - Elders/seniors are also highly vulnerable for neglect and abuse Review of Systems Sometimes patients leave out pertinent facts or pieces of their history because they don’t realize Review of Systems the connection to a problem they may be experiencing (ROS) This allows for a discussion of various body organ systems that may uncover problems not Data Gathering: Subjective already mentioned or pertinent negatives to support or better History streamline a diagnosis Closed ended “yes or no” questions are okay here ROS Questions: General Any recent changes in weight? State of consciousness Orientation (x4) ○ Gain or loss Do they look well? Sick? Diaphoretic? Fatigue? Drowsiness? Not Affect: happy? Content? Sad? Crying? feeling well? Grooming Fever or chills? In any distress? Position? Difficulty sleeping? Change in Visible changes in weight (sunken eyes, sleep patterns? wasting, cachetic) Chronic pain? Fatigue? Sweats or night sweaths? ROS Questions: Skin Known diseases? Changes in hair: growth/loss, oily/dry, color Changes in nails: cracking, spooning, Skin eruptions/rashes? clubbing, color, growth Hair loss? Changes in lesions/moles: Growths? ○ A: asymmetry ○ B: borders Sores that grow or/and don’t ○ C: color heal? ○ D: diameter ○ E: evolving Lesions changing in size/shape/color? Itching? ROS Questions: Head/Neck Head or face pain? Symmetry of face Enlarged appearing thyroid Injuries? Masses or growths? Swollen glands? Pain? Stiffness? Lumps? Goiter? History of thyroid problems? ROS Questions: Eyes Chronic or past eye disorders? Decrease/change in vision or blurriness? Pain in the eyes? Visual changes? ○ Blurry, scotomas, diplopia, auras, ﬂoaters, halos, photophobia Eye discharge? Tearing or dryness? Redness? Itchiness? Glaucoma or cataracts? Use of corrective lenses/eye surgeries? Last eye exam? ROS Questions: Ears Hearing aids? Changes in hearing? Tinnitus? (ringing in ears) Vertigo? Pain, discharge, itchiness? History of frequent or recent infections? ROS Questions: Nose and Sinuses Frequent colds/sinus infections? Runny nose? Congestion? Pain? Itchiness? Epistaxis? Changes in sense of smell? ROS Questions: Mouth and Throat History of dental work? Frequent sore throats? Dentures or partials? Hoarseness? Bleeding or irritation of the Dry mouth? gums? Last dental appointment? Difficulty chewing or Dysgeusia (parageusia) or swallowing? ageusia = distortion of taste or Pain or irritation? loss of taste ROS Questions: Breasts SBE (self breast exam) routine? Aware of correct technique? Last CBE (clinical breast exam)? Last mammogram? History of abnormal mammogram? Lumps? Discoloration? Pain/discomfort? Discharge? Galactorrhea? ROS Questions: Respiratory Cough? Histories of abnormal chest ○ Sputum (color, quantity, x-rays? frequency) History of asthma, COPD, Hemoptysis? Pneumonia, TB, etc? Dyspnea (SOB)? Wheezing? Pain (with breathing? I.e. pleuritic pain) Cyanosis? ROS Questions: Respiratory Cough? Histories of abnormal chest ○ Sputum (color, quantity, x-rays? frequency) History of asthma, COPD, Hemoptysis? Pneumonia, TB, etc? Dyspnea (SOB)? Wheezing? Pain (with breathing? I.e. pleuritic pain) Cyanosis? ROS Questions: Cardiovascular “Heart trouble”? History of murmurs, Chest pains? hypertension, CHF, MI? Palpitations? Cyanosis? Dyspnea/PND (paroxysmal Exercise intolerance? nocturnal dyspnea)? Fatigue? Orthopnea (# of pillows? Sitting Past ECG? Echo? Nuclear up to sleep?)? medicine test? Other cardiac Edema - hands, ankles, feet? procedures? ROS Questions: Gastrointestinal Dysphagia? Constipation? Heartburn? Diarrhea? Nausea? Food intolerance? Regurgitation? GERD? Hematochezia, melena? Change in appetite or weight loss? Hemorrhoids? Belching/gas? Last EGD? Colonoscopy? And Abdominal pain? Results? Change in stool color, size, Gallstones, hepatitis, cirrhosis? consistency? Pancreatic disorders? Cancer? ROS Questions: Urinary (GU) Frequency? Hematuria? Dysuria? Decreased strength of ﬂow? Retention? Dribbling, hesitance? Polyuria? Stones, incontinence? Nocturia? Known prostate problems or Flank pain? elevated PSA? Suprapubic pain? Cancer? Color, odor, discharge? ROS Questions: Genital Male: Female: ○ Hernias? ○ Age of menarche ○ Circumcised? ○ STDs? ○ Regularity, frequency, Discharge, lesions, ulcerations duration of menses ○ Sexual dysfunction? ○ Bleeding between Performance, desire, pain ○ Incontinence ○ Pain ○ STDs Penile Vaginal discharge, Scrotal ○ Deformities itching Masses ○ Pregnancies ○ Last PAP ROS Questions: Musculoskeletal Muscle/joint/bone pain, Bone deformity stiffness, weakness, instability? Systemic symptoms associated Neck or back pain? with joint pain? (fever, chills, Injury? Altered/restricted ROM? rash, weight loss, weakness) Assistance needed such as cane, walker, wheelchair, prosthetics? Swelling (edema)? ROS Questions: Psychiatric Changes in mood Previous or current Depressed, anxious, tension, psychotherapy memory change? Psychiatric admissions Difficulty concentrating? Insomnia/sleep disturbance? Thoughts of suicide, plan, previous attempts? ○ PHQ-9 if not already done or compare with previous visit ROS Questions: Neurologic Changes in mental status? Fainting, lightheadedness? Recurrent falls? HAs, dizziness, numbness, paresthesia, paresis, paralysis? Tremors, involuntary movements? Seizures? ROS Questions: Hematologic Anemia? Past transfusions? ○ Reactions? Leukemia? Easy bruising/bleeding? History of blood clots? On a “blood thinner” (anticoagulant therapy)? ○ Why? Clot, Aﬁb, stroke… ROS Questions: Endocrine Thyroid Weight changes? masses/enlarged/tender? Energy level changes? Heat or cold intolerance? Trouble sleeping? Excessive sweating? Fatigue? Changes in skin color? Hunger, thirst, unexplained ○ Addison’s weight changes? Changes in face or body hair/fat distribution? What is the next section of our SOAP note? Vital Signs Contact Information: PA Hannah Pruzinsky - Lead Lecture ○ [email protected] Dr. Joel Tetzlaff - Lead Lab ○ [email protected] References: https://medicine.yale.edu/news/yale-medicine-magazine/articl e/the-lost-art-of-the-physical-exam/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7786733/ Bates Guide to Physical Examination and History Taking 13th Edition

History Taking - PACA 1 - Module 1 PDF

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