1 Location

Where exactly is it felt most?
Where else is it felt?
How easily does patient localize?

Point to it.

Radiation - does the pain spread anywhere else?

QUALITY

What exactly does it feel like?

What words, gestures are used?

Please describe the pain.

Throbbing, squeezing, sharp, dull?

Frequency, size, amount, and severity.

How intense is it?

How much functional impairment?

How many times? How much ...?

How functionally limiting?

What are the effects of the symptoms on lifestyle?

When & how quickly did it begin?

Is it constant or episodic?

How long, frequent are episodes?

Has it changed over time?

MOST IMPORTANT DIMENSION, since it provides the framework for organizing the HPI

Establish an anchor of dates and times.

Under what circumstances?

Where, when, doing what, how, with whom?

What makes it better or worse?

Changes in activity, lifestyle, or diet?

Alternative medicine uses?

Over the counter prescription meds?

What other symptoms occur too?

What else happens?

What percentage of diagnoses are based on info obtained

From the medical interview?

From the physical exam?

From the lab tests and IR?

70%/20%/10%

How does the type of interview dictate the content?

New patient interview?

Return patient interview?

New: (1) comprehensive in scope, (2) problem-focused story, (3) thorough biopsychosocial story

Return: (1) specific issue/ problem, (2) follow-up of prev. issues, (3) new-problem focused story, (4) interim followup story

(1) To understand the patient’s story (est. the diagnosis);         Patient-centered flow (psychosocial)-->doctor-centered flow (disease-specific)         

(2) To develop an effective therapeutic (prof.) relationship competence, trust, empathy, resolve barriers to communication

(3) To educate the patient so effective treatment plans can be carried out; give the patient a basis for making decisions; must have cultural competence.

Disease- The medical condition that afflicts the patient

Illness- How a patient responds to the medical condition that impacts a patient’s life

What are the 7 Dimensions of evaluating symptoms?

Acrostic:

Look Q, Quiet Cats Come After Annoying Ana Marie?

PMH (PSH)

1. Previous illnesses during adulthood and their residual effects
2. Surgical procedures and their residual effects
3. Childhood illnesses and " " ""
4. Psychiatric problems and " " "
5. OB/GYN History and " " "
6. Injuries and accidents and " " "
7. Occupational Illnesses and " " "

How to calculate the GPA (Gravida, para, aborta)?

A pregnant woman has had one miscarriage before the 20th week, one misacarriage after the 20th week, and one carried to full term. What's her GPA?

Gravida - Total # of pregnancies

Parida - Total # that terminated after 20th week

Aborta - Total # that terminated prior to 20th week

G = P + A (+1 if currently pregnant)

G₄P₂A₁

What is the order of the medical interview?

CC->HPI->PMH->FMH->PP->I/HMH->ROS

PP = Patient Profile

I/HMH = Immunizations & Health Maintenance History

ROS = Review of Systems

How to ask sensitive questions: spirituality

Spirituality- FICA

Faith->What is your spiritual or religious heritage? Are the Bible, the Quran, or other religious writings important to you? Do these beliefs help you cope with stress?

Importance and Influence -> How have these beliefs influenced how you handle stress? To what extent?

Community -> Do you belong to a formal religious or spiritual community?

Action in Care->How do your religious beliefs affect your health care decision?

How to ask sensitive questions: culture/ethnicity

Culteral Competancy, avoid stereotyping

How to ask sensitive questions: alcohol use

Have you ever had a drinking problem?

When was your last drink?

Overestimate the amount that the patient drinks...makes patient feel better about the amount he does drink.

CAGE -> Cut-down, Annoyed, Guilty, Eye-opener (waking)

BUMP -> Blackouts, Unplanned, Medicinally, Protect your supply

FATAL DT -> FMH, AA, Thoughts of suicide, Alcoholism, Legal, Depression, Tranquilizers

Pack-Year

If someone has smoked ten cigarettes a day for six years they would have a ___________ history. Someone who has smoked forty cigarettes daily for twenty years has a ___________ history.

Packs/day * years as smoker

1 pack = 20 cigarettes

10/20 * 6 = 3 pack-year

40/20 * 20 = 40 pack-year

How to ask sensitive questions: domestic violence

40% of ED visits by adult women relate to episodes of physical abuse

20% women experience abuse in their adulthood

SAFE

Stress/Safety- Do you feel safe in your relationships? What stress do you experience in relationship?

Afraid/Abused- Have you been abused or threatened?

Friends/Family- Are your friends/family aware of your situation?

Emergency Plan- Do you have a safe place you can go in an emergency?

How to ask questions to special age group: adolescents

Mnemonic: HEED SASS

Rationale: Because they can be brats

1. Home environment
2. Education/Employment
3. Eating
4. Drugs
5. Sexuality
6. Activities/Affect/Ambitions/Anger
7. Suicide/Depression
8. Safety from injury/violence

What are some verbal facilitation (communication) skills?

Use Open Ended Questions! "Tell me about your pain."

1. Summarizing
2. The use of minimal facilitators, e.g. "Uh, huh"
3. Echoing, using the patients own words...repeating what they just said in a form of a question.
4. Checking, "Let me get this straight. You said that..."
5. Surveying, "What else is bothering you?"
6. Setting limits, "What have we talked about that bothers you the most?"

What are some non-verbal facilitation (communication) skills?

1. Eye Contact, except for SE Asians and Native Americans
2. Open posture
3. Position yourself in a non-threatening position, e.g. don't block the door, don't look down on the patient, minimize barriers (silence TV)
4. Remain silent when patient stops talking gives patients the opportunity to continue with their thoughts
5. Head Nodding

What is themost important relational skill the physician can have?

A: The ability to communicate empathy (understanding what it's like to be in their situation), not sympathy (feeling sorry for them).

What verbal aids help establish rapport with patients?

1. Reflect (Name) their feelings. "You seem sad."
2. Legitimize feelings "It's understandable that you feel this way."
3. Express respect for their coping efforts. "You are doing a great job coping with your illness"
4. Provide support "I am here to help you work through this."
5. Partnership "We'll work together to solve these problems"

What non-verbal aids help the physician establish rapport?

1. Touching, e.g. patient self-report that the time spent with the physician increases by 5 minutes!
2. Pay close attention to facial features, esp. the eyes-> the eyes tell the truth, the mouth lies.
3. Observe their body posture, protected (folded arms, legs, etc.)--> anxious vs. open--> willingness
4. Patterns of breathing, e.g. patients who speak at height of inspiration are nervous, while patients who speak at the end of expiration are depressed.
5. Patients gestures,

• rub of nose + clearing throat + averting eyes indicate digust and displeasure
• Hand wringing indicate dispair
• Steepling may indicate confidence
• Hands tightly clutching the chair causing "white knuckles" may indicate fear and anxiety.

What are some common barriers to effective communication?

1. Physician barriers (A ELITE): (1) Lack of knowledge, (2) being attentive to wrong agenda, (3) interrupting or talking-over the patient, (4) using jargon, (5) too much note taking, (6) failure to maintain eye contact
2. Environmental barriers: noise, lack of privacy, patient comfort or cleanliness
3. Physical (health-related) barriers: hearing loss, visual loss, speech impediments and pain.
4. Cultural, psychosocial, and language barriers: poverty, sexual orientation, substance abuse
5. Emotional Barriers: anxiety, depression, anger
6. Educational Barriers: differences in level of education and training
7. Philosophical and religious barriers
8. Stigmatizing problems such as AIDS, disfiguring diseases, and mental illness (venereal disease)

Physicians Envy Physical Education, Causing Emotional, Stigmatizing Philosophies.

5 Signs that may indicate that barriers to effective communication exist.

1. Cognitive dissonance: When information elicited from patient doesn't added up with what you know
2. Unexpected resistance to empathatic attemps
3. Physician/patient discomfort
4. Discrpancy bet objective and subjective observations
5. Treatment is not working may indicate that the patient is not following the doctors recommendations.

• Subjective: What the patient says
• Objective: What the physician actually observes about the patient

Cognitive Aspect of Illness:

4 Patient health beliefs?

1. God’s Punishment

2. Weakness

3. Wrong doing

4. Loss of soul

3 levels of Health Beliefs?

•    Descriptive – describe problem you’re having

•    Conceptual – why did problem start when it did? How do you think your illness works? What do you think will happen w/o treatment?

•    Personal – why do you think you got sick? What’s most frightening about your illness