Presentation on theme: "Obtain a Health History"— Presentation transcript:
1 Obtain a Health History Ref(s): C1 - Bates “A Guide to Physical Examination”, eighth EditionEO 001Breakdown:3 x 50 min TL17 x 50 min Role play34 x 20 min practice for EC’s17 x 50 min practice for PC’s21 x 20 min student stations- Test
2 Obtaining a health history The Health History InterviewTechniques of skilled interviewingComponents of the Comprehensive Adult History
3 Health History Interview 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.
4 Health History Interview Conversation with a purposeTo improve the well-being of the patient:Establish a trusting and supportive relationshipGather information.Offer information.
5 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 andStill find a way to explore the patient’s “feelings and beliefs about their problem(s)”.
6 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.
7 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?
8 Health History Interview Before you begin:Taking time for Self-reflectionHow can you remain or become consistently open and respectful to individual differences?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?e.g . How do you feel about patients with addictions, drunk drivers, chronic fatigue, previous hx of malingering, chronic back pain, fibromyalgia patients, etc…
9 Health History Interview 2. Reviewing the ChartProblem listMedicationsAllergiesPast diagnoses and treatmentsThe chart or ER triage sheet does not, “capture the essence of the person that you are about to meet”
10 Health History Interview 3. Setting Goals for the interviewProvider centered goals:Write-up for your supervisorInsurance formPatient centered goals:Relieve the painNote for workThere has to be a balance between the above as well as the institutional needs.
11 Health History Interview 4. Reviewing Clinician Appearance and BehaviorWhat 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!e.g.1.what do parents think of a clinician that smells of smoke when they are bringing their child with asthma to the ED,or WIC??2. Impatient, upset, not interested+++
12 Health History Interview 5. Improving the environmentHow 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?”
13 Health History Interview The sequence of the interview:Greeting the patient and establishing rapport.Inviting the patient’s story.Establishing the agenda for the interview.Expanding and clarifying the patient’s story: generating and testing diagnostic hypotheses…Q and Q!!!Creating a shared understanding of the problem(s).Negotiating a plan. (further evaluation, treatment and patient education)Planning for follow-up and closing the interview.
14 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 paramountKnow 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 placeArrange the room appropriately:Do not have objects between you and the patient when avoidable.Avoid arrangements that connotate disrespect or inequality of powerConsider the need for a chaperone nurse/ Med TechAsk what their relationship is to the patient…not whether or not they are husband, father, mother, etc…Greet: Introduce yourself maintain eye contact
15 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!Opening question; What brings you here today?Clarification: What do you mean by….Note taking: ask the pt if you can take notes during the interview.
16 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.Continuers - nodding, yes…go on., I seeDirect question: they should lead from the general to the specific e.g. What color were your stools?Graded response - “how many steps can you climb before you get SOB” rather than “ do you get SOB walking upstairs?MC - is your chest pain stabbing, pressure, burning?Have you had any of the following -TB, pleurisy, asthma, bronchitis? Ask each one and wait for a response.Do you have Paroxysmal Nocturnal Dyspnea, orthopnea, edema? Vs…..Dizzy vs. Vertigo vs. feeling faint.
17 Expanding and clarifying the patient’s story Language is important:Shortness of breath vs. dyspneaBright red blood in your stools vs. hematocheziaEstablishing 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?Use example of duration of a seizure…I.e. looking at a watch and asking witness to let you know when to say”okay stop”
18 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.
19 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”.
20 Symptom attributesLocation: Where is it? Can you point to it? Does it radiate?Quality: What is it like?Quantity or severity: How bad is it?Timing: When, how long, how often?Setting in which it occurs: environmental and personal activities.Remitting or exacerbating factors.Associated manifestations.
21 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!!!!!!
22 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?The Sore throat:Patient: pain, difficulty swallowing, missing work, or a cousin who was hospitalized and missed a great deal of work.Physician: differentiate strep from other etiologies that can cause a sore throat (mono, peri-tonsillar abscess, simple viral illness) or a questionable hx of allergy to penicillin.
23 Creating a shared understanding of the problem(s). Exploring the patient’s perspective:Pt’s thoughts about the nature and cause of the problem.Pt’s feelings, esp. fears about the problem.Pt’s expectations of the clinician and healthcare.The effect of the problem on the patients life.Prior personal or family experiences that are similar.Therapeutic responses that the patient has previously tried.
24 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?Use the example of BRBPR
25 Create a plan that is feasible for you and the patient…not just you! Negotiating a planCreate 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.Use example of self-employed male carpenter with probable scaphoid fracture
26 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.
27 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.
28 Techniques of Skilled interviewing Non-verbal communicationEye 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.Paralanguage - qualities of speech - Pacing, tone, and volume are useful to observe and may be mirrored to increase connection
29 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”?
30 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”It is very difficult to lose a family member and I can understand why it is so upsetting….But rather “It is very difficult to lose a family member …this must be horrible for you”.Mention details about what happened
31 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.
32 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.Recounting the pertinent positives and Negatives not every single detail from the Hx* Remind them of how it is very helpful in the testing situation…extra marks etc….
33 Techniques of Skilled interviewing Highlighting transitions“Now I would like to ask you some questions concerning your past health.”
34 Taking a History on Sensitive Topics Drug / Etoh abuseSexual orientation or habitsDeath and dyingFinancial concernsRacial and ethnic experiencesFamily interactionsDomestic violencePsychiatric illnessPhysical deformitiesFunctioning of the Urinary Tract / Bowels, etc..
35 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”!Clinician role is to learn about the patient and help the patient achieve better health.“Because certain sexual practices put people at risk for certain diseases I ask all of my patients with similar complaints the following questions.Not “down there”, private parts, vajajy”
36 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!
37 CultureA 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.Chapter 1 pg. 16
38 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.Allows you to approach each patient as unique and distinct.
39 Self-awareness How do you define yourself by: Ethnicity Class Region ReligionPolitical affiliationHow are you the same or different than your family of origin?
40 Values vs. BiasValues - 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.Questions to ask?Are you on time?
41 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.
42 Adapting Interview Techniques The Silent PatientSilence: 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?“ You seem very quiet, have I or anyone here at _____ done something to upset you?”Silent Pt’s: are difficult to manage some keys points to remember - be very attentive, watch for physical gestures, or offer verbal encouragement.
43 Adapting Interview Techniques The Talkative patientDo 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.Talkative Pt’s: Be courteous . Try and elicit the primary reason for the visit.
44 Adapting Interview Techniques The Anxious PatientIt 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.
45 Adapting Interview Techniques The Crying PatientEmotions: 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?Does it make a difference if it is a male or female patient?
46 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.
47 Adapting Interview Techniques The Angry or Disruptive patientReasons: 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.
48 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.
49 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.For example: getting them admitted to a hospital for the sake of convenience
50 Global CompetencyOverall technique of applying the knowledge of the skillGreeting patient & IntroductionEstablishing 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..
51 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.
52 Comprehensive Adult History Demographic DataChief complaint.History of present illness (HPI).Medication/Allergies.Past Medical History.Personal and Social History.Family HistoryReview of Systems.Do we always use a comprehensive hx…let us talk about that.
53 Comprehensive Adult History Comprehensive vs. focused (problem oriented) interviewComponents structure the patient’s interview and the format of the written record…but do not dictate the sequence of the interview!
54 Comprehensive Adult History Demographic (identifying) Datanameagegenderoccupationmarital status(years of service)Source of the historyInclude date and time of the hx being takenConsider if the hx is being given from a reliable sourceBrief identifying data - 50 year old Fijian male/man from Labasa presents with……Reliable Source:Language barrier examplesHard of hearingDementiaHead injuryEtoh / drugs / metabolic disorderCooperative or not
55 Comprehensive Adult History Chief Complaintuse 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.”Short/specific in one clear sentence communicating present/major problem/issue.Timing – fever for last two weeks or since MondayRecurrent – patient present with recurring episode of abdominal pain/coughAny major disease important with CC e.g. DM, asthma, HT, pregnancy, IHD: 20 year old Indian female from Nabua with 7 months pregnant presents with 1 day vaginal bleeding.Note: CC should be put in patient language.
56 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:
57 Comprehensive Adult History - HPI Location: Where is it? Can you point to it? Does it radiate?Quality: What is it like?Quantity or severity: How bad is it?Timing: When, how long, how often?Setting in which it occurs: environmental and personal activities.Remitting or exacerbating factors.Associated manifestations.
58 Principal Symptoms Description PainCHLORIDE PPPSOLDCARTOPQRSTOther presenting sx’s i.e fatigue, SOB, vertigo, unwell, vomiting, diarrhea, etc…DDx list
59 CHLORIDE PPPS Ch –Character L – Location O – Onset, gradual vs sudden R – RadiatingI – IntensityD - DurationE – Events surrounding ccP – PalliativeP – ProvokingP – Previous episodeS – Sx’s associatedPain: Can be describe as sharp, dull, stabbing, burning.Quality. Is theSeverity: Scale 1-10 One being the least Ten being the worst pain ever feltTiming: Constant, intermittent, steady, occur only at night, post meals, during the day.Setting: What was your activity during the onset?Aggravating/Relieving factors: What makes the pain worse? What makes it better?Associated: Any other symptoms with the pain (i.e., nausea, dizziness, vertigo, thirst, weakness, blurred vision etc)
60 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
61 Chloride PPP…sIs 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.
62 Chloride PPP…sIt 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.”Could introduce the topic of prevalence here and how this can play a role in different patient populations
63 Chloride PPP…sThe “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 diagnosesE.g. Sob, palpitations, cough, LOC, nausea, vomiting, PND, Orthopnea, edema, fever,etc…To help in differentiating cardiac and non-cardiac causes of chest pain
64 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 cliniciansCan 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.
65 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.
66 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 chloridepppsAlso the short list, systems approach, diagnostic template among others
67 OLDCART O – Onset L – Location D – Duration C – Characteristics A – Aggravating FactorsR – Relieving FactorsT – Time it occurred
68 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 toRelieving or aggravating factors – any activities or positionSeverity – 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.
69 VINDICHATEM V - Vascular I - Infectious/Inflammatory N - Neoplastic D - degenerativeI - Idiopathic, IatrogenicC – CongenitalH - HematologicalA – AutoimmuneT – TraumaE - EndocrineM - MetabolicIdiopathic-disease without a recognizable cause, spontaneous.
70 Current Health Status Medications taken Allergies to include home remedies, herbal supplementsprescription and non-prescriptionAllergiesenvironmentalmedicationsfoodsIf allergy +ve make sure to investigate what they mean…gi upset vs. allergy
71 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 feverB. Adult illnesses (divided in four categories):Medical ( DM, HTN, CAD, Asthma)Surgical and/or injuries ( dates, indications)Obstetrical / GynecologicalPsychiatricC. Health MaintenanceImmunizations, Screening Tests i.e CXR, PSA, mammogramsIHD/Heart Attack/DM/Asthma/HT/RHD, TB/JaundiceE.g. if diabetic- mention time of diagnosis/current medication/clinic check upPast surgical/operation historyE.g. time/place/ and what type of operation. Note any blood transfusion and blood grouping.
72 Comprehensive Adult History Personal and Social hxOccupation and last year of schoolingHome situation and significant othersStressors: recent and long-termLeisure activitiesExercise and dietary habitsDrug, alcohol, and tobacco usageReligious affiliation and spiritual beliefsActivities of Daily LivingSafety MeasuresAlternate Health Care PracticesOccupational factors: What is the work environment like; stressful, noisy, dust, fumes, smoke environment.Home environment: stress, martial problems, pets, financial problems, illness
73 Comprehensive Adult History Family History (FHx)Pertinent health of patients blood relatives to include all immediate relatives:ParentsSiblingsGrandparentsChildrenGrand childrenIHelpful information gathered here to include:parents age, any significant health issues, age,living or deceased(if deceased determine the circumstance)siblings, any significant health issues, age,grandparents, any significant health issues, age,Note: A detailed hx will give you as theclinician a global picture of the patient.
74 Comprehensive Adult History Determine the occurrence of the following:diabetes headachestuberculosis mental illnessAsthma COPDheart disease Elevated Cholesterolhigh blood pressure strokekidney disease Seizure disorderCancer Alcohol or drug addictionarthritisanemiaWhen doing a focused Hx you should concentrate on the disease processes that are related to the Symptoms / disease that the Pt is presenting with!!!!During this phase if the Pt has a positive answer to and elicit as much info pertaining to the finding as possible.
75 Comprehensive Adult History Review of Systems (ROS)Or Functional InquiryConsider it to be a “head to toe assessment”Remember to use layperson’s languageWhat is the time frame that we are talking about…give them a time frame, hours, days, weeks, monthsContrast the difference between past med hx ( diseases) vs. ROS (sx’s of disease / illness)
76 ROS General or Usual state of health Episodes of chills, weakness or malaiseFatigueSweatsUsual weight including gain or loss of weight
77 Any changes in skin color, nails or hair EOR.O.SSkinAny changes in skin color, nails or hairbrittle hair, alopecia, clubbing, or paronychiaAny of the following:- rashes, sores, lumps, moles, infections, lesions,masses, eruptions, general or localizedpruritisNote: The finger nails for Beau’s lines (transverse grooving) indicative of a acute severe illness.Paronychia: inflammation of proximal/.lateral nail folds. Red and tender Caused by, frequent immersion in water. Pg BatesAlopecia: refers to hair loss, patchy, diffuse, or totalClubbing: the distal nail is rounded and bulbous. Causes are many, including chronic hypoxia and lung cancer. Pg Bates
78 HEENT Head Eyes Ears Noses & Sinuses Throat / Mouth & Neck Head: EOHEENTHeadEyesEarsNoses & SinusesThroat / Mouth & NeckHead:Any hx of head trauma or headache.
79 Eyes Determine the fol: EOEyesDetermine the fol:vision changes with most recent eye test resultsVisual field changesocular painpain with eye movementrednessirritation
80 Ears Ascertain the fol: tinnitus hearing loss (acuity) earache EOEarsAscertain the fol:tinnitushearing loss (acuity)earacheInfection with or without drainage/dischargevertigoTinnitus: is a perceived sound that has no external stimulus, commonly heard as a musical ringing or as a rushing or roaring noise. One or both ears may be involved. Tinnitus may accompany hearing lossof any kind and often remains unexplained. Occasionally, popping sounds originate in the TMJ or vascular noises from the neck may be audible.Vertigo: refers to the false perception that the patient or the environment is rotating or spinning. These sensations are primarily to a problem in the inner ear, the cochlear nerve, or its central connections in the brain.
81 Nose & Sinuses Sense of smell Common ailments: EO 001.01 cranial nerve ICommon ailments:stuffiness/congestionbleedingdischargesinus pain
82 Mouth, Throat, &Neck Common ailments: EO 001.01 bleeding sores lumps frequent sore throatvoice change/hoarsenessdifficulty swallowing - dysphagia
83 Breasts EO 001.01 Signs / Symptoms Lumps / nodules Pain / tenderness DischargeIs self-examination performed?Last Clinical Breast Exam (CBE)?Mammograms in the past?Note:(is SBE of any use?)Clinicians recommend a Clinical Breast Examination (CBE) baseline at 40 years of age.
84 Respiratory EO 001.01 Cough(productive/dry) Sputum (color, amount, smell)HaemoptysisChest painSOBIncreased RRWheezingChest X-RayDate and resultTachypnea – Abnormal rapidity of resp.DyspneaPleuritic
85 Cardiac EO 001.01 Chest pain, Palpitations, claudication SOB, Cough PND, Orthopnea, EdemaSyncope or pre-syncopeBase-line or previous EKG/Stress Test
86 Gastrointestinal Common ailments: EO 001.01 appetite < or > dysphagia / odynophagian & vheartburnrefluxjaundiceindigestionabd painDysphagia: difficulty in swallowing.Odynophagia: pain on swallowingOne method to ensure all the G.I. Is covered visualize a portion of food being eaten and follow it through the G.I. system
87 Gastrointestinal EO 001.01 Bowel movements? What is normal for them? Daily or not.constipation/diarrheahematocheziaMelenahemorrhoids
88 Is the patient suffering from: EOUrinary SystemIs the patient suffering from:DysuriaFrequencyUrgencyNocturiaHematuriaHesitancyDecreased streamDribbling post voidingDysuria: painful urinationNocturia: refers to urinary frequency at night, sometimes defined as awakening the pt more than once a night.Hematuria: blood in urine.Urgency: it is an unusually intense and immediate desire to void.
89 Genito-Reproductive Male EOGenito-Reproductive MalePenile dischargehow oftencolorbloododorPain and/or lesionsoccurrencelocationfrequency
90 Genito-Reproductive Male EOGenito-Reproductive MaleHx of STD’s# of exposuresTesticular painlocationSwellingSelf-examinationSexual problems or concerns
91 Genito-Reproductive Female EOMenstruationage of menarcheregularityfrequency and durationlast menstrual cycle (LMP)abnormal menses (discharge/pruritus)amount of bleedinglast gyne exam and PAP smear resultsHx of STD’sDyspareuniaOvarian cystsMenopauselibido
92 Full term deliveries (vaginal or C/S) EOObstetrical HxNumber of pregnanciesFull term deliveries (vaginal or C/S)Abortions (spontaneous and/or therapeutic)Complications of pregnancyInfertilityMethod(s) of contraception usedFamilial obstetrical hx (if relevant)
93 Musculoskeletal Extremities EO 001.01 joint or muscle location severityaggravating/relieving factorswith movementswellingROMtemp sensitive
94 Neurologic - CNS/PNS EO 001.01 Syncope - Abnormalities in sensation Seizures Abnormalities in coordinationWeakness and balanceNumbness/TinglingTremorsCVA/TIA sx’sMemory lossInvoluntary movementsHeadaches, visual sx’s
96 Endocrine System Common ailments EO 001.01 polyuria polydipsia (thirst)intolerance to temp changeexcessive sweatingweight changes/problemsHair/skin changesGU related problemsPolyuria: abnormal high production of urine.Polydipsia: abnormal high intake of water commonly associated with polyuria.
97 Hematologic EO 001.01 Bleeding Bruising hx of abnormal/excessive bleedingdurationany transfusionsBruisingecchymosis
99 SOAPSubjective- how patient feels/thinks about him. How does he look. Includes CC and general appearance/condition of patientObjective - relevant points of patient complaints/vital sings, physical examination/daily weight, fluid balance, diet/laboratory investigation and interpretation
100 Assessment – address each active problem after making a problem list Assessment – address each active problem after making a problem list. Make differential diagnosis.Plan – about management, treatment, further investigation, follow up and rehabilitation