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Obtain a Health History

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1 Obtain a Health History
Ref(s): C1 - Bates “A Guide to Physical Examination”, eighth Edition EO 001 Breakdown: 3 x 50 min TL 17 x 50 min Role play 34 x 20 min practice for EC’s 17 x 50 min practice for PC’s 21 x 20 min student stations- Test

2 Obtaining a health history
The Health History Interview Techniques of skilled interviewing Components 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 purpose To improve the well-being of the patient: Establish a trusting and supportive relationship Gather 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 and Still 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-reflection How 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 Chart Problem list Medications Allergies Past diagnoses and treatments The 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 interview Provider centered goals: Write-up for your supervisor Insurance form Patient centered goals: Relieve the pain Note for work There has to be a balance between the above as well as the institutional needs.

11 Health History Interview
4. Reviewing Clinician Appearance and Behavior What 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 environment How 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 paramount Know 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 place Arrange the room appropriately: Do not have objects between you and the patient when avoidable. Avoid arrangements that connotate disrespect or inequality of power Consider the need for a chaperone nurse/ Med Tech Ask 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 see Direct 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. dyspnea Bright red blood in your stools vs. hematochezia Establishing 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 attributes 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.

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 plan Create 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 communication Eye 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 abuse Sexual orientation or habits Death and dying Financial concerns Racial and ethnic experiences Family interactions Domestic violence Psychiatric illness Physical deformities Functioning 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 Culture A 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
Religion Political affiliation How are you the same or different than your family of origin?

40 Values vs. Bias Values - 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 Patient Silence: 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 patient Do 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 Patient It 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 Patient Emotions: 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 patient Reasons: 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 Competency Overall technique of applying the knowledge of the skill Greeting patient & Introduction Establishing 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 Data Chief complaint. History of present illness (HPI). Medication/Allergies. Past Medical History. Personal and Social History. Family History Review of Systems. Do we always use a comprehensive hx…let us talk about that.

53 Comprehensive Adult History
Comprehensive vs. focused (problem oriented) interview Components 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) Data name age gender occupation marital status (years of service) Source of the history Include date and time of the hx being taken Consider if the hx is being given from a reliable source Brief identifying data - 50 year old Fijian male/man from Labasa presents with…… Reliable Source: Language barrier examples Hard of hearing Dementia Head injury Etoh / drugs / metabolic disorder Cooperative or not

55 Comprehensive Adult History
Chief Complaint use 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 Monday Recurrent – patient present with recurring episode of abdominal pain/cough Any 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
Pain CHLORIDE PPPS OLDCART OPQRST Other 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 – Radiating I – Intensity D - Duration E – Events surrounding cc P – Palliative P – Provoking P – Previous episode S – Sx’s associated Pain: Can be describe as sharp, dull, stabbing, burning. Quality. Is the Severity: Scale 1-10 One being the least Ten being the worst pain ever felt Timing: 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…s Is 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…s It 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…s The “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 diagnoses E.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 clinicians Can 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 chlorideppps Also the short list, systems approach, diagnostic template among others

67 OLDCART O – Onset L – Location D – Duration C – Characteristics
A – Aggravating Factors R – Relieving Factors T – 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 to Relieving or aggravating factors – any activities or position Severity – 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 - degenerative I - Idiopathic, Iatrogenic C – Congenital H - Hematological A – Autoimmune T – Trauma E - Endocrine M - Metabolic Idiopathic-disease without a recognizable cause, spontaneous.

70 Current Health Status Medications taken Allergies
to include home remedies, herbal supplements prescription and non-prescription Allergies environmental medications foods If 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 fever B. Adult illnesses (divided in four categories): Medical ( DM, HTN, CAD, Asthma) Surgical and/or injuries ( dates, indications) Obstetrical / Gynecological Psychiatric C. Health Maintenance Immunizations, Screening Tests i.e CXR, PSA, mammograms IHD/Heart Attack/DM/Asthma/HT/RHD, TB/Jaundice E.g. if diabetic- mention time of diagnosis/current medication/clinic check up Past surgical/operation history E.g. time/place/ and what type of operation. Note any blood transfusion and blood grouping.

72 Comprehensive Adult History
Personal and Social hx Occupation and last year of schooling Home situation and significant others Stressors: recent and long-term Leisure activities Exercise and dietary habits Drug, alcohol, and tobacco usage Religious affiliation and spiritual beliefs Activities of Daily Living Safety Measures Alternate Health Care Practices Occupational 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: Parents Siblings Grandparents Children Grand children I Helpful 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 the clinician a global picture of the patient.

74 Comprehensive Adult History
Determine the occurrence of the following: diabetes headaches tuberculosis mental illness Asthma COPD heart disease Elevated Cholesterol high blood pressure stroke kidney disease Seizure disorder Cancer Alcohol or drug addiction arthritis anemia When 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 Inquiry Consider it to be a “head to toe assessment” Remember to use layperson’s language What is the time frame that we are talking about…give them a time frame, hours, days, weeks, months Contrast 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 malaise Fatigue Sweats Usual weight including gain or loss of weight

77 Any changes in skin color, nails or hair
EO R.O.S Skin Any changes in skin color, nails or hair brittle hair, alopecia, clubbing, or paronychia Any of the following: - rashes, sores, lumps, moles, infections, lesions, masses, eruptions, general or localized pruritis Note: 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 Bates Alopecia: refers to hair loss, patchy, diffuse, or total Clubbing: 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:
EO HEENT Head Eyes Ears Noses & Sinuses Throat / Mouth & Neck Head: Any hx of head trauma or headache.

79 Eyes Determine the fol:
EO Eyes Determine the fol: vision changes with most recent eye test results Visual field changes ocular pain pain with eye movement redness irritation

80 Ears Ascertain the fol: tinnitus hearing loss (acuity) earache
EO Ears Ascertain the fol: tinnitus hearing loss (acuity) earache Infection with or without drainage/discharge vertigo Tinnitus: 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 I Common ailments: stuffiness/congestion bleeding discharge sinus pain

82 Mouth, Throat, &Neck Common ailments: EO 001.01 bleeding sores lumps
frequent sore throat voice change/hoarseness difficulty swallowing - dysphagia

83 Breasts EO 001.01 Signs / Symptoms Lumps / nodules Pain / tenderness
Discharge Is 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) Haemoptysis Chest pain SOB Increased RR Wheezing Chest X-Ray Date and result Tachypnea – Abnormal rapidity of resp. Dyspnea Pleuritic

85 Cardiac EO 001.01 Chest pain, Palpitations, claudication SOB, Cough
PND, Orthopnea, Edema Syncope or pre-syncope Base-line or previous EKG/Stress Test

86 Gastrointestinal Common ailments: EO 001.01 appetite < or >
dysphagia / odynophagia n & v heartburn reflux jaundice indigestion abd pain Dysphagia: difficulty in swallowing. Odynophagia: pain on swallowing One 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/diarrhea hematochezia Melena hemorrhoids

88 Is the patient suffering from:
EO Urinary System Is the patient suffering from: Dysuria Frequency Urgency Nocturia Hematuria Hesitancy Decreased stream Dribbling post voiding Dysuria: painful urination Nocturia: 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
EO Genito-Reproductive Male Penile discharge how often color blood odor Pain and/or lesions occurrence location frequency

90 Genito-Reproductive Male
EO Genito-Reproductive Male Hx of STD’s # of exposures Testicular pain location Swelling Self-examination Sexual problems or concerns

91 Genito-Reproductive Female
EO Menstruation age of menarche regularity frequency and duration last menstrual cycle (LMP) abnormal menses (discharge/pruritus) amount of bleeding last gyne exam and PAP smear results Hx of STD’s Dyspareunia Ovarian cysts Menopause libido

92 Full term deliveries (vaginal or C/S)
EO Obstetrical Hx Number of pregnancies Full term deliveries (vaginal or C/S) Abortions (spontaneous and/or therapeutic) Complications of pregnancy Infertility Method(s) of contraception used Familial obstetrical hx (if relevant)

93 Musculoskeletal Extremities EO 001.01 joint or muscle location
severity aggravating/relieving factors with movement swelling ROM temp sensitive

94 Neurologic - CNS/PNS EO 001.01 Syncope - Abnormalities in sensation
Seizures Abnormalities in coordination Weakness and balance Numbness/Tingling Tremors CVA/TIA sx’s Memory loss Involuntary movements Headaches, visual sx’s

95 Humor, Anxiety, Depression, Mood changes Nervousness, Irritability
EO Psychiatric Hx Humor, Anxiety, Depression, Mood changes Nervousness, Irritability Sleep disturbances, Memory changes Attention, concentration Hallucinations, delusions Suicidal / homicidal ideation

96 Endocrine System Common ailments EO 001.01 polyuria
polydipsia (thirst) intolerance to temp change excessive sweating weight changes/problems Hair/skin changes GU related problems Polyuria: 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 bleeding duration any transfusions Bruising ecchymosis


99 SOAP Subjective- how patient feels/thinks about him. How does he look. Includes CC and general appearance/condition of patient Objective - 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


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