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General Demographics
- Age
- Gender
- Race/ethnicity
- ---------------- Above are risk factors
- Primary language
- Education
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Social History
- 1. Family resources
- ----Does someone from home have to interact with us bc pt not competent
- 2. Activities and interactions
- ----Goal setting/ what caused the problem
- 3. Level of fitness (sedentary?)
- 4. Living environment
- ----Don’t teach stairs if they don’t have stairs in their home
- 5. Cultural beliefs
- ----Beliefs on pain; Effects how pain effects their life
- 6. Health behavior
- ----Smoke/exercise
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General Health Status
- 1. Patient’s perception
- ----People think they are healthy when they are not
- 2. Physical function
- ----Desk job vs manual laborer
- ----Determines prognosis
- 3. Psychological function
- 4. **Work role
- 5. **Social role
- ----Pts feel dismissed (think it is unrealistic)
- ----Goal setting, and pt believes they have been listened too
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Family/Personal History
- 1. Congenital conditions
- 2. Age specific
- ----Things present different in different genders or ages
- 3. Medical conditions
- ----Hospitalization last 10 yrs
- 4. Psychologic conditions
- 5. Prior hospitalizations
- 6. Prior surgeries
- 7. Immediate family members
- ----Parents and siblings and What do/did they have
- 8. Women specific
- ----Things present different in different genders or ages
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Medications (don’t need to know specific med or class of meds)
- 1. Current medications
- ----Can affect how the pt presents
- 2. Recent changes in meds
- 3. Adverse events
- ----Falls
- --------Bc they tripped or syncope?
- ----Anorexia
- ----Cognitive impairment
- ----Urinary incontinence
- 5. Side effects
- ----Diarrhea
- ----Constipation
- ----Nausea
- ----Abdominal pain
- ----Sedation
- 6. Severe reactions
- ----Confusion
- ----Drowsiness
- ----Weakness
- ----Loss of coordination
- Pt taking too much meds or cant handle meds
- Talk to family member bc pt probably doesn’t realize
- When on >4 med then at greater risk
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NSAID Complications
- 1. Cardiopulm
- ----Increased BP
- 2. Renal
- ----Edema
- ----Dehydration
- ----Weakness
- ----Paraesthesia
- 3. Integumentary
- ----Pruritus
- ----Delayed wound healing
- 4. NMS
- ----Symptoms linked to food intake
- --------Bc of active bleed or ulcer
- ----Scapulo-thoracic pain
- ----*Increase in symptoms after med intake
- 5. GI
- ----Heartburn
- ----Nausea
- ----Fatigue
- ----Bleeding
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Components of a Patient-Centered Interview
- Explore the disease and its effect on the patient’s life
- ----Learn about person as a whole
- ----Don’t do manip if don’t want to
- Understand the person as a whole
- Finding common ground regarding intervention
- Advocating prevention and wellness
- Enhancing patient-provider relationship
- Provide realistic expectations
- Communication
- Active listening
- Empathy
- Non-verbal cues
- You don’t understand how they feel but you validate them that they don’t feel well
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Interviewing Techniques
- 1. Open-ended questions
- ----What brings you in today?
- 2. Funnel sequencing using follow-ups
- ----Go from open ended to closed ended?
- 3. Closed-ended questions
- 4. Paraphrasing
- ----Saying back what say in your language
- ----So you are experiencing this and it is preventing you from doing this
- 5. Reverse paraphrasing
- ----So when start with tx everyone is on the same page with the plan
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The Core Interview
- 1. History of present illness
- ----Chief complaint: onset
- 2. Pain and symptom assessment
- ----Location
- ----Description
- ----Pattern
- ----Frequency
- ----Duration
- ----Intensity
- ----Associated symptoms: follow-ups based on previous answers
- ----Aggravating factors
- ----Relieving factors
- 3. Medical treatment and medication
- ----Previous or current therapies
- ----ANY medications
- 4. Level of fitness
- ----Current exercise levels
- --------So don’t push pt too hard first day
- ----Shortness of breath
- 5. Sleep history
- ----Chemicals released and pt may not get better quicker
- 6. Stress
- ----Plays a big role on how person heals
- 7. Final question
- ----ANY other symptoms even unrelated?
- ----Any thing else you want to tell me?
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Current Symptoms using SINSS
- Severity: intensity as it relates to patient function
- ----How easily is something provoked and does it stop when we stop
- ----Decrease tx if severity last after we stop
- Irritability: ease of symptom provocation
- ----How much activity triggers symptoms
- ----The severity once provoked
- ----How long until symptoms subside
- Nature of complaint: clinicians assessment of:
- ----Structure or syndrome involved
- ----Components of condition warranting caution with objective examination
- ----Effects of personality, ethnicity, socioeconomics, and psychology on pain tolerance
- ----No ones 5/10 is the same
- Stage of condition: acute, sub-acute, chronic
- Stability: progression over time
- ----Getting worse, better, or staying the sane since when first started
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Review of Systems
- Cancer
- Cardiovascular
- Endocrine
- Gastrointestinal
- Genitourinary
- General Questions
- Hepatic/biliary
- Hematologic
- Integumentary
- Immunologic
- NMS
- Rheumatologic
- Pulmonary
- Psychological
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