Pt interview 1

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  1. General Demographics
    • Age
    • Gender
    • Race/ethnicity
    • ---------------- Above are risk factors
    • Primary language
    • Education
  2. 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
  3. 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
  4. 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
  5. 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
  6. 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
  7. 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
  8. 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
  9. 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?
  10. 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
  11. Review of Systems
    • Cancer
    • Cardiovascular
    • Endocrine
    • Gastrointestinal
    • Genitourinary
    • General Questions
    • Hepatic/biliary
    • Hematologic
    • Integumentary
    • Immunologic
    • NMS
    • Rheumatologic
    • Pulmonary
    • Psychological
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320968
Card Set
Pt interview 1
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Pt interview 1
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