1
EXAM 1 KEY POINTS
Key Point to Review - Health STUDENT NOTES
History
What are the concepts of developing a
relationship with the patient?
A primary objective is to discover the
details about a patient’s concern, explore
expectations for the encounter and display
interest, curiosity and partnership.
Identifying underlying worries, believing
them, and trying to deal with them
optimizes your ability to be of help. You
need to understand what is expected of
you.
You don’t have similar perspectives but you
need to grasp theirs if you are to establish
a meaningful partnership.
What are effective communication Communication built on courtesy,
strategies when obtaining a health comfort, connection, and confirmation.
history? Ensure courtesy
Knock on door
At the start greet the patient, and those
with the patient.
Address by Ms. or Mrs., ensure
confidentiality, respect the need for
modesty.
Ensure comfort- maintain privacy, ensure
necessary quietness, try not to overtire the
patient,
Asking open ended questions (How have
you been feeling since we last met?)
What questions would you like to discuss?
What do you want to make sure we cover
in today’s visit?
Connection
, 2
Look at the patient, maintain eye contact
Watch your language, avoid professional
jargon
Listen alertly, let the patient order priorities
if several arise.
Define any concern completely:
Where? How severe? How long? What
soothes or aggravates the problem?
Confirmation
Ask the patient to summarize the
discussion. Allow open ended
questions, Anything else you want to
bring up?
Make a mistake repair it, this helps to
develop trust. Most patients respect it
What is a patient-centered question? Patient centered care is: “respecting and
Give examples. responding to patients wants and needs so
they can make choices that best fit their
circumstances” ex: how would you like to
be addressed? Are you coping with your
illness? Do you think treatment will help?
(See BOX 1-1 in Seidel for complete list)
What are potential barriers of patient Potential barriers of communication are
and provider communication? moments of tension this includes: patient
curiosity about you, anxiety, silence,
depression, seduction, anger, crying,
financial issues, and avoidance.
What is the structure and the Providers build a history to establish a
components of a patient history? What relationship with the patient, so that you
kind of patient information is obtained in can jointly discover the issues and
each section? problems that need attention and priority.
This approach can be modified with each
individual circumstance.
First, the identifiers, name date, time, age
gender race, occupation and referral
source.
Chief Concern-a brief statement about why
the patient is seeking care. Many
interviewers include duration in the CC
History of present illness-( HPI)-use
OLDCARTS, Onset,Location, Duration,
, 3
Characteristics, Aggravating factors,
Relieving factors, Severity. Include state of
health just prior to present illness.
Past Medical History-(PMH)-General
health, childhood illnesses, adult illnesses
or chronic diseases, Immunizations,
surgeries, serious injuries resulting in
disability, medications, ability to complete
ADLs, allergies and reactions,
transfusions, recent screening tests,
emotional status.
Family History (FM)-Investigate blood
relatives in the immediate family with
features similar to the patient’s. If a
disease “runs in the family”, ask about
everyone from grandparents to cousins.
Ask about heart disease, hypertension,
cancer, TB, stroke, sickle cell, CF, kidney
disease, thyroid disease, blood diseases,
Ascertain whether cancers are multiple,
bilateral, and occurring more than once in
the family, or at a young age.
Personal and Social History (SH)-
birthplace, home environment, cultural and
ethnic background, education, occupation,
marital status,hobbies or interests, sources
of stress, habits of self-care (self breast
exams, etc), habits regarding smoking,
alcohol and drug use, and sexual history.
Five Ps of sexual history-partners,
practices, protection, past history of STIs,
pregnancy prevention.
Review of Systems (ROS)-Identify the
absence or presence of health related
issues in each body system. Beginning
with general, skin hair and nails, head and
neck, eyes, ears, nose, throat and mouth,
lymph nodes, chest and lungs, breasts,
heart and blood vessels, peripheral
vasculature, hematologic, GI, diet,
endocrine, GU, musculoskeletal,
neurologic, psychiatric.
Females-start and character of meneses,
, 4
LMP, last PAP smear, pregnancies
Males-puberty onset, difficulty with
erections, emissions, testicular pain and
libido.
What is the difference between objective Seidel pg 618: objective: “direct
and subjective data? What components observation, what you see, hear, and
of the health history are objective and touch”. This includes vital signs and actual
subjective? assessment. Subjective: “information
patients offer about their condition or
feelings” This includes chief complaint,
past medical history, history or present
illness, family history, and review of
symptoms.
How do you approach sensitive issues Sensitive issues, which may be difficult to
when interviewing a patient? discuss (sex, drugs, and alcohol)
· Provide privacy
· Do not waffle be, direct and firm. Avoid
asking, leading questions
· Do not apologize for asking a question
· Do not preach. Avoid confrontation. You
are not there to pass judgement
· Use language that is understandable to
the patient, yet not patronizing
· Do not push too hard
· Afterward, document carefully, using
that patient’s words (and those of others
with the patient) whenever possible. It is all
right to take notes
Open ended question first to explore
patient feeling about the issue
What does it mean to be culturally Being culturally aware requires the
aware and culturally competent when provider to be sensitive to heritage, sexual
caring for patients with diverse orientation, economic situation, and
backgrounds? background. It requires acquiring
knowledge and developing skills (Seidel,
pg 22)
What are examples of questions to Questions that explore patient’s culture
explore the patient’s culture? should avoid any judgment or stereotype.
Ex: What do YOU call your problem? What
do you think caused it? Who makes
EXAM 1 KEY POINTS
Key Point to Review - Health STUDENT NOTES
History
What are the concepts of developing a
relationship with the patient?
A primary objective is to discover the
details about a patient’s concern, explore
expectations for the encounter and display
interest, curiosity and partnership.
Identifying underlying worries, believing
them, and trying to deal with them
optimizes your ability to be of help. You
need to understand what is expected of
you.
You don’t have similar perspectives but you
need to grasp theirs if you are to establish
a meaningful partnership.
What are effective communication Communication built on courtesy,
strategies when obtaining a health comfort, connection, and confirmation.
history? Ensure courtesy
Knock on door
At the start greet the patient, and those
with the patient.
Address by Ms. or Mrs., ensure
confidentiality, respect the need for
modesty.
Ensure comfort- maintain privacy, ensure
necessary quietness, try not to overtire the
patient,
Asking open ended questions (How have
you been feeling since we last met?)
What questions would you like to discuss?
What do you want to make sure we cover
in today’s visit?
Connection
, 2
Look at the patient, maintain eye contact
Watch your language, avoid professional
jargon
Listen alertly, let the patient order priorities
if several arise.
Define any concern completely:
Where? How severe? How long? What
soothes or aggravates the problem?
Confirmation
Ask the patient to summarize the
discussion. Allow open ended
questions, Anything else you want to
bring up?
Make a mistake repair it, this helps to
develop trust. Most patients respect it
What is a patient-centered question? Patient centered care is: “respecting and
Give examples. responding to patients wants and needs so
they can make choices that best fit their
circumstances” ex: how would you like to
be addressed? Are you coping with your
illness? Do you think treatment will help?
(See BOX 1-1 in Seidel for complete list)
What are potential barriers of patient Potential barriers of communication are
and provider communication? moments of tension this includes: patient
curiosity about you, anxiety, silence,
depression, seduction, anger, crying,
financial issues, and avoidance.
What is the structure and the Providers build a history to establish a
components of a patient history? What relationship with the patient, so that you
kind of patient information is obtained in can jointly discover the issues and
each section? problems that need attention and priority.
This approach can be modified with each
individual circumstance.
First, the identifiers, name date, time, age
gender race, occupation and referral
source.
Chief Concern-a brief statement about why
the patient is seeking care. Many
interviewers include duration in the CC
History of present illness-( HPI)-use
OLDCARTS, Onset,Location, Duration,
, 3
Characteristics, Aggravating factors,
Relieving factors, Severity. Include state of
health just prior to present illness.
Past Medical History-(PMH)-General
health, childhood illnesses, adult illnesses
or chronic diseases, Immunizations,
surgeries, serious injuries resulting in
disability, medications, ability to complete
ADLs, allergies and reactions,
transfusions, recent screening tests,
emotional status.
Family History (FM)-Investigate blood
relatives in the immediate family with
features similar to the patient’s. If a
disease “runs in the family”, ask about
everyone from grandparents to cousins.
Ask about heart disease, hypertension,
cancer, TB, stroke, sickle cell, CF, kidney
disease, thyroid disease, blood diseases,
Ascertain whether cancers are multiple,
bilateral, and occurring more than once in
the family, or at a young age.
Personal and Social History (SH)-
birthplace, home environment, cultural and
ethnic background, education, occupation,
marital status,hobbies or interests, sources
of stress, habits of self-care (self breast
exams, etc), habits regarding smoking,
alcohol and drug use, and sexual history.
Five Ps of sexual history-partners,
practices, protection, past history of STIs,
pregnancy prevention.
Review of Systems (ROS)-Identify the
absence or presence of health related
issues in each body system. Beginning
with general, skin hair and nails, head and
neck, eyes, ears, nose, throat and mouth,
lymph nodes, chest and lungs, breasts,
heart and blood vessels, peripheral
vasculature, hematologic, GI, diet,
endocrine, GU, musculoskeletal,
neurologic, psychiatric.
Females-start and character of meneses,
, 4
LMP, last PAP smear, pregnancies
Males-puberty onset, difficulty with
erections, emissions, testicular pain and
libido.
What is the difference between objective Seidel pg 618: objective: “direct
and subjective data? What components observation, what you see, hear, and
of the health history are objective and touch”. This includes vital signs and actual
subjective? assessment. Subjective: “information
patients offer about their condition or
feelings” This includes chief complaint,
past medical history, history or present
illness, family history, and review of
symptoms.
How do you approach sensitive issues Sensitive issues, which may be difficult to
when interviewing a patient? discuss (sex, drugs, and alcohol)
· Provide privacy
· Do not waffle be, direct and firm. Avoid
asking, leading questions
· Do not apologize for asking a question
· Do not preach. Avoid confrontation. You
are not there to pass judgement
· Use language that is understandable to
the patient, yet not patronizing
· Do not push too hard
· Afterward, document carefully, using
that patient’s words (and those of others
with the patient) whenever possible. It is all
right to take notes
Open ended question first to explore
patient feeling about the issue
What does it mean to be culturally Being culturally aware requires the
aware and culturally competent when provider to be sensitive to heritage, sexual
caring for patients with diverse orientation, economic situation, and
backgrounds? background. It requires acquiring
knowledge and developing skills (Seidel,
pg 22)
What are examples of questions to Questions that explore patient’s culture
explore the patient’s culture? should avoid any judgment or stereotype.
Ex: What do YOU call your problem? What
do you think caused it? Who makes
