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Patient Interview

Patient Interview. Chief complaint- subjective statement regarding most significant symptoms or signs of illness Description of general health Description of lifestyle Changes in status since last visit All info is considered confidential!!. Components.

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Patient Interview

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  1. Patient Interview

  2. Chief complaint- subjective statement regarding most significant symptoms or signs of illness • Description of general health • Description of lifestyle • Changes in status since last visit • All info is considered confidential!! Components

  3. The interview will become part of a legal document- follow the 6 c’s • Client’s words in quotation mark’s • Clarity • Completeness • Concise • Chronological • Confidentiality 6 C’s

  4. Private area without interruptions • Develop plan before interview, look up pt. hx, chronic problems, meds etc… • Use broad knowledge base- look up diseases, drugs tests, etc.. That you don’t know Tips for successful interview

  5. Open-ended • Hypothetical questions • Mirroring response • Focusing on pt. • Encouraging pt. to take lead • Encouraging pt. to evaluate his/her situation Effective questioning

  6. Closed-ended questions • Leading questions • Challenging • Probing • Agreeing or disagreeing Ineffective questioning

  7. Methods include: inspection, palpation, percussion, auscultation, mensuration, manipulation Examination of pt.

  8. Neurological: LOC- level of consciousness and orientation to person, place and time. Motor ability- ambulation. Senses, speech, hearing, vision • Cardiovascular/pulmonary: characteristics of peripheral(arm/leg) pulses. Characteristics of respirations: shallow, deep, regular, dyspnea, SOB. Breath sounds- crackles/rhonchi, rales, wheezes, diminished, labored. Cough- productive or nonproductive Components of general physical exam

  9. Integumentary: wounds, scars, ecchymosis, contracture, rash, lacerations, decubitus ulcers. Color, temp., surgical incisions, stitches, staples • Musculoskeletal: contractures, amputation, deformity, atrophy, ROM, ambulation, fractures, dislocations • Gastrointestinal: Abdomen, bowel sounds, nutrition, NG tubes, special diets, I & O Exam cont.

  10. GYN/Reproductive: Date of LMP, breast self-exam, testicular exam, problems • Elimination: Stool- constipation, diarrhea, date of last bowel movement. Urine- voiding, incontinent, dysuria, nocturia, foley catheter, external catheter Exam cont.

  11. Psychosocial: affect, mood, anxious, angry, conversant, defensive, non-cooperative, combative. Living environment: alone, with spouse, nursing home, etc. Vocation/avocation: jobs, hobbies, interests Exam cont.

  12. Symptoms: Objective and subjective • Diagnostic tests and their results • Plan of action: meds, therapies, surgeries, diet, activity level • Documentation of result of tx • Modification of plan • Pt. education Components of tx plan

  13. S- subjective symptoms (pt. says) • O- objective sx (can be seen or measured) • A-assessment, dx • P- plan (tx plan) • I- Implementation (putting plan in action) • E- evaluation (results of plan) • R-revision (change plan based on evaluation) SOAPIER

  14. Diabetes: inability of pancreas to produce enough insulin resulting in lack of sugar available for cell metabolism. • Symptoms: polyuria, polydipsia, polyphagia, sudden weight loss • Diagnostic tests: Fasting blood sugar, glucose tolerance test Sample treatment plan

  15. Plan of action: insulin SQ, ADA diet, moderate exercise • Pt. education: use of glucometer, insulin injections, symptoms and treatment of insulin shock, care of infections, care of feet (prone to develop foot ulcers that can result in amputation) Treatment plan cont.

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