NR509 Shadow Health History Assignment Week 1 Paper

NR509 Shadow Health History Assignment Week 1 Paper

Pre-brief

Obtaining an accurate history is the critical first step in determining the etiology of a patient’s problem. A large percentage of the time, you will actually be able to make a diagnosis based on the history alone. The value of the history, of course, will depend on your ability to elicit relevant information. Your sense of what constitutes important data will grow exponentially as you practice your interviewing skills and through increased exposure to patients and illness. However, you are already in possession of the tools that will enable you to obtain a good history. Specifically, you must listen and ask appropriate questions to define the nature of a particular problem. In fact, seasoned clinicians occasionally lose sight of this important point, placing more reliance on the use of diagnostic testing rather than taking the time to listen to their patients. Interviewing patients is an art and should remain an essential skill for successful practice.

In this activity, you will interview Tina Jones to collect data to assess Ms. Jones’ condition. You will also have the opportunity to educate and empathize with Tina to engage in effective therapeutic communication; create a problem listusing evidence from the data you collected; prioritize the identified problems to differentiate immediate from non-immediate care; plan how to best address the most important concern with further assessment, interventions, and patient education; and compare your documentation to model documentation.

Ms. Jones is a pleasant, 28-year-old obese African American single woman who presents to establish care and with a recent right foot injury. She is the primary source of the history. Ms. Jones offers information freely and without contradiction. Her speech is clear and coherent and she maintains eye contact throughout the interview.

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Determining the etiology of a patient’s problem

Introduction

In order to provide good care, it’s important to understand your patient’s health problems and how they relate to each other. This article will describe some basic methods used by medical students to gather information about patients and determine the etiology of their problems.

Medical students should demonstrate to their patients that they are listening and are interested in their health problems.

• Listen carefully to what the patient is saying.

• Show that you are listening by acknowledging what the patient is saying, such as “Yes, I understand,” or “Yes, I hear you.”

• Ask questions to clarify what the patient is saying. For example: “What happened when?” or “How did this happen?”

• Use open-ended questions to get more information about their health problems or concerns (e.g., “Tell me about your symptoms”).

Organize your approach by grouping related symptoms together.

Once you’ve determined the etiology of a patient’s problem, organize your approach by grouping related symptoms together.

In general, this means starting with the most common symptom and working backwards through the list until you find something that fits. For example, if a patient comes in with abdominal pain and diarrhea, he may have irritable bowel syndrome (IBS) or constipation-predominant IBS (C-PIB). If he also has fatigue and weakness in his legs after standing for long periods of time but no other symptoms or signs of illness (such as fever), then these symptoms could point towards iron deficiency anemia—a condition that would require treatment with iron supplements before moving onto gastrointestinal issues like Crohn’s disease or ulcerative colitis

Obtain a relevant review of systems (ROS).

• List all the systems you need to cover, including:

• heart and lungs (including heart rate and rhythm)

• circulatory system (including blood pressure)

• nervous system (including sensation and movement)

• Begin with a review of systems. List the questions you will ask your patient about each body system, including:

• “What is happening?” or “How are things going?” The answers should be specific enough that someone who doesn’t know what’s wrong can understand them clearly. If there is something missing from an answer—or if someone gives one that seems nonsensical—ask for clarification by asking open-ended questions such as “What did it feel like when…?” or “I don’t understand how…and why not?”

Obtain past medical, surgical, family, and social histories.

Before you begin to treat the patient, it is important that you obtain past medical, surgical, family and social histories. These data will help determine if there are any other contributing factors to their problem that need to be considered when treating them. A good relationship between the physician and patient is essential in order for both parties to be able to provide quality care for each other.

Obtain a medication history and a substance use history.

To determine the cause of a patient’s problem, it is important to evaluate medications. Medications can cause symptoms and side effects, interact with other drugs or substances and be a source of allergies. Additionally, they may be addictive or habit forming.

Review development, milestones, and immunizations as indicated.

The doctor will review the patient’s developmental history and milestones, as well as their immunizations. This information can help determine whether there is a defect causing this problem.

A good patient-physician relationship is important to making sure patients have access to good healthcare.

The patient-physician relationship is an important component of good healthcare. Patients are more likely to follow recommendations, return for follow-up visits and provide accurate information if they feel that their doctors have a good rapport with them.

Conclusion

As medical students, we need to be aware of the role we play in the healthcare-seeking process and how our actions can influence it. We should be able to identify when a patient is asking you questions because they want answers or because they don’t have any. And if you find yourself asking them questions after they leave your office, ask yourself: Did I provide good care today? Did I embody what it means to be a doctor?