6. • Interviewing is a skill.
• Taking medical history can be a challenge.
client’s issues
• Telescoping: Clients may forget, underreport,
or combine separate health events into a
single memory,.
• Fabricated medical recall that never occurred.
• Mental state at time of injury/illness
Concepts in Communication
7. Compassion & Caring
– Verbally and non verbally
– Body language
– Sit down and maintain Social distance
– Lean forward, nod , encourage
– Take notes maintaining adequate eye contact.
– Silent attentiveness.
8. Communication style
• Individual Differences are there.
• Gender based styles
• Temprament/ personality based styles
• Religon, socioeconomic differences, beliefs
and behaviours of both therapist and client.
• Cultural differences.
9. Health Illiteracy
• The inability to read, understand, and respond to
health information
• Filling out medical History forms.
• Instruction written on medicine bottle.
• Read details of exercise form.
• minimize the use of medical terminology
• Use simple but not demeaning language.
10. Cultural competence
• It be defined as the ability to understand,
honor, and respect the beliefs, lifestyles,
attitudes, and behaviors of others.
• As health care professionals, we must develop
a deeper sense of understanding of how
ethnicity, language, cultural beliefs, and
lifestyles affect the interviewing, screening,
and healing process.
11. Cultural competence
• A 25-year-old African American woman who is also a physical therapist came to a physical
therapy clinic with severe right knee joint pain. She could not recall any traumatic injury
but reported hiking 3 days ago in the Rocky Mountains with her brother. She lives in New
York City and just returned yesterday. A general screening examination revealed the
following information:
• Frequent urination for the last 2 days
• Stomach pain (related to stress of visiting family and traveling)
• Fatigue (attributed to busy clinic schedule and social activities)
• Past medical history: Acute pneumonia, age
• Nonsmoker, social drinker (1-3 drinks/week)
• What Are the Red/yellow Flag Signs/Symptoms?
• How Do You Handle a Case like This?
• Young age
• African American
• With the combination of red flags (change in altitude, increased fatigue, increased
urination, and stomach pain) there could be a possible systemic cause, not just life's
stressors as attributed by the client. The physical therapist treated the symptoms locally
but not aggressively and referred the client immediately to a medical doctor.
Result: The client was subsequently diagnosed with sickle cell anemia. Medical treatment
was instituted along with client education and a rehab program for local control of
symptoms and a preventive strengthening program.
12. Cultural Competency
• Minority Groups
• Hindus
• Christians
• Shias , 12 imam followers or 6 imam followers
• Sunnis :various ethnic groups
• Courtesy is very important in Asian cultures.
Clients may act polite, smiling and nodding, but
not really understand the clinician's questions.
13. Cultural Competency in a Screening Interview
• •Wait until the client has finished speaking
before interrupting or asking questions
• •Allow "wait time" (time gaps) for some
cultures .
• •Be aware that eye contact, body-space
boundaries, even handshaking may differ
from culture to culture
14. Cultural Competency
• In some cultures (e.g., Muslim) information about the
client's diagnosis and condition are relayed to the
head of the household who then makes the decision
to share the news with the client or other family
members .
• sustained direct eye contact may be considered
aggressive behavior in some cultures.
• Watch the client's body language while listening to
him or her speak
• Head nodding and smiling do not necessarily mean
understanding or agreement;
15. Cultural competence
• Keep comments, instructions, and questions
simple and short.
• Avoid using medical terms
Minority Health's Web site
(www.omhrc.gov/clas)." The Council on
American-Islamic Relations" or the Muslim
American Society. "The APTA offers a wide range
of information on cultural competence.
16. The study of patient begins
with history
HISTORY TAKING
17. Qualities of skilled listener
• Can hear the vocal inflection
• Understand Non verbal clues
• Integrate history and physical examination
18. Patient complaining of anxiety and he has on
first glance bulging eyes and tremors of
hyperthyroidism
Examiner would make mental notes to ask for
a history of weight loss or family history of
thyroid disease and on physical examination
would seek confirming signs like rapid pulse
and enlarged thyroid
19. The patient who moves slowly and stifly,
speaks monotonically and softly, and has
minimal facial expression & tells you that he
has swallowing difficulty.
Examiner would need to ask for other
parkinsonian risk factors and physical
findings such as tremors, cogwheel rigidity
and gait abnormalities.
20. I'm beginning to get an idea of the nature of
your problem. Let me ask you some other
questions.
At this point the interviewer may begin to use
closed-ended questions (i.e., questions
requiring the answer to be "yes" or "no") in
order to characterize the symptoms more
clearly.
23. Patient centered interviews
Clinician centered interviews
Combination of both
24. Questioning skills
Relationship building
skills
Non-focusing skills:
◦ Silence
◦ Nonverbal
encouragement
◦ Neutral utterances
Focusing skills:
◦ Echoing
◦ Open ended requests
◦ Summerising/
◦ paraphrasing
Emotion seeking skills
Direct inquiry
Indirect inquiry
◦ Self disclosure
◦ Impact of the problem
◦ Patients’ explanatory
model
Empathy skills(NURS)
◦ Name
◦ Understand
◦ Respect
◦ support
25. Step 1: Setting the stage for the interview(30-
60sec)
◦ Welcome the patient
◦ Use patient’s name
◦ Introduce yourself and identify your specific role
◦ Ensure patient readiness and privacy
◦ Remove barriers to communication.
◦ Ensure comfort and put the patient at ease.
26. “SALAM/ Good morning(?), Mr. ZAHID(?). I am
Dr.ALI, and I will be your doctor today(?). (He
may Shakes patient’s hand; positions chair so
that he is at the same eye level with the
patient(?); closes the door to ensure privacy;
and puts the patient at ease with some small
talk.) “I hope you had no trouble getting here
today(?).”
27. Indicate time available
Indicate interviewer’s needs
Obtain list of all issues the patient wants to
discuss.(chief complaint)
Summerize and finalize the agenda
28. “We have 15 minutes together(?). I will need
about 5 minutes to examine you and go over
some of your vital signs(?). But before I do
that, I’d like to get a list of what you want to
talk about today.…(?)
Is there something else? So you’d like to talk
about your headache and get some refills;
anything else?”….(?)
29. State opening question (ok! Tell me about the
headache)
Listen attentively for clues to the patient’s
personal circumstances…using non focusing
questioning skills( remain silent,nodding,lean
forward)
Obtain additional data from non-verbal
sources (patient’s physical characteristics and
appearance)
30. “Okay, tell me all about the headache.”
(Remains silent while the patient talks; nods
head, leans forward, and intermittently says
“uh huh” to encourage the patient to keep
talking. Listens for at least 30 seconds, or
longer if the patient is giving a coherent,
nonrepetitive story.)
31. Help patient to tell his Bio-psycho-social story(
symptom, emotional & personal story)
Obtain the patient’s description of his
symptoms/problems(good overview of
problem in patient’s own words…avoid CCQ
like onset? Duration? Severity?)
Develop personal(work) and emotional
context(scared) of patient’s story…focus Q
and emotion seeking skills
Expand the patient’s story
32. Continuing from above, the interviewer focuses on a symptom
mentioned by the patient: “You said the headache was really
painful….” This invites the patient to expand on the symptom
description. Then the interviewer picks up a personal issue
mentioned by the patient: “work . . . say more about that….”
The interviewer listens for the first opportunity to naturally ask
for emotion, “How do you feel about that?” When the patient
responds with an emotion (eg, scared), the interviewer NURSes
emotion by (1) naming (“scared”), (2) understanding (“I can see
how that would be scary.”), (3) respecting (“It’s been a hard
time for you.”), and (4) supporting (“Let’s work together to get
to the bottom of it.”).
The interviewer then expands on the patient’s story by focusing
on another symptom or personal issue previously mentioned by
the patient: “You mentioned your son; tell me about him.” The
interviewer continues with cycles of focusing-emotion-
seeking-NURS.
33. Summerize patient centered HPI (review the
list of patient’s symptoms, personal and
emotional story in 2-3 sentences…you have
headache that get worse at work and u r
worried about losing your job)
Check accuracy
Ask patient whether it is ok to ask more
specific questions.
34. “You are having headaches that get worse at
work and you are worried about losing your
job—is that right? Is it okay if I ask you some
more specific questions about the
headaches?”
35. Patient centered interview gives you
psychosocial information
Clinician centered interview helps u to make
diagnosis(e.g. symptom characteristics,
family, social history )
36. The clinician takes charge of the interaction
to acquire specific details not provided
already by the patient , usually to diagnose
disease or to fill in the routine database.
Close ended questions
Open ended questions
37. 7 cardinal features:
1. Onset and chronology
2. Position and radiation
3. Quality
4. Quantification
5. Related symptoms
6. Setting factors
7. Transforming factors
Mneumonic OPQQRST
38. History of presenting illness
Inquire about symptoms in the same body
system(focused review of systems)…absence
of dyspnea in patient with chest pain weighs
against the diagnosis of pulmonary
embolism.
Ask about other relevant symptoms…ask for
GI bleed in RA patient with fatigue.
41. Common medications side effects
• Skin reactions, non-inflammatory joint pain
(antibiotics)
• Muscle weakness/cramping (diuretics)
• Muscle hyperactivity (caffeine and medications with
caffeine)
• Back and/or shoulder pain (NSAIDs;retroperitoneal
bleeding)
• Hip pain from femoral head necrosis (corticosteroids)
• Gait disturbances (Thorazine/tranquilizers)
• Movement disorders (anticholinergics,
antipsychotics, antidepressants)
• Hormonal contraceptives (elevated blood pressure)
42. Risk Factors for NSAID Gastropathy
Back, shoulder, neck, or scapular pain in any client taking NSAIDs in the
presence of the following risk factors for NSAID-induced gastropathy
raises a red flag of suspicion:
• Age (65 years and older)
• History of peptic ulcer disease, GI disease, or rheumatoid arthritis
• Tobacco or alcohol use
• NSAIDs combined with oral corticosteroid use
• NSAIDs combined with SSRIs
• Chronic use of NSAIDs (duration: .3 months or more)
• Higher doses of NSAIDs, including the use of more than one NSAID
(dual or duplicate use)
• Concomitant infection with Helicobacter pylori (under investigation!
• Use of acid suppressants (e.g., HA-receptor antagonists, antacids);
43. Is Your Client at Risk for NSAID-
lnduced Gastropathy?
• A g e in years x 2 =
• History of NSAID symptomse.g., upper abdminal
pain , bloating , nausea,heart burn, loss of
appetit,vomiting + 50 points
• A R A class; add 0, 10, 20 or 30 based on class
• t N S A I D dose (fraction of maximum
recommended) x 15
• If currently using prednisone add 40 points
• TOTAL SCORE: Risk/year = [Total score - 100] / 40
• Range: 0-5
44. American Rheumatism Association
(ARA) Functional Class
• +0 points for class 1 (normal)
• +10 points for ARA class 2 (adequate)
• +20 points for ARA class 3 (limited)
• +30 points for class 4 (unable)
ARA Criteria for Classification of Functional Status in Rheumatoid Arthritis:
• Class 1 Completely able to perform usual ADLs (self-care, vocational,
avocational)
• Class 2 Able to perform usual self-care and vocational activities, but limited
in avocational activities
• Class 3 Able to perform usual self-care activities, but limited in vocational
and avocational activities
• Class 4 Limited in ability to perform usual self-care, vocational, and
avocational activities
45. Case study:
• A 66-year-old woman with a history of rheumatoid
arthritis (class 3) has been referred to physical therapy
after three metacarpal-phalangeal (MCP) joint
replacements. Although her doctor has recommended
maximum dosage of ibuprofen (800 mg tid; 2400 mg), she
is really only taking 1600/day. She says this is all she
needs to control her symptoms. She was taking
prednisone before the surgery, but tapered herself off and
has not resumed its use.
• She has been hospitalized 3 times in the past 6 years for
gastrointestinal (GI) problems related to NSAID use, but
does not have any apparent GI symptoms at this time. Use
the following model to calculate her risk for serious
problems with NSAID use:
47. HISTORY TAKING
• Current smoker?
• Past smoker?
• How many years?
• Cigarettes/ roll-ups / cigars?
• How many per day?
• Who lives at home – partner? Children?
• Stairs at home?
• Need help with housework, shopping, cooking?
• Do you drink alcohol?
• What? Wine? Beer?
• How much?
• Calculate units/week
48. Have you had any fractures or dislocations to
your bones or joints?
• Have you been injured in a road traffic
accident?
• Have you injured your head?
• Have you been in a fight or assault?
49. Couple of questions for each body system e.g:
• Fits, faints, funny turns
• Headaches
• Vision problems
• Shortness of Breath (SOB)
• Cough – blood (red flag)
• Chest pain
• “Heart fluttering” (palpitations)
• Ankle swelling
• Change in bowel habits – blood (red flag)
• Nausea or vomiting
• Weight loss – red flag
• Change in waterworks
• Blood in urine
• Menstrual problems
• Joint or muscle pain
• Skin rashes
• Lumps or bumps
HISTORY TAKING
50. Fill in the HPI
Past medical history
Social history
Family history
Drug history
Review of systems
51.
52.
53.
54. Human aging is best characterized as the
progressive constriction of each organ
system's homeostatic reserve.
"homeostenosis," begins in the third decade
and is gradual, linear, and variable among
individuals.
Acute confusion , Depression, Falling,
Incontinence ,Syncope
55. A past medical history of prostate cancer in a
55-year-old man with sciatica of unknown
cause should raise the suspicions of the
therapist.
56. Guillain-Barre syndrome, Any age; history of
infection/alcoholism
Multiple sclerosis; 15-50
Rotator cuff degeneration 30+
Spinal stenosis, Men > women 60+
Tietze's syndrome, Before 40, including
children
Costochondritis , Women > men 40+
Neurogenic claudication 40-60+
57. AIDS/HIV Men > women; 20-49
Burger's disease; Men > women; 20-40 (smokers)
Abdominal aortic aneurysm (hypertensive); Men >
women ;40-70
Cancer
Breast cancer; Women > men 45-70 (peak
incidence)
Hodgkin's disease; Men > women ;20-40, 50-60
Osteoid osteoma (benign); Men > women; 10-20
Pancreatic carcinoma; Men > women; 50-70
Skin cancer Men = women Rarely before puberty
Gallstones Women > men; 40+
Gout Men > women; 40-59
Gynecologic conditions Women 20-45 (peak
incidence)
58. Male Gender
◦ the presentation of joint pain accompanied by (or a
recent history of) skin lesions in an otherwise healthy,
young adult raises the suspicion of a sexually
transmitted infection (STI).
◦ Osteoporosis
◦ Mortality double after fracture
Female gender
◦ hip fracture is equal to her combined risk of
developing breast, uterine, and ovarian cancer.
◦ Women of age 26-49 more prone to mental illness.
59. When a 55-yearold woman with a significant
family of heart disease comes to the therapist
with shoulder, upper back, or jaw pain, it will be
necessary to take the time and screen for
possible cardiovascular involvement.
For women, gender-linked protection against
coronary artery disease ends with menopause. At
age 45 years, one in nine women develops heart
disease. By age 65 years, this statistic changes to
one in three women
60. Clinical Presentation: A 45-year-old obese english
woman presents with midthoracic pain that
radiates to the interscapular area on the right.
What are risk factors???
If the client had a primary pain pattern with
gastrointestinal symptoms, she would have gone
to see a medical doctor first.
Physical therapists see clients with referred pain
patterns, often before the disease has progressed
enough to be accompanied by visceral signs and
symptoms. They may come to us from a physician
or directly.
61. Watch for specific risk factors. In this case,
look for the five Fs associated with
gallstones:
fat,
fair,
forty (or older),
female, and
fertile .
62. When the disease advances, gastrointestinal
distress may be reported. This is why it is
always important to ask clients if they are
having any symptoms of any kind anywhere
else in the body.
The report of recurrent nausea, flatulence,
and food intolerances points to the
gastrointestinal system and a need for
medical attention.
