jovana template questainnaire/csa - jovana

[ArchivalUser]

Here is one example how we can combine the open -ended questions, teh facilatation, the closed -ended and e.t.c


What brougth you in to see me today ,Ms Jovana
Well I have acouph ..


TELL ME MORE ABOUT THE COUPH THAT YOU 'VE BEEN HAVING

iT IS WORSE AT NIGTH..i CAN'T SLEEP

WHAT HAPPENS ?
I ma up on atree pillow..I am miserable that is all .
HOW IS IT MISERABLE ?
Well I lay flat an di can't bretahe, and then I start gasping and gasping for breth and the only way I can stop is when I sit up an dwatch TV pr something...


WHEN DID THIS ALL START (Wh question )
Well, just sins=ce the weather has been hot, like it is you know...

SEVERAL WEEKS IT'S BEEN GOING ON, WOULD YOU SAY (clarification )

Uh huh,just -now the chest pain is not continous like, during the dya..

AND WHERE DO YOU FEEL IT ??Wh question)

It is in here.and just like a fulnes here .

ANMD THEN HOW LONG DOES IT LAST WHEN IT COMES (Wh question )
Not to long ...

MINUTES, HOURS (clarification, laundery list )

Not hours, justmaybe a half hour...

DO YOU DO ANYTHING THAT SEEMS TO REALIVE IT ?(Wh question )

No I don't take naything , just sit and qut or eother I'll rest.

Ok.. oe and then ?(minimal facilitator )
and rest seems to help..

DOES IT SOMETIMES COME ON WHILE YOU ARE DOING SOMETHING (closed -ended question )
Yes, mostly..ye sif I am trying to clena or sweep or something like that.


HOW ABOUT WITH WALKING ?(clarification, closed ended question )

Sometime with walking , too ..yes

AND THEN HOW LONG DOES IT TAKE TO GO AWAY ONCE YOU SIT ?(Wh question )

I will say half to an hour ..

AN DIT WILL TAKE AHALF OR ONE HOUR TO GO AWAY ?????????????(CLARIFICATION )

Uh huh..

OR DO YOU SIT FOR THAT LONG ENOUPH TROUGTH IT'S GONE BEFORE THAT ?(clarification )

UH HUH
AND IT TAKES A HALF TO ONE HOUR FOR YOU TO EASE UP ?
uh huh...

[ArchivalUser]

Good way to start a PAST MEDICAL HISTORY

"How has your health neen in the past '?
"Tell me about how your health has been in the past '?
"Tell me about any serious illnesses you have had in the past ?
"Now I would lik eto ask you about any ilnesses or medical problems in the past.How has your health been ?
"Hav eyou had :
any serious ilnesses, begining in the childhood
any hospitalizations
any surgical procedures
any accidnets or injuries
any allergies
current mediactions
any oby -gyn (for woman )


Good ways to begin the routine family history
"Now I would like to now little bit about your family "
"Are there any ilness that seems to run in your family ?'
"Has anyone in your family been seriously ill " ?
"How about your parents ?Children ?"
"has anyine in your family had heart attacks "
"Do you hav eany concerns about problems that you think run in the family "?



The style of questions in the ROS

"I would like next to ask some general questions about your health to make sure I haven't miss anything.I 'd like you to think especially about things that may have bothered you recentelly, OKey ?
"Hav eyou had any headache or problems with your head and neck "?
"How about with your vision an dyour eyes ?"
"What about your ears, nos eor troats ?
"Any allergy or hay fever symptoms ?"
"aNY PROBLEMS WITH YOUR SKIN?
lUMPS OR BUMPS OR MOLES THAT CONCERN YOU "
An dso on.....

[ArchivalUser]

MAKING THE TRANSITION TO THE PHYSICAL EXAMENATION

First give the pt an opportunity for the LAST WORD.For example "Is there anything else we haven't covered or that you'd like to tell me before I examinae you "????????
Second:
Tell the pt what the game plan is.For example "Ok, next I am going to do physical examenation and then afther that, w ecan sit down and talk about possible diagnoses and what test you migth need ".

Third , be very specific aboiut what clothing the pt should "remove " where to sit or lie, an din what position.


Fo rexample "May I untie your gown, may I pull the gown down , up, may you hold your legs up, hold your knee up, could you turn to the left side, could you step over here, could you walk, could you turn around this way..."

[ArchivalUser]

thanks j........... u r doing a great job ..may god bless u dear.......

[ArchivalUser]

hi jovana, nice, a few thoughts...

SIQOR AAA is a fine way to remember the "W" questions especially for pain.

For other complaints i think one must develop our own protocol of questions to be asked, simple questions (so as not to confuse the SPs and not to get confused especially IMG whose mother tounge is not english)...key is to prepare the right questions.

DD list must be prepared beforehand for major symptons so as to be in a position to ask questions to rule out them, a few important ones

a good way would be to spend time at the hallway and write make a note of possible DD based on teh pt info before entering the room

always SMILE,...show concern or empathy if pt is in pain (dont keep smiling then...!!!)

[ArchivalUser]

ENDING THE INTERVIEW
When you hav ecomplited the PE , you reconvene the interview to terminate it.
Overall , the pt should expect and our SP will EXPECT to feel undrstood and not be "abused " in any way.
In history taking , this means that you have gotten the STORY STRAIGTH an dSHOW APPROPRIATE CONCERN for his or her COMFORT, PRIVACY and MODESTY.
The techique of being empatetic, respectfull and genuine apply to this part of the encounter as they do to all the pther parts.
It is always good idea to GIVE the PT the opportunity to have THE LAST WORD.
"Anything else to tell me " ?
"Is there anything else you'd like to tell me or ask me " ?????

When you close the encounter YOU SHOULD :

Provid e asummary of what the pt has told you
Be sure to let the pt have the last word or ask any additional questions
Give a pleasant thank and goodbye


When you hav e aresponsibility for a patient care you rclosure is like a having a CONTRACT between you an dyour patient; it acknowledge responsibility for solving problems an dproviding care.
So you have to tell the PT couple of Differential Diagnoses an dhypothesis " Keeping in mind what you hav ejust tole me , as well as teh PE I have afew possibilitie sin my mind , such as ...1.2.3....

So you devis e aproblem list with priorities

Don't firget to COUNSEL on ALCOHOL, DRUGS, TOBACCO, SAFE SEXUAL PRACTICES, DOMESTIV VIOLENCE, Diet modification classes, behavior modification classes, HABITS, excerzise plan/classes na de.t.c.

Mak esure you OFFER THE EDUCATIONAL CLASSES , AS WELL AS YOU "NEGOTIATE " WITH THE PT FOR HIS WILLIGNESS TO TRY ALL OF THOS ECOUNSELLING SESSION.lET THEM KNOW THAT THEY ARE AVAILABLE TO THEM.

Agre on a plan of action and clarify reponsibilities "Iam mor ethen glad to refill your medicine, but before I od that I have to be true with my blood work, as well some other procedures, imaging studies and aftherwards I will be glad to sit down with you an dgo over the details.How that sound for you """

You are polite, but you are setting the bounderis,...
Or "Ms.Jovana your coperation will be really appreciete it beacsue in order for me to help you with your problem , I need to get some fedback from you..It is very important for your health to know about this.So tell me what is it "

Setting the bounderies and clarifying the responsibilities becasue MEDICAL CARE IS PARTNERSHIP!!!!!!!!!!!!!111

Again SUMMARY of ROS, PE and CLOSURE

The objective sof ROS ARE TO :
Identify activ eproblems not yet disscused
associeted additioinal symptoms with current ilnesses

The ROS may occur late in the interview or afther the HPI or during the PE ..

For our CSA w emak esure you do it whenever we remember it or it is better afther the HPI so we ARE DONE WITH IT...
Afther the PE , YOU CLOS ETHE ENCOUNTER BY :
SUMMARIZING WHAT YOU HAV EHEARD AN DWHAT YOU FOUND (negative or positive )
Devising a problem list an dnegotiating/COUNSELING priorities
Outline aplan of action an dresponsibilities
Continue to "educate" -COUNSEL the Pt
GIVING THE PT LAST WORD !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
Warm thank an dgoodbye.....
And VOILA!!!!!!

"Base don what you have just tole me and teh PE Inee dto run some blood test, some imiging studies, as well as inform you about ythe next folow up appointment

[ArchivalUser]

Yes Dinace you are EXACTELLY RIGTH, BUT I went from A, B..C..D..so the IMG will get the feel that this EXAM IS ABOUT COMMUNICATION AND INTERPERSONAL REACTION with SP....

yes we have to ask as simple as we can

And my self I will do the following :


Good Morning Mr.Cook.Let me introduce my self.I am Dr.Jovana, teh doctor of this facility.
Is anything bothering you in this room ?
Let me mak eyou mor ecomfortable..LET ME COVER YOU ?

WHAT BROUGTH YOU TO SEE ME IN TODAY?
I need to take some note while talking to you.Would you mind ?
So tell me more about ypur problem ?

Chest pain, adbominal pain, shoulder pain, knee pain, low back pain.any pain

I will start with
WHEN it start it ?
Does it come and go ?
How frequent ?
How long it last ?
From 1 to 10 HOW would you grade your pain ?
WHERE IS IT , with one finger could you point ??????
Does anything alliviete your pain
or What mak eyour pain better or worse
Any other symptoms that you NOTICE ?????//
Any fveer, chils, SOB, any vomiting, any headache, any sweating, any diziness, any weaknes in your arms , leg, any pinprick sensations in your arm or legs ,any change s in your BM , in your urinary habits..
So SIQORAAA or Ws Questions who ever feel mor ecomfortable with....

All rigth Mr.Cook ..Now WOULD LIKE TO ASK YOU ABOUT YOUR HELATH IN GENERAL.IS THAT OK WITH YOU ?
Have you ever ha dany previous episodes like that ?
Hav eyou ever been hospitalize ?
Any accidnets ?
Any injuries
Any allergie that you know of ?
Are you on any prescribrtion medications or drugs ?
How about any OTC or vitamins or herbal supplemenst?

Thank youMr.Cook Let's talk about your family health.
Is there any family h./o of similar problems, heart attacks, high blood pressure , high cholestreol ?
Are your parents helathy and alive ?
....
Thank you Mr.Cook, Now I would like to ask you a few questions about your Sexual history which will be kept confidential as teh rest of the history.Are you sexualy actiive ?
Who is your partener?
Are you using any condoms ? (if he is going to say that his partenr is his wife for 30-40 years I am not going to ask about the condoms )
High risk ye scondom busniss and Hav eyou ever been tetd for STD's or HIV ?

Thank you, Now I would lik eto ask you few questions about your life style in general.I sthat OK with you ?
Have you ever smoke tobaco or any other related tobaco product ?
Hav eyou ever drink alcohol ?
Yes
How ofthen?
On teh weekends
How much
I glas of vine..
Now I mov eon
Have you ever use any illicit drugs ?


Thank you Mr.Cook.No wI would like to do a physical exam.Before I do that Let me wash my hands.Exus eme ..
While washing with fcae turn to the pt I ask "
Mr.Cook what do you do for a living ?
Is anything els eyou want to tell me ?
Do you have any questions ?


No wlet me start with the physical.May I untie your gown?
Let me listen to your heart?
Ok..let me lsiten to your lungs...
Allrigth Mr.Cook ..could you turn on the left side., please...
May I pull up your gown up...Ok..Yes..Let me listen to your heart over here..
Let me listen to your belly., now .
Could you hold your knee up ?
All rigth , thank you...

Let me feel your neck veins for any brruit..let m e feel your pulses..here ..here and over here...
Ok, let me tie your gown bak.Thank you..

Allrigth Mr.Cook I done with my physical exam and now Let summarize what you have just told me ,OK
You just told me that you are havind sudden sharp chest pain in the last tree days that last for about 30 min na dcomes and goes..it is 6/10 on intensity and it is alliviete it with nitro, but worsen with movment.Also you notice some SOB, nausea, vomiting na dchils along with the chest pain.Is that correct ?

Yes..
Keeping in mind what you hav ejust told me , as well as the PE which at this point dosent show any murmurs and taking to consideration your vitals that are WNL except the HR is about 12o, almost as twice as normal, I ma having couple of possibilitie sin my mind SUCH as an acute MI, unstable angine, as well as some infection of your heart.having said that I nee dto run some blood work, as well as order na EKG that access the function of the cardiac musle an dits pumping ability.

Now if he smokes I will say..
Mr.Cook also I would like to empohasize the importance of knowing the negative efefct on cigaretes on your health in general.It is proven that people who smoke are increase risj for herat infarct, high chilsterol, high blood pressure, high blood sugar levels.Are you aware of that ?
Not really..
I would lik eto tell you that w edo have an excellant eduaction program here on smoking cesation, as wlel as an excellant team of experts, counselers who deals with this an dsimilar issue.
I do undrstund that must be diffucult for you,BUT did you ever trie dto quit ?
No

Would you like to try now ?
Yes.
Mr.Cook I really appreciete your desire to quit smoking an dyou are in the rigth place and in the rigth time.
Would you like me to set up in appoiintment for you or would you like m eto give you teh phone number..
Ye syou can set up in appointment.

IS ANYTHING ELSE I CAN DO FOR YOU TODAY ??
NO thanks
You are welcome , nice talking to you and have a nice dayMr.Cook..

So this is how I will approaches any pt an dwe can just swich the questions depend on the chief complain, but even with the Ws I can try to be quick and figure out what to ask...

The most important I introduce my sle..I explain my role..I ask open -ended questions, I drape, I aks fro permission to take notes, to do a physical..I wash my hands..I ask for any questions or anything els ethat may I forgot to ask or he forgot to tell me by just asking simple question "Is anything els eyou want to tell me "

I did a FOCUS exam..I respect the modesty and I ask for permission to pul up , pul down the gown, I instruct it what position teh pt need to go and I didi my manuvers in anorgansie fashion means when he is laying on teh left sid eI check the mitral , but I ask to listen to the stomack, so NOT to many manuvars..and I tie the gown back
Then I summarize and I give some differential work up with some test orders and I try to us elayman launguage ,BUT fro the doagnosis we are allowed to us emedical diagnosis term..I explain what EKG is and I counsel the pt in a non-judmental manner and i CLOSE DTHE ENCOUNETR PRIPERLY WITH LEAVING TEH LAST WORD FOR THE PT.
IS ANYTHING ELS EI CAN DO FOR YOU TODAY ?
NO...

So THIS IS IT ..MAK EYOUR ROUTINE beacsue what works for me , maybe doesebt work for you,BUT the key is doesent matterbythe which routine is better as LONG a swe stay in teh CSA STANDARS and as well as teh OUTCOME is teh SAME =PASS !!!!!!!!!!!!!!!
Any comments welcome..
Your Jovana

[ArchivalUser]

Now let's put D/D an dWORK UP for all possible cases

CHEST PAIN
Differentials of CHEST PAIN with out knowing the details

1.MI/anterior/posterior /inferior
2.Angina/stable/unstable/prinzem..
3.Pulmonary Embolus
4.Pericarditis
5. Spontenous Pneumothorax
6.Pleural Effusion
7.Pneumonia
8.Infective Ednocarditis
9.Costochondritis
10.Aortic Aneurysm


Diagnostic Workup :

1.X -ray ,EKG
2.Cardiac Enzymes, CK-MB,Troponin
3.CBC with differentials,ESR, Sputum Gram Stain, C/S
4.Echocardiogram/TEE
5.V/Q Scan/Angiogram
6.Carotid Dopller
7.Lipid Panel
8.Basic Metabolic Panel

[ArchivalUser]

Now ABDOMINAL PAIN

First of all if we go back to the anatomy in
MID EPIGASTRUIM =stomack, duodenum, hepathobilliary sytem, pancreas

MID ABDOMEN = Jejunum, ileum

LOWER ABDOMEN =Colon, internal reproductive organs


Now based on the type of character of the pain /location we can hav e adifferentials for acute abdomen

ABRUPT, EXCRUCIATING PAIN in :
1.Biliary Colic=RUQ
2.Uretral Colic=RLQ+lumbar region
3.Perforated Ulcer=Epigastrium
4.MI =Subepigastric


RAPID ONSET OF SEVERE, CONSTANT PAIN
1.Acute PAncreatitis=Epigastrium
2.Mesenteric Trombosis, strangulated Bowel =Umbilical Area
3.Ectopic Pregnancy =LLQ +RLQ


gradual. steady pain
1.Acute Cholecystitis =RUQ
2.Acute Cholagitis =RUG
3.Acute Hepatitis -RUQ
4.Appendicitis =RLQ
5.Acute Salpingitis =RLQ


INTERMITTENT , COLICY PAIN, CRESCENDO FREE INTERVALS
1.Early Pancreatitis (RARE ) =SUBEPIGASTRIC AREA
2.Small Bowel Obstruction =umbilical/periumbilical region
3.Inlammatory Bowel disease =Lower abdomen +subrapubic region

[ArchivalUser]

ABRUPT, EXCRUCIATING PAIN in :
1.Biliary Colic=RUQ
2.Uretral Colic=RLQ+lumbar region
3.Perforated Ulcer=Epigastrium
4.MI =Subepigastric


Diagnostic Workup
1.CBC with differentials, ESR
2. KUB/Ultrasound/HIDA Scan
3.Endoscopy
4.Lipid Panel,Serum Amylase
5.Basic Metabolic Panel