Order Description
need help with a question to a post.
Case 3
Subjective Data
CC: “Annual physical exam”
History of Present Illness (HPI): 23-year-old Native American male comes in to see you because he has been having anxiety and wants something to help him. He has been smoking “pot” and says he drinks to help him too. He tells you he is afraid that he will not get into Heaven if he continues in this lifestyle.
Drug Hx:
Current medication – denied
Allergies: no allergies to food or medications.
Family history: is very positive for diabetes, hypertension, and alcoholism.
Review of Systems (ROS)
General: no recent weight gains of losses, fatigue, fever or chills.
Head, eyes, ears, nose & throat (HEENT):
Neck:
Respiratory:
CV: no chest discomfort or palpitations
GI:
GU:
Integument: history of eczema – not active
MS/Neuro: no syncopal episodes or dizziness, no change in memory or thinking patterns; no twitches or abnormal movements
Psych:
Objective Data
PE: B/P 158/90; Pulse 88; RR 18; Temp 99.2; Ht 5,7; wt 208; BMI 32.6
General: 23 year old male appears well developed and well nourished. He is anxious – pacing in the room and fidgeting, but in no acute distress.
HEENT: Atraumatic, normocephalic, PERRLA, EOMI, sclera with mild icterus, nares patent, ornasopharynx clear, poor dentition – multiple carries.
Lungs: CTA AP&L
Cor: S1S2, +II/VI holosystolic murmur; without rub or gallop
Abd: benign, normoactive bowel sounds x 4; Hepatomegaly 2cm below the costal margin.
Ext: no cyanosis, clubbing or edema
Integument: intact without lesions masses or rashes.
Neuro: No obvious deficits and CN grossly intact II-XII

(MY POST)
My choice was case three, a patient seeking help for anxiety.

The twenty-three-year-old has social problems he is a smoker and an alcoholic. His BMI is higher than the standard but looks energetic. Spiritually he is afraid his ways are not straight. He does not show other vulnerability to diseases apart from hypertension and diabetes. He has no acute distress but just pacing and fidgeting in the room.

Interviewing a patient for health history differ from the social conversation in that it aims at improving the well-being of the patient, establish a trusting and supportive relationship, and to gather and offer information. The choice of words, tone, and the well-designed question that give the patient confidence in the security of the information they disclose helping them open up and talk out their problem. An excellent approach to the patient is important in establishing a rapport.

The questions administered should be able to invite the patients’ history, expand and clarify the patients’ story, create a shared understanding of the patients concern, and finally negotiating a plan. Five questions to help build the patient’s history (Burnett, Lee, Rushmer, Ellis, Noble, & Davey, 2010; Swartz, 2014)

1. Many diseases that affect us are passed along the family line, are there common diseases along your family line you have tested positive?

2. You look strong and healthy, have you experienced weight loss, gain, fatigue, fever, or chills in the recent past? Since your last physical examination.

3. In the past, has anxiety caused you any chest discomfort like pains or palpitations?

1.Is there a time when you get syncopal episodes or dizziness, or you have your memory experiencing no change in the state of thinking patterns or abnormal movements?
2.Would you mind if I take your blood pressure, pulse rate, temperature, height, and weight

Maintaining a constant conversation during the examination ensuring effective communication and relational skills. The interviewer needs to be aware of what they are probing for to make the process not deviate too much from the main topic. The patient needs enough time to exhaust their answers as they explain their situation. Maintaining a clear facial expression, reacting to patients behavioral cues and feelings require a delicate sensitivity than just asking a series of questions.

Patient communication has several challenges including the sex of the physician, specialty, and the patient mix (Ghosh, 2004). Patient empowerment, mistrust of medication and medical practice, non-adherence to doctor’s prescriptions and ineffective communication were among the issues raised by (Bezreh, 2012). Physicians have to devise ways to counter these problems and enhance the relationship with their patients.
References

Bezreh, T., Laws, M. B., Taubin, T., Rifkin, D. E., & Wilson, I. B. (2012). Challenges to physician–patient communication about medication use: a window into the skeptical patient’s world. Patient preference and adherence, 6, 11.

Burnett, E., Lee, K., Rushmer, R., Ellis, M., Noble, M., & Davey, P. (2010). Healthcare-associated infection and the patient experience: a qualitative study using patient interviews. Journal of Hospital Infection, 74(1), 42-47.

Ghosh, A. K. (2004). Doctor–patient communication: emerging challenges. Family practice, 21(1), 114-115.

Swartz, M. H. (2014). Textbook of physical diagnosis: history and examination. Elsevier Health Sciences.