Case History flashcards |

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Case History

a description of a patient's audiological, medical, developmental (etc.) history.

Why is case history important?

-Tells us why the patient has come in to see us
-Guides us in our testing
-Helps us come up with an overall diagnosis

• Symptoms tells us more then results from tests
• You need to make sure you answer the one question the patient comes in asking

Purpose of getting a case history

•Information-Getting or information counseling
•Obtain a statement of the problem
•Formulate a hypothesis
•Cross-check results
•Aid in making referrals

Quality Issues of Interviewing

•Be a Good Interviewers
•Facilitating Good Communication
•Understand their motivation
•Listening Skills

How to be a good interviewer

-Talk through probs, LISTEN!!
-Review intake info before appointment, so we can dev. a hypothesis and think of what kind of questions to ask.
-ASK about things that are NOT present on the intake forms!!

How to facilitating good communication

-Develop rapport
-Sensitivity
-Respect
-Be empathetic
-Be objective

Listening skills

-Concentration →Pay attention to what's going on when pt. and sup. are talking!!
-Active Participation → say things back that indicates you are listening
-Comprehension →Know what's going on
-Objectivity → be objective

Long forms

-intake form or an interview form
•ADVANTAGES: meds in front of them, have access to info
•DISADVANTAGES: If not filled out, it takes a long time to fill out, sometimes it can trigger guilt asking in person so they may tell you more in person

Short forms

-narrows list down; most people using these after they become comfortable with case history
•ADVANTAGES: allows for specific question, narrows down long form, short, we can write down what we want specifically
•DISADVANTAGES: not as many questions might not be specific enough, leaves things out.

Informal Observations

-Look at their general affect
-Age/Sex
-Physical appearance
-Use of hearing aids
-Comprehension

Formal Questions

-Statement of the problem → What is the prob? What brings you in?
-Onset of the problem → When did you 1st notice and how long ago?
-Prior testing/Remediation → What did you get done? What did they do for you?
-Serious Illness/Trauma → hospitalization? Can cause neural probs; ever use anesthesia? (can cause temporary loss)
-Dizziness/Tinnitus → can be vestibular prob; ringing from loud noises?
-Noise exposure → can cause tinnitus and hearing loss; how much?
-Family history → Other adults in fam. have loss? Other children?

Adult questions

• Audiological history (Diagnosed HL?, history of HAs, asymmetry, gradual or sudden, tinnitus)
• Family history
• History of ear infections or ear surgeries (we call this otologic
health)
• Dizziness
• Speech and Language status ( this includes problems with memory, anomia, or cognitive problems)

Pediatric questions

•Difficulties at birth (ICU? Ear infections?)
•Speech-Lang. Development
•Developmental Milestones
•School Performance
•Red Flags for high risk

Red Flags for high risk

A - Anoxia: lack of oxygen at birth (look at Apgar score: # given to describe child's functions at birth)
B - Bacterial (or viral) Meningitis
C - Congenital Infections (infection your born with)
D - Defects of Head & Neck (cleft? Other physical dev. probs)
E - Elevated Bilirubin: jaundice (yellow skin)
F - Family history
G - Gram birth weight (<1500 grams or 3lbs.)

Congenital Infections

S.T.O.R.C.H. (Syphilis, Toxoplasmosis, Other, Rubella, Cytomegalovirus, Herpes)

Differences b/w a SIGN & SYMPTOM VS. an AUD.
DIAGNOSIS CODE

-Sign & Symptom: something that you can include in your report that suggests a relationship to why the person is having hearing or balance problems (e.g., otitis media). As an audiologist you are not technically allowed to diagnose anything no audiological but you can list is as a sign and symptom you

-Audiological Diagnosis Code: is the code you designate based on the test results you perform

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