Respond to at least two of your colleagues on 2 different days who selected a different patient than you, using one or more of the following approaches:    Share additional interview and communication techniques that could be effective with your colleague’s selected patient.  Suggest additional health-related risks that might be considered.  Validate an idea with your own experience and additional research 

     Case 1: 85-year-old white female living alone with no family in declining health.    Upon meeting this patient, my communication and interview techniques used to build a health history would take a patient-centered approach. I would begin by introducing myself and using Ms/Mrs and their last name. Generally, the elderly has grown up in a different culture with more formality than we are currently accustomed to. This sets the tone for the interview and helps patients to feel empowered by giving respect. The health history of a geriatric patient is different than that of an adult or child. Due to the decline that occurs with the natural aging process, it is likely that there may be some cognitive impairment or sensory impairment. Within the first few minutes of meeting the patient, I can determine if I need to alter my communication methods in terms of volume, active listening, nonverbal signals, and so forth. Some patients require longer periods of pause in order to gather and verbalize their thoughts.    With regard to this patient, I will go through a brief health history by asking if the patient has any difficulties or concerns regarding each system: neurologic, cardiovascular, respiratory, endocrine, genitourinary, gastrointestinal, and of course pain. It is important to give a couple of examples when asking about each system. For example, “Do you have any cardiovascular issues such as high blood pressure or swelling in your legs or feet?” Avoiding words like “hypertension” and “edema” is important because not all elderly patients understand the medical terms. Next, it’s important to ask about medications. I have noted many patients stating they do not have diabetes but when I look at their medication history, they are taking metformin. They often think because it is controlled, it no longer exists. During verbal intake of information, I can always do the physical examination as I go along or complete the physical exam at the end of verbal intake. Every practitioner has their own way of assessment after some experience. I like to learn from those who are more experienced than I, when I see a more efficient and effective way of practice.    Once each of the systems is touched upon, I would focus on the social determinants. In this case, this female patient has declining health and lives alone with no family. I would target my questions around who provides her with support when needed. Does she rely on a neighbor or friend? Is there a paid home health aid that comes in? How many falls has she had in the past year? Furthermore, while performing a health history, it is important to observe if the patient came in using an assistive device or not. This gives insight into her functional status, which can be followed up during this time by asking questions such as “are you able to bathe yourself? Dress yourself? Make meals?” The information provided by the patient, in combination with my observations on gait, balance, and overall appearance, gives further insight into patient needs or potential risks based on age and environmental concerns. This may also be a good time to ask if the patient has any advanced directives, or whether they would like help in creating one. My best approach when asking this is to ask casually, as a formality, in the event the patient wants to keep a record on file.    One risk assessment instrument that is helpful for a patient such as this is the multi-factorial fall assessment tool, also known as MAHC 10, or the fall risk assessment tool (FRAT). The latter is easier to use in a clinical setting due to scoring out of 20, with clear corresponding risks ranging from low to high. It scores off 4 items: recent falls, medications, psychological, and cognitive status. The former is used more in OASIS for Medicare billing. This is ideal for the patient in case 1 because information regarding decline is not given. This tool gives a general idea of the likelihood of falling based on information by the patient.