CHAPTER 1: FOUNDATIONS OF CLINICAL PROFICIENCY Flashcards
What are the 5 essential elements of clinical care
- empathic listening
- ability to interview px of all ages, mood and backgrounds
- proper technique of examination
- examining the level of illness
- process of clinical setting
what are the ways of assessing the patient
comprehensive and focused or problem based assessment
assessment for new patients and provides personalized knowledge about the px and serves as a baseline for future assessments
comprehensive assessment
assessment appropriate for established patients and addresses focused concerns and is restricted to the specific body system
focused assessment
what do you call the data that is subjective and it is what the patient tells you and is a finding of chief complaint and review of systems
symptoms
what do you call the objective data that is what you observe and is a finding of physical examination and laboratory
signs
what are the components of comprehensive health history
identifying data and source of history and reliability chief complaint present illness past history family history personal and social history review of systems
identifying data includes the:
age gender occupation marital status the source of history and the source of referral
reliability varies according to:
patient’s memory, trust and mood
it is the concern of the px causing to seek care
chief complaint
it amplifies the chief complaint and it describes how each symptom is developed
present illness
what are the seven attributes of symptom
location quantity quality timing setting factors (relieved or aggravated) associated manifestation
medications should be noted in HPI with the following data:
name, dose, and route and the frequency of use
what other things you should include in HPI
allergies
tobacco use
alcohol and drug use
in allergies, what you should take note for?
specific reactions like rash or nausea
what you should take note in tobacco use?
the type of tobacco
pack years
if someone quits, take note for how long
what are included in the past history?
childhood illnesses
adult illnesses such as medical, surgical, obstetrics and psychiatric
and health maintenance
it is the outline of the age and health or age and cause of death of each immediate relative
family history
it captures the patients personality and interests. source of support, coping style, strengths and concerns
personal and social history
it is the summary of all symptoms
review of systems
what seven attribute of symptoms that could answer “where is it? does it radiate?”
location
what seven attribute of symptoms that could answer “what is it like?”
quality
what seven attribute of symptoms that could answer “how bad it is or use of pain scale?”
quantity or severity
what seven attribute of symptoms that could answer “when did it start?”
timing
what seven attribute of symptoms that could answer “setting in which the symptoms occurs?”
onset
what seven attribute of symptoms that could answer “is there anything that makes It feel better or worse?”
remitting or exacerbating factor
what seven attribute of symptoms that could answer “have you noticed anything else that accompanies it?”
associated manifestations
