Complete H&P

Question 1

Complete H& P components

Answer 1

1. Hx
2. ROS
3. PE
4. Documentation (SOAP)

Question 2

In a complete H&P, waht extra things should you ask in a history?

Answer 2

1. Preventative health
2. Hospitailizations
3. Reproductive/sexual
4. Blood transfusions
5. Accidents
6. Childhood diseases
7. Cardiac risks
8. Advanced directives

Question 3

In a women, what should you always do a PE on in a complete H&P?

Answer 3

Breasts

Question 4

Cardinal techniques

Answer 4

Inspect

palpate

percuss

auscultate

Question 5

What is the purpose for a cmoplete H&P?

Answer 5

1. Interval Assessment (q3years)
2. Pre-Op
3. Consult
4. Age-related topics
5. Patient Expectations
6. Establish Care

Question 6

appropriate components of h&p

Answer 6

Interview

exam

disposition: findings and plan

Question 7

in making accurate diagnosis, what is the process you should follow?

Answer 7

fusion of analytical and non-analytical

1. Pattern recognition
2. Illness script
3. Apply science

Question 8

How do you make a accurate dianogsis?

Answer 8

• 1. ID ABNL findings
• 2. Localize findings anatomically
• 3. Cluster the findings
• 4. Look for cause
• 5. make a hypothesis about presentation
• 6. cluster clinical data
• 7. test hypothesis and establish a working diagnosis

Question 9

when making a dianogsis, what is one rule of thumb?

Answer 9

Include “WORST CASE SCENARIO” in DDx and make sure you rule it out based in findings and assessment of patient

Question 10

how do you document findings in complete h&p?

Answer 10

document as you go

clinica reasoning starts at the FIRST of the encounter

develop meaning and impact of findings

Diagnosis should be supported by fingings

conside and succent

Question 11

where do we indicate our impression and describe our reasoning?

Answer 11

Assessment = make a dx, do NOT list signs or symptoms