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PDR II > Comprehensive Adult Hx Taking > Flashcards

Comprehensive Adult Hx Taking Flashcards

1
Q
  • These are for px you are seeing for the first time
  • All elements of health hx
  • Complete physical hx
A

Comprehensive px assessment

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2
Q

What is used for follow up pxs?

A

Focused/problem oriented assessment

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3
Q

What is used for specific “urgent care” concerns?

A

Focused/problem oriented assessment

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4
Q

You’ll adjust the scope of your hx and PE to the situation at hand, keeping several factors mind s/a:

A
  • magnitude and severity of px probs
  • the need for thoroughness
  • the clinical setting - in or outpx
  • primary or subspecialty care
  • time available
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5
Q

What assessment?

  • fundamental and personalized knowledge abt the px
  • strengthens clinician px rel
  • ID or rule out physical causes rel to px concerns
  • provides baseline for future assessment
  • platform for health promotion through education and counselling
  • develops proficiency in the essential skills of PE
A

Comprehensive px assessment

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6
Q
  • est px esp during routine or urgent visits
  • sp body sys
  • applies examination mtds relevant to assessing the concerns and probs
A

Focused/problem oriented assessment

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7
Q

Screening tests

A

Routine clinical check up/periodic health exam

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8
Q
  • rational clinical examination to improve diagnostic decision; making more selective assessments and plans of care
  • Symptoms are subjective concerns, or what the patient tells you.
A

PE FINDINGS AS DIAGNOSTIC TESTS

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9
Q

Symptoms and Hx can be

A

subjective

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10
Q

All PE findings/signs

A

objective

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11
Q

What are considered one type of objective information, or what you
observe?

A

Signs

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12
Q

What are the components of the comprehensive health hx?

A

1) Identifying data and source of the history, reliability
2) Chief complaint (s)
3) Present illness
4) Past history
5) Personal and Social History
6) Family History
7) Review of systems

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13
Q

What amplifies the chief complaint and describes how each symptom developed?

A

Present illness

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14
Q

These may include medications, allergies, and tobacco us, wc are frequently pertinent to the present illness

A

Present Illness

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15
Q

Lists of childhood illnesses, adult illness (medical, surgical, ob/gyn, psych), health maintenance practices (immunization, screening tests, lifestyle issues, home safety)

A

Past Hx

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16
Q

includes, age and health , or age and COD of sibs, parents, grandparents

A

Fam hx

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17
Q

Describes ed lvl, fam of origin, current household, personal interests, and lifestyle

A

Personal and Social Hx

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18
Q

Initial data includes

A
  • Date and time
  • ID data
  • Reliability
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19
Q
  • questions relevant to the chief complaint
  • pertinent “-“ and “+”
  • may uncover problems that the patient has overlooked
A

REVIEW OF SYSTEMS (ROS)

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20
Q

STEPS FOR IDENTIFYING PROBLEMS AND MAKING DIAGNOSIS

A

1) Identifying abnormal findings
2) Localize findings anatomically
3) Cluster the clinical findings
4) Search for the probable cause of the findings
5) General hypotheses about the cause of pts problem
6) Test the hypotheses and establish a working diagnosis

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21
Q

IDENTIFYING ABNORMAL FINDINGS

A
  • list of pts symptoms and signs

- laboratory reports

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22
Q

LOCALIZE FINDINGS ANATOMICALLY

A 
e.g scratchy throat
PE: erythema on the pharynx
e.g chest pain
 cardiovascular
 GI
 musculoskeletal
 pulmonary
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23
Q

CLUSTER THE CLINICAL FINDINGS

A
  • Pts age
  • Timing of symptoms
  • Involvement of different parts
  • Multisystem conditions
  • Key questions
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24
Q

Pts age: younger vs older

A
  • Younger (single problem)

- Older (Multiple diseases)

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25
Q

Timing of symptoms

A
  • e.g problems: fever chills cough a day PTC
    hx of pharyngitis 6 weeks PTC
  • e.g yellow penile discharge followed by 3 weeks later by painless penile ulcer
  • e.g penile ulcer in 6 weeks followed by a maculopapular rash and lymphadenopathy (syphilis – 1o and 2o)
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26
Q
  • S/Sx in single system - 1 disease
  • problems in different unrelated system
    o e.g elevated blood sugar, numbness on LE,
    blurring of vision, gnawing epigastric pain (DM)
    o e.g Elevated blood pressure, chest tightness, decreased urine output (Hypertension)
A

Involvement of different parts

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27
Q

e.g 60 y.o plumber male cough hemoptysis weight loss
smokes 1 pack of cigarettes for 40 years cyanotic nailbeds
o dysphagia, jaundice, changes in sensorium (malignancy)

  • e.g 22 y.o male odynophagia fever weight loss
    o purplish skin lesions leukoplakia
    o lymphadenopathies chronic diarrhea (AIDS)
A

Multisystem conditions

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28
Q
  • e.g what produces and relieves the patient’s chest pain?
    o answer: exertion and rest (cardio and
    muscoskeletal)
    o answer: related to meals (GI)
A

Key questions

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29
Q

SEARCH FOR THE PROBABLE CAUSE OF THE FINDINGS

A
  • congenital
  • infectious; inflammatory
  • immunologic
  • neoplastic (benign/malignant)
  • metabolic
  • nutritional
  • degenerative (elderly)
  • vascular
  • traumatic
  • toxic

e.g headache
pathologic: sinus infection
concussion 2 to trauma
SAH
brain tumor
pathophysiologic : migraine headache
psychopathologic: depression
e.g headache + fever + stiff neck/ nuchal rigidity
infectious : meningitis

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30
Q

a. Select the most specific and critical findings to support your
hypothesis
o “worst headache of my life” nausea vomiting altered
mental status
papilledema - neurologic/ inc ICP

b. Match your findings against all the conditions that can produce
them
o inc ICP
o infectious, vascular, metabolic, neoplastic

c. Eliminate the diagnostic possibilities that fail to explain the findings
o migraine vs tension headache

d. Weigh the competing possibilities and select the most
likely diagnosis
o statistical probability - age, sex, ethnic, habits, lifestyle
and locality
e.g 65 y.o male urinary frequency, low back pain
25 y.o female
o timing of pts illness
e.g new onset headache + fever + rash + stiffneck
Vs
recurrent headache + nuasea/ vomiting + visual scotoma

e. Give special attention to potentially life threatening conditions
o “ always include the worst case scenario”

A

GENERATING CLINICAL HYPOTHESIS

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31
Q

TEST YOUR HYPOTHESIS

A

further history, PE , laboratory studies
o e.g 50 y.o female cough dyspnea fever coryza
o CXR- infiltrates both lower lobes

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32
Q

ESTABLISH WORKING DIAGNOSIS

A
  • highest level of certainty that the data allow
    e.g HCVD in CHF
    Bacterial meningitis- pneumococcal
    Obstructive uropathy 2 to BPH
    ACS -STEMI
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33
Q

The foundation of clinical proficiency

A

Comprehensive adult hx

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34
Q

It places the foundation for px asses, recommendation of care, and your choice for further evaluation.

A

Quality of your hx and PE

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35
Q

The challenges of integrating the essential elements of care:

A

● Empathetic listening
● The ability to interview patients of all ages, moods, and backgrounds.
● The techniques for examining the different body systems
● Levels of illness
● The process of clinical reasoning leading to your diagnosis and plan.

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36
Q

What includes all the elements of the health history and the complete physical examination?

A

Comprehensive px assessment

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37
Q

This assessment is appropriate, particularly for patients you know well returning for routine care, or those with specific “urgent care” concerns.

A

Flexible or problem oriented

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38
Q
  • Provides fundamental and personalized knowledge about the patient
  • Strengthens the clinician-patient relationship
  • Helps identify or rule out physical causes related to patient concerns
  • Provides a baseline for future assessments
  • Creates a platform for health promotion through education and counseling
  • Develops proficiency in the essential skills of physical examination
A

Comprehensive hx assessment

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39
Q
  • Addresses focused concerns or symptoms
  • Assesses symptoms restricted to a specific body system
  • Applies examination method relevant to assessing the concern or problem as thoroughly and carefully as possible
A

Focused assessment

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40
Q

Varies according to the patient’s memory, trust, and mood

A

Reliability

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41
Q

The one or more symptoms or concerns causing the patient to seek care

A

CC

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42
Q

● Amplifies the chief complaint; describes how each symptom developed
● Includes patient’s thoughts and feelings about the Illness
● Pulls in relevant portions of the Review of Systems

A

HPI

43
Q

Called the pertinent positives and negatives

A

ROS

44
Q

May include medications, allergies, and tobacco use and alcohol, which are frequently pertinent to the present illness

A

HPI

45
Q

● Lists childhood illnesses
● Lists adult Illnesses with dates for events in at least four categories: medical, surgical, obstetric/gynecologic, and psychiatric
● Includes health maintenance practices such as immunizations, screening tests, lifestyle issues, and home safety

A

Past medical hx

46
Q

HPI should be

A

(2) COMPLETE
(3) CLEAR
(1) CHRONOLOGIC

47
Q

7 attributes of a symptom

A
  1. Location
  2. Quality
  3. Quantity or Severity
  4. Timing, including onset, duration, and frequency
  5. The setting in which it occurs
  6. Factors that have aggravated or relieved the
    symptoms
  7. Associated manifestations
48
Q

Pain “PQRST”

A

Pain, Quality, Radiating or Not, Scale, and Timing

49
Q

● Childhood Illnesses.

● Adult Illnesses: 4 areas
1. MEDICAL: Illnesses such as diabetes, hypertension,
hepatitis, asthma, and human immunodeficiency virus; hospitalizations; number and gender of sexual partners; and risk-taking sexual practices.

  1. SURGICAL: Dates, indications, and types of operations.
  2. OBSTETRIC/GYNECOLOGIC: Obstetric history, menstrual history, methods of contraception, and sexual function.
  3. PSYCHIATRIC: Illness and time frame, diagnoses, hospitalizations, and treatments.

● Psychiatric history is different from adult and pediatric history.

A
50
Q

● Captures the patient’s personality and interests, source of support, coping style, strengths, and concerns.
● It should include occupation and the last year of schooling.
● Home situation and significant others.
● Sources of stress, both recent and long-term.
● Important life experiences such as military service, job
history, financial situation, and retirement.
● Leisure activities, religious affiliation and spiritual beliefs.
● Activities of daily living (ADLs).

A

Personal and social hx

51
Q

Steps for identifying for problems and making diagnosis

A

1) Identifying abnormal findings
2) Localize findings anatomically
3) Cluster the clinical findings
● Cluster for example:
○ DM, body weakness, dizziness
○ HTN, SOB, chest pain
4) Search for the probable cause of the findings
5) Cluster the clinical data
6) Generate hypothesis about the cause of pts problem
7) Test the hypotheses and establish a working diagnosis

52
Q

Headache
○ Pathologic Causes:

A

■ Sinus infection
■ Concussion from trauma
■ Subarachnoid hemorrhage
■ Even compression from a brain tumor
■ Fever and stiff neck or nuchal rigidity are two of
the classic signs of headache from meningitis.

53
Q

Steps for generating clinical hypotheses:

A

○ Select the most specific and clinical findings to support your hypothesis

○ Match your findings against all the conditions that can produce them

○ Eliminate the diagnostic possibilities that fail to explain the findings

○ Weigh the competing possibilities and select the most likely diagnosis

○ Give special attention to potentially life-threatening conditions

54
Q

Pertinent data:
○ 45 y/o female, overweight, housewife
○ CC: abdominal pain
○ HPI: 2 days PTC, epigastric, RUQ, colicky, radiating at
the back, aggravated by food intake, lasting for 2-3 hours, took Kremil S 1-2 tab/day without relief. Associated with bloatedness, nausea and vomiting
○ No changes in urination and bowel movement
○ DM2 controlled

A

DDx
○ Cholelithiasis
■ Rule in:
● Colicky epigastric that radiates to the RUQ pain
● Pain radiates to the back
● Aggravated by food
● Bloatedness, N/V
● Age, gender, BW
○ Acute Pancreatitis
■ Rule in:
● Abdominal pain radiating to the back
● Pain aggravated by food
● Bloatedness, N/V
■ Rule out:
● No fever
○ PUD
■ Rule in:
● Epigastric pain
● Bloatedness, N/V
■ Rule out:
● Not relieved by antacid
○ GERD
■ Rule in:
● Bloatedness
● Abdominal pain ● N/V
■ Rule out:
● Colicky pain
● Absence of burping or throat discomfort

Working diagnosis is Cholelithiasis

55
Q

Pertinent data:
○ 50 y/o tricycle driver
○ 3 wks productive cough with night sweat
○ Fatigue, intermittent low grade fever
○ Weight loss
○ Hemoptysis
○ Shortness of breathing
○ Diabetic uncontrolled: poor compliant
○ SMoker 30 pack years

A

DDx
○ Pulmonary Tuberculosis
■ Rule in:
● Productive cough of more than 2 weeks
● Shortness of breath
● Intermittent fever
● Night sweat
● Hemoptysis
● Weight loss
● Fatigue
○ Community Acquired Pneumonia
■ Rule in:
● Fever ● Cough ● SOB
■ Rule out:
● Duration of cough
● Night sweat
○ COPD
■ Rule in:
● Productive cough
● Shortness of breath
● Smoker
■ Rule out:
● Fever (not almost always there)
● Night sweat
○ Lung CA
■ Rule in:
● Cough
● Weight loss
● Fatigue
● Hemoptysis
● Smoker
■ Rule out:
● Fever
● Night sweat

Working diagnosis is Pulmonary Tuberculosis

56
Q

Factors contribute to the patient’s body habitus:

A

● Socioeconomic status
● Nutrition
● Genetic makeup
● Physical fitness
● Mood state
● Early illnesses
● Gender
● Geographic location
● Age cohort

57
Q

Signs of Distress

A

● Cardiac or respiratory distress
● Pain
● Anxiety or depression

58
Q

● If the BMI is >35 kg/m2, measure the patient’s waist circumference just above the hips

● Risk for diabetes, hypertension, and cardiovascular disease increases significantly if the waist circumference is:

A

○ 35 inches or more in women
○ 40 inches or more in men

59
Q

Steps in preparing for the PE

A
  1. Reflect on your approach to px
  2. Adjust lighting and environment
  3. Check equipment
  4. Make px comfy
  5. Observe std and universal precautions
  6. Choose the sequence, scope, and positioning of examination
60
Q

Reflect on your approach to the patient

A

● Appear calm and organized even when you feel inexperienced

● Simply examine that area out of sequence

● To avoid alarming the patient, warn the patient ahead of time by saying:

● As a beginner, avoid interpreting your findings

61
Q

Is optimal for inspecting structures such as the jugular venous pulse, the thyroid gland, and the apical impulse of the heart

A

Tangential lighting

62
Q

It casts light across body surfaces that throw contours, elevations, and depressions, whether moving or stationary, into sharper relief

A

Tangential

63
Q

Shadows are reduced and subtle undulations across the surface are lost

A

Perpendicular lighting

64
Q

What are the cardinal techniques of examination?

A
  • Inspection
  • Palpation
  • Percussion
  • Auscultation
65
Q

Close observation of the details of the patient’s appearance, behavior, and movement such as facial expression, mood, body habitus and conditioning, skin conditions such as petechiae or ecchymosis, eye movements, pharyngeal color, symmetry of thorax, height of jugular venous pulsations, abdominal contour, lower extremity edema, and gait.

A

Inspection

66
Q

Tactile pressure from the palmar fingers or finger pads to assess areas of skin elevation, depression, warmth, or tenderness, lymph nodes, pulses, contours and sizes of organs and masses, and crepitus in the joints.

A

Palpitation

67
Q

Use of the striking or plexor finger, usually the third, to deliver a rapid tap or blow against the distal pleximeter finger, usually the distal third finger of the left hand laid against the surface of the chest or abdomen to evoke a sound wave such as resonance or dullness from the underlying tissue or organs.

A

Percussion

68
Q

Use of the diaphragm and bell of the stethoscope to detect the characteristics of heart, lung, and bowel sounds, including location, timing, duration, pitch, and intensity.

A

Auscultation

69
Q

Sequence of Examination

A
  1. Move from “head to toe”
  2. Examining from the patient’s right side
  3. Examining the patient at bedrest
70
Q

During ophthalmoscopic exam, the room should be darkened because this promotes?

A

Pupillary dilation and visibility of the fundi

71
Q

Neck PE

A

Move behind the sitting patient to feel the thyroid gland and to examine the back, posterior thorax, and lungs.

72
Q

Cardiovascular examination

A

○ elevate the head of the bed to ~300
○ adjusting as necessary to see the jugular venous
pulsations.
○ Ask the patient to roll partly onto the left side while
you listen at the apex for an S3 or mitral stenosis.
○ The patient should sit, lean forward, and exhale while
you listen for the murmur of aortic regurgitation.

73
Q

Nervous system (sitting or supine)

A

○ Mental Status
○ Cranial nerve
○ Motor system
○ Sensory system
○ Reflexes

74
Q

■ Inspect the sacrococcygeal and perianal areas.

■ Palpate the anal canal, rectum, and prostate. If the patient cannot stand, examine the genitalia before doing the rectal examination.

A

Genital and Rectal Examination in Men

75
Q

Examine the external genitalia, vagina, and cervix, with a chaperone when needed. Obtain a Pap smear. Palpate the uterus and adnexa bimanually. Perform the rectal examination if indicated

A

Genital and Rectal Examinations in Women

76
Q

measures blood pressure at preset intervals over 24 to 48 hours, usually every 15 to 20 minutes during the day and 30 to 60 minutes during the night.

A

Automated ambulatory blood pressure monitoring

77
Q

Four types of office blood pressure devices are currently used: Four types of office blood pressure devices are currently used:

A

mercury, aneroid, electronic, and “hybrid”

78
Q

Width of the inflatable bladder of the cuff should be

A

about 40% of upper arm circumference (12-14cm in average adult)

79
Q

Length of the inflatable bladder should be about

A

80% of the upper arm circumference (almost long enough to encircle the arm)

80
Q

What is the standard cuff size that is appropriate for arm circumferences up to 28cm?

A

12x23cm

81
Q

With the arm at heart level, center the inflatable bladder over the

A

Brachial artery

82
Q

The lower border of the cuff should be about

A

2.5cm above the antecubital crease

83
Q

A silent interval that may be present between the systolic and the diastolic pressures

A

Auscultatory gap

84
Q

Inflate the cuff again rapidly to the target level, and then deflate the cuff slowly at a rate of about

A

2-3mmHg per second

85
Q

Note the level when you hear the sounds of at least two consecutive beats. This is the

A

Systolic pressure

86
Q

● Continue to deflate the cuff slowly until the sounds become muffled and disappear.
● To confirm the disappearance point, listen as the pressure falls another

A

10-20mmHg

87
Q

Slow or repetitive inflations of the cuff should be avoided because ___________ can result to false readings

A

Venous congestion

88
Q

What is commonly used to assess the heart rate?

A

Radial pulse

89
Q

What do you compress during detecting the maximal pulsation of the HR?

A

Radial artery

90
Q

What are generally lower than the core body temperature?

A

Oral temp

They are also lower than rectal temperatures by an average of 0.4 to 0.5°C (0.7 to 0.9°F), and higher than axillary temperatures by approximately 1°.

91
Q

What takes 5 to 10 minutes to register and are considered less accurate than other measurements?

A

Axillary temp

92
Q

● Can be more variable than oral or rectal temperatures
● Oral and temporal artery temperatures correlate more closely with the pulmonary artery temperature, but are about 0.5°C lower

A

Tympanic membrane temperatures

93
Q

Lies at the heart of the patient interview

A

Active listening

94
Q

Vital to patient rapport and healing.

A

Empathetic responses

95
Q

Your goal is to facilitate full communication in the
patient’s own words without interruption

A

Guided questionning

96
Q

Techniques for guided questioning

A
  • moving from open-ended to focused questions
  • use questioning that elicits a graded response
  • ask series of qs, one at a time
  • offer multiple choices for answers
  • clarifying what the px means
  • encouraging w continuers
  • using echoing
97
Q

Being sensitive to nonverbal cues allows you to “read the patient” more effectively and send messages of your own

A

Nonverbal communication

98
Q

Another way to affirm the patient is to validate the legitimacy of his or her emotional experience.

A

Validation

99
Q

When patients are anxious or upset, it is tempting to provide reassurance

A

Reassurance

100
Q

When building rapport with patients, express your commitment to an ongoing relationship.

A

Partnering

101
Q

It communicates that you have been listening carefully.

ID what u don’t know.

A

Summarization

102
Q

○ Help prepare patients for what comes next
○ As you move through the history and on to the physical examination, orient the patient with brief transitional phrases like “Now I’d like to ask some questions about your past health.”

A

Transitions

103
Q

Empowering the px, techniques for sharing power:

A
  • evoke the px’s perspective
  • convey interest in the person, not just the prob
  • follow the px’s leads
  • elicit and validate emotional content
  • share info w the px, especially at transition points during the visit
  • make your clinical reasoning transparent to the px
  • reveal the limits of your knowledge

PDR II (6 decks)

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