Comprehensive Adult Hx Taking Flashcards
- These are for px you are seeing for the first time
- All elements of health hx
- Complete physical hx
Comprehensive px assessment
What is used for follow up pxs?
Focused/problem oriented assessment
What is used for specific “urgent care” concerns?
Focused/problem oriented assessment
You’ll adjust the scope of your hx and PE to the situation at hand, keeping several factors mind s/a:
- magnitude and severity of px probs
- the need for thoroughness
- the clinical setting - in or outpx
- primary or subspecialty care
- time available
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
Comprehensive px assessment
- est px esp during routine or urgent visits
- sp body sys
- applies examination mtds relevant to assessing the concerns and probs
Focused/problem oriented assessment
Screening tests
Routine clinical check up/periodic health exam
- 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.
PE FINDINGS AS DIAGNOSTIC TESTS
Symptoms and Hx can be
subjective
All PE findings/signs
objective
What are considered one type of objective information, or what you
observe?
Signs
What are the components of the comprehensive health hx?
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
What amplifies the chief complaint and describes how each symptom developed?
Present illness
These may include medications, allergies, and tobacco us, wc are frequently pertinent to the present illness
Present Illness
Lists of childhood illnesses, adult illness (medical, surgical, ob/gyn, psych), health maintenance practices (immunization, screening tests, lifestyle issues, home safety)
Past Hx
includes, age and health , or age and COD of sibs, parents, grandparents
Fam hx
Describes ed lvl, fam of origin, current household, personal interests, and lifestyle
Personal and Social Hx
Initial data includes
- Date and time
- ID data
- Reliability
- questions relevant to the chief complaint
- pertinent “-“ and “+”
- may uncover problems that the patient has overlooked
REVIEW OF SYSTEMS (ROS)
STEPS FOR IDENTIFYING PROBLEMS AND MAKING DIAGNOSIS
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
IDENTIFYING ABNORMAL FINDINGS
- list of pts symptoms and signs
- laboratory reports
LOCALIZE FINDINGS ANATOMICALLY
e.g scratchy throat PE: erythema on the pharynx e.g chest pain cardiovascular GI musculoskeletal pulmonary
CLUSTER THE CLINICAL FINDINGS
- Pts age
- Timing of symptoms
- Involvement of different parts
- Multisystem conditions
- Key questions
Pts age: younger vs older
- Younger (single problem)
- Older (Multiple diseases)
Timing of symptoms
- 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)
- 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)
Involvement of different parts
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)
Multisystem conditions
- 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)
Key questions
SEARCH FOR THE PROBABLE CAUSE OF THE FINDINGS
- 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
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”
GENERATING CLINICAL HYPOTHESIS
TEST YOUR HYPOTHESIS
further history, PE , laboratory studies
o e.g 50 y.o female cough dyspnea fever coryza
o CXR- infiltrates both lower lobes
ESTABLISH WORKING DIAGNOSIS
- highest level of certainty that the data allow
e.g HCVD in CHF
Bacterial meningitis- pneumococcal
Obstructive uropathy 2 to BPH
ACS -STEMI
The foundation of clinical proficiency
Comprehensive adult hx
It places the foundation for px asses, recommendation of care, and your choice for further evaluation.
Quality of your hx and PE
The challenges of integrating the essential elements of care:
● 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.
What includes all the elements of the health history and the complete physical examination?
Comprehensive px assessment
This assessment is appropriate, particularly for patients you know well returning for routine care, or those with specific “urgent care” concerns.
Flexible or problem oriented
- 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
Comprehensive hx assessment
- 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
Focused assessment
Varies according to the patient’s memory, trust, and mood
Reliability
The one or more symptoms or concerns causing the patient to seek care
CC
● 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
HPI
Called the pertinent positives and negatives
ROS
May include medications, allergies, and tobacco use and alcohol, which are frequently pertinent to the present illness
HPI
● 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
Past medical hx
HPI should be
(2) COMPLETE
(3) CLEAR
(1) CHRONOLOGIC
7 attributes of a symptom
- Location
- Quality
- Quantity or Severity
- Timing, including onset, duration, and frequency
- The setting in which it occurs
- Factors that have aggravated or relieved the
symptoms - Associated manifestations
Pain “PQRST”
Pain, Quality, Radiating or Not, Scale, and Timing
● 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.
- SURGICAL: Dates, indications, and types of operations.
- OBSTETRIC/GYNECOLOGIC: Obstetric history, menstrual history, methods of contraception, and sexual function.
- PSYCHIATRIC: Illness and time frame, diagnoses, hospitalizations, and treatments.
● Psychiatric history is different from adult and pediatric history.
● 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).
Personal and social hx
Steps for identifying for problems and making diagnosis
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
Headache
○ Pathologic Causes:
■ 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.
Steps for generating clinical hypotheses:
○ 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
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
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
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
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
Factors contribute to the patient’s body habitus:
● Socioeconomic status
● Nutrition
● Genetic makeup
● Physical fitness
● Mood state
● Early illnesses
● Gender
● Geographic location
● Age cohort
Signs of Distress
● Cardiac or respiratory distress
● Pain
● Anxiety or depression
● 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:
○ 35 inches or more in women
○ 40 inches or more in men
Steps in preparing for the PE
- Reflect on your approach to px
- Adjust lighting and environment
- Check equipment
- Make px comfy
- Observe std and universal precautions
- Choose the sequence, scope, and positioning of examination
Reflect on your approach to the patient
● 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
Is optimal for inspecting structures such as the jugular venous pulse, the thyroid gland, and the apical impulse of the heart
Tangential lighting
It casts light across body surfaces that throw contours, elevations, and depressions, whether moving or stationary, into sharper relief
Tangential
Shadows are reduced and subtle undulations across the surface are lost
Perpendicular lighting
What are the cardinal techniques of examination?
- Inspection
- Palpation
- Percussion
- Auscultation
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.
Inspection
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.
Palpitation
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.
Percussion
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.
Auscultation
Sequence of Examination
- Move from “head to toe”
- Examining from the patient’s right side
- Examining the patient at bedrest
During ophthalmoscopic exam, the room should be darkened because this promotes?
Pupillary dilation and visibility of the fundi
Neck PE
Move behind the sitting patient to feel the thyroid gland and to examine the back, posterior thorax, and lungs.
Cardiovascular examination
○ 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.
Nervous system (sitting or supine)
○ Mental Status
○ Cranial nerve
○ Motor system
○ Sensory system
○ Reflexes
■ 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.
Genital and Rectal Examination in Men
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
Genital and Rectal Examinations in Women
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.
Automated ambulatory blood pressure monitoring
Four types of office blood pressure devices are currently used: Four types of office blood pressure devices are currently used:
mercury, aneroid, electronic, and “hybrid”
Width of the inflatable bladder of the cuff should be
about 40% of upper arm circumference (12-14cm in average adult)
Length of the inflatable bladder should be about
80% of the upper arm circumference (almost long enough to encircle the arm)
What is the standard cuff size that is appropriate for arm circumferences up to 28cm?
12x23cm
With the arm at heart level, center the inflatable bladder over the
Brachial artery
The lower border of the cuff should be about
2.5cm above the antecubital crease
A silent interval that may be present between the systolic and the diastolic pressures
Auscultatory gap
Inflate the cuff again rapidly to the target level, and then deflate the cuff slowly at a rate of about
2-3mmHg per second
Note the level when you hear the sounds of at least two consecutive beats. This is the
Systolic pressure
● Continue to deflate the cuff slowly until the sounds become muffled and disappear.
● To confirm the disappearance point, listen as the pressure falls another
10-20mmHg
Slow or repetitive inflations of the cuff should be avoided because ___________ can result to false readings
Venous congestion
What is commonly used to assess the heart rate?
Radial pulse
What do you compress during detecting the maximal pulsation of the HR?
Radial artery
What are generally lower than the core body temperature?
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°.
What takes 5 to 10 minutes to register and are considered less accurate than other measurements?
Axillary temp
● 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
Tympanic membrane temperatures
Lies at the heart of the patient interview
Active listening
Vital to patient rapport and healing.
Empathetic responses
Your goal is to facilitate full communication in the
patient’s own words without interruption
Guided questionning
Techniques for guided questioning
- 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
Being sensitive to nonverbal cues allows you to “read the patient” more effectively and send messages of your own
Nonverbal communication
Another way to affirm the patient is to validate the legitimacy of his or her emotional experience.
Validation
When patients are anxious or upset, it is tempting to provide reassurance
Reassurance
When building rapport with patients, express your commitment to an ongoing relationship.
Partnering
It communicates that you have been listening carefully.
ID what u don’t know.
Summarization
○ 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.”
Transitions
Empowering the px, techniques for sharing power:
- 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
