Foundations of Health Assessment Flashcards
Spiritual, physical, emotional, social, environmental, creative, career, financial, and intellectual are…
The nine dimensions of wellness
Consistently implementing EBP results in the highest quality of care, improved population health outcomes, decreased costs, and clinician empowerment. This is known as…
The quadruple aim in healthcare
What is a reliable, informative source for clinicians to find EBP?
USPSTF
What is often the most important aspect of the patient visit to help with diagnostic decision-making?
History taking
Difficulties occurring in all three areas of functioning: impairments, activity limitations, and participation restrictions are defined as
Disability
Why are functional assessments important in the elderly?
Changes can be an early indicator of mental or physical decline which can decrease their independence
Onset
Location
Duration
Characteristics
Aggravating factors
Relieving factors
Timing
Severity
OLDCARTS
When did it start?
Onset
Where is it located?
Location
How long does it last?
Duration
Describe in your own words the quality of the symptoms: sharp, dull, stabbing, burning, crushing, throbbing, nauseating, shooting, twisting, or stretching
Characteristics
What makes it worse? What symptoms are associated with the symptom?
Aggravating factors
What makes it better?
Relieving factors
When did the symptom start? How long does it last? Is it constant, intermittent, sudden, etc.?
Timing
How severe is the symptom on a scale of 0-10?
Severity
OLDCARTS is used to ellicit…
The HPI in relation to the CC
What are subjective pieces of information?
CC, HPI, PMH, FH, SH, ROS
What are objective pieces of information?
PE, VS, Diagnostics/results, interventions during exam
What is documented in the assessment portion of the note?
Diagnosis or diagnostic assessment with rationale
What is documented in the plan?
Non-pharmacologic and pharmacologic interventions, patient education, follow-up instructions
What is the first thing assessed with every encounter?
Environment you are assessing in for safety
What are the ABCDE’s of assessment?
Airway
Breathing
Circulation
Disability
Exposure
Where is a pulse assessed in children <2 y/o?
Apical pulse
Which age group has poor insulation and a harder time regulating body temperature?
Infants
If a baby less than 6 weeks comes in with a fever, what is a MNM diagnosis?
Sepsis
What rhythm is common in infants and children?
Sinus arrhythmia
Is fever a good indicator of infection in the older adult?
No, they are less likely to develop fevers making this a poor indicator
Where is the body temperature regulated?
Hypothalamus
Vitamins A, D, E, K are ____-soluble
fat
Vitamins C, B6, B12, thiamin, riboflavin, niacin, choline, and folate are ______-soluble
water
Energy expenditure = energy intake makes for….
healthy body weight maintenance
Waist circumference is used when patients are/have:
BMI >35
Height <5ft (in a grown adult)
18.5-24.9kg/m
normal BMI
When is head circumference assessed?
Every visit from birth-2 y/o
Are there changes in lab values during periods of malnutrition?
Not normally, they often remain the same. Changes in lab values are a very late sign
Deficiencies of excesses or imbalances in a person’s intake of energy and/or nutrients
Malnutrition
A 20-year-old patient presents to the office for a wellness exam. The clinician assess the patient’s use of seat belts. Which component of the wellness exam is assessed?
Anticipatory guidance
Which of the following is NOT an element of history taking?
a. Chief concern
b. Family history
c. Physical exam
d. History of present illness
c. Physical exam
Patient presents to the office with shoulder pain for 1 week. Pain is constant, burning, and reported at night. During the patient interview, the clinician asks the patient “Can you tell me what you have been doing for your shoulder pain?” The clinician is asking information about…
Modifying factors
What is the difference between an open-ended and a closed-ended question?
Open-ended provides more details whereas the close-ended at Y/N answers
True/False: An established patient presents for a follow-up visit for her stable HTN. During this visit, the clinician can update the ROS, PMH, FH, SH by simply stating the information was reviewed and updated from the previous patient encounter.
True
A 70 y/o patient presents for his wellness exam. That patient’s last vaccines were over 40 years ago. Patient states “I don’t believe in all those shots. I already had chicken pox when I was a kid. My kids made me come today since I haven’t been to see a clinician in 30 years.” Which vaccines would you recommend the patient receive today?
Flu, Tdap, PNA, zoster
When considering history collection during a wellness exam, which statement below is NOT correct?
a. Wellness exams do not require a chief concern
b. Wellness exams are age/gender appropriate
c. Wellness exams include counseling and anticipatory guidance
d. Wellness exams are based on a presenting problem
d. Wellness exams are based on a presenting problem
Which is TRUE about the use of screening tools to assess depression?
Screening tools like the PHQ-2 and PHQ-9 are recommended and evidence based.
Weight obtained during a patient’s chronic care management follow-up for HTN finds the patient’s weight was increased 10lbs over the past year and that her BMI is now in the morbidly obese category. During this visit, the clinician should place greater emphasis on…
Lifestyle modifications
