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Clinical Medicine Exam 1 > Foundations of Health Assessment > Flashcards

Foundations of Health Assessment Flashcards

0
Q

Why is the history so important?

A

60-80% of diagnoses can be made by history alone

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1
Q

2 parts of medical history

A

presenting concern

past history

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2
Q

Types of histories

A
  1. Comprehensive - aka Complete, Expanded; for new patients
  2. Focused - aka Problem oriented or Basic; for established patients and/or urgent/acute care
  3. Inventory - Related to “complete” note but not as detailed
  4. Interim - chronicles events between visits
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3
Q

SOAP note

A

S-subjective; what patient tells you
O-objective; your findings
A-assessment
P-plan

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4
Q

Question types

A

open-ended; used for general information seeking

direct or closed; for seeking specific facts

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5
Q

Methods to assess patient-clinician communication

A
  1. “Ask me 3”
  2. Teach back - patient explains in their own words
  3. 4 C’s; call, cause, concern, cope
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6
Q

SIG E CAPS

A 
S-sleep changes
I-interest (loss of)
G-guilt
E-energy (lack of)
C-cognition/concentration
A-appetite
P-psychomotor
S-suicide
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7
Q

Histories to use for alcohol

A

CAGE
TACE
MAST
ACEDIT

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8
Q

Histories to use for illicit drugs

A 
CAGE
CRAFFT (adolescents)
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9
Q

CAGE

A

C-concern (about your drinking)
A-annoyed (criticism of your drinking?)
G-guilty about drinking?
E-Eye opener?

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10
Q

TACE

A

T-Take – how many drinks does it take?
A-annoyed
C-cut – feel that you should cut down on drinking?
E-eye opener?

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11
Q

CRAFFT

A

C-car; ever been in a car driven by someone under the influence?
R-relax; use or take to relax?
A-alone; use alone?
F-forget; forget what you do while using?
F-family/friend; someone ask you to cut back?
T-trouble; gotten into trouble?

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12
Q

HITS

A 
Used for domestic violence
H-hurt you physically?
I-insult or talk down to you?
T-threaten physical harm?
S-scream or curse at you?
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13
Q

What goes in ‘S’ part of SOAP note?

A

Information
Absence or presence of symptoms
Pt. offered information

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14
Q

What goes in ‘O’ part of note?

A

Findings

Direct observations

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15
Q

What to avoid in writing a SOAP note?

A

words like “good,” “normal”
documenting things you did not do (excluding vitals)
blank lines
white-out

16
Q

Symptom vs. sign

A

Symptom - manifestation of disease of which the patient is usually aware
Sign - observation or palpable phenomenon associated with a given disorder

17
Q

Sections in Subjective section

A 
CC
HPI (history of present illness) with PROS
MEDS
allergies
PMHx
PSHx
FMHx
SOCHx
ROS
18
Q

CC

A

Chief complaint; what they are being seen for

Placed in quotation marks; simple statement “headache”

19
Q

HPI

A

Tells the story of the CC

Onset, location, duration, character, aggravation, alleviating, radiation, timing, severity, etc.

20
Q

PROS

A

Pertinent review of symptoms

Ask questions about other things related to the CC

21
Q

MEDS

A

List all medications
In SOAP note with no punctuation
3 sections: Rx, OTC, herbal/vitamins
name, dosage, number of tablets, route, frequency, last dose taken

22
Q

Allergies

A

3 sections: drug, food, environment

List the reaction to the allergy (rash, etc.)

23
Q

PMHx

A 
Past Medical History
medical problems and illnesses
childhood illnesses
immunizations
THE CHADS - list any positives before negatives
24
Q

THE CHADS

A 
Goes in PMHx
T-Thyroid disease
H-hypertension
E-emphysema 
C-cancer
H-heart disease
A-asthma
D-diabetes
S-stroke
25
Q

PSHx

A

Past surgical history

type of history, reason for surgery, date, hospital, complications

26
Q

FMHx

A

Family history
Parents, siblings, kids
age, alive or deceased/cause of death
grandparents (for a ped history)

27
Q

SOCHx

A 
Social history
occupation, relationship status
habits: tobacco alochol, drugs, diet, caffeine 
sexual history
travel
military
exercise
28
Q

ROS

A

Review of symptoms (general)

Ask about all body systems

29
Q

Parts of sports physical

A

medical history
physical exam
clearance

30
Q

Major reasons for sports disqualifications

A 
dizziness with exercise
asthma history
unfavorable BMI
BP elevation
visual issues
heart murmur
musculoskeletal abnormality
31
Q

Non-qualified, no exceptions (for sports)

A

CARDITIS
Diarrhea
FEVER
Structural heart disease

32
Q

Qualified or qualified with explanation

A 
asthma
congenital heart disease
diabetes
eating disorders
hep or HIV
loss of eye
malabsorption syndromes
obesity
seizures
sickle cell
33
Q

Female athlete triad

A

disordered eating
amenorrhea (loss of period)
osteoporosis

Clinical Medicine Exam 1 (1 decks)

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