Health Assessment Flashcards
Cultural humanity
A process of learning to have an approach that is other-oriented. Life long commitment to learning and critical self-reflection
Apply the elements of a clinical presentation to a health history
6 items
Chief concern
History of present illness
Past medical history
Family history
Social History
Review of Symptoms ROS
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HPI begins with
Chief concern - patients main reason for the episodic visit
What is the best practice in interviewing techniques
Therapeutic approach: active listening, eye contact, avoid looking only at the computer, talk to pt when using interpreter, be professional, know your own biases and avoid bias. Repeat what the patient has said in your own words to ensure accuracy. AVOID medical jargon
Open-ended questions do what
OEQ ultimately saves the clinician time by having the patient elaborate on their symptoms. You start with OEQ
What are Clinician-centered questions
Clinician-centered questions are answers based on the clinicians perspective usually a yes or no
Begin conducting a patient history with
Patient-centered interviewing skills to obtain the patient’s perspective with OEQ
How do you implement an evidence-based assessment
Prioritizing the establishment of a partnership with the patient: this starts with therapeutic communication, listening, responding, and interacting with the focus on the patient’s health and well being
What are the common biases in clinical reasoning
Availability Bias - common dx bc you have seen it alot
Base Rate Neglect - persuing zebras
Representativeness - so focused on being right you ignore atypical features of favored dx
Confirmation Bias - seeking to confirm rather than refuting initial dx
Premature Closure - not fully investigating
Anchoring Bias - giving excess weight to early dx. accepting handed off dx
Availability Bias
Considering easily remembered diagnoses Focusing on a dx because you have been seeing it a lot or just did a paper for class on it
Base Rate Neglect
Pursuing “zebras”. Seen a lot with new NP
Representativeness
Ignoring atypical features that are inconsistent with the favored diagnosis. So focused on proving you’re right you are ignoring some details
Confirmation Bias
Seeking data to confirm rather than refuting the initial hypothesis. Ignoring contradictory evidence
Premature Closure
Stopping the diagnostic process too soon. Don’t collect enough data
Anchoring Bias
Giving excess weight to early/initial information. Just accepting the diagnosis handed off
Identify terms associated with data analysis and problem identification
Clinical reasoning and data analysis have to do with reasoning, skills, and knowledge. It is important to understand what the patient is telling you. Different statements made by the patient could have different meanings, so it is very important to ask the patient and repeat the information back to the patient for accuracy.
What does the HPI provide
The HPI allows the provider to gather pertinent information regarding the chief complaint and start to ID the problem
What are the two main types of clinical reasoning
Analytic/reductionist approach (novice level to complex cases)
Holistic/constructionist (expert level)
Analytic/reductionist approach
Novice level to complex cases. This breaks down the problem into the elements necessary to solve it
Holistic/constructionist approach
This is expert level problem solving based on
Holistic/constructionist approach
This is expert-level problem solving based on previous experience, pattern recognition that is stored in the provider’s personal memory through experience.
Name some diagnostic errors
Knowledge deficit of provider
Faulty data gathering
Faulty information processing
Differential diagnosis
The process of differentiating between two or more conditions that share similar signs and symptoms
An organic process of refining your diagnosis towards a working diagnosis
What is an algorithm also known as
The transformation of a patient’s story into a meaningful clinical problem - a problem representation.
When should new providers use DD
Until they learn to synthesize information into their practice
What is clinical reasoning also known as?
Clinical judgment
When do you start your DD
When you pick up the chart and start gathering information on the patient.
Step one in clinical reasoning - generating differential diagnosis
Identify the problem. Most will be identified by the patient but as the NP we must look at other issues that could lead to the complaint.
(Dysuria at night - maybe its a mobility issue and not a bladder issue).
Step two in clinical reasoning - generating a differential diagnosis
Generating using framework approaches. DD are more than just a list of illnesses that explain s/s or diagnostic results exist but rather DD distinguish a disease or condition from others that present in a similar pattern. done by novice or in situations that are unfamiliar
Step three in clinical
reasoning - generating a differential diagnosis
In order to organize the DD it is very important to look at labs, clinical presentation, and physical examination as a whole in order to prioritize the differential diagnosis based on data
Step four in clinical reasoning - generating a differential diagnosis
Narrow the list. Consider age, gender and ethnicity into your DD to narrow your list of problems
Step five in clinical reasoning - generating a differential diagnosis
Assess for clinical clues during your physical examination and focused on positive assessment findings to confirm your working diagnosis
Eliminate prostetitis in a female patient
Step six in clinical reasoning - generating a differential diagnosis
Always rank your #1 potential diagnosis at the top of your list based on the information from step five
Step seven in clinical reasoning - generating a differential diagnosis
Obtain additional data to test, supplement and validate your hypotheses
Step eight in clinical reasoning - generating a differential diagnosis
Be flexible and organize your DD based on new information. If a working diagnosis cannot be reached and things just don’t make sense, go back to your interview process and see what missing information you can find in order to guide in the right direction. Always reassess and reprioritize new information to support your statements
Define the various sections of a health history
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Medical history (acute and chronic)
Surgical history
Ob/Gyn
Hereditary conditions
Health maintenance such as vaccines and screenings
Allergies
Family history
Social history
ROS
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What’s included in a focused exam
CC, HPI, PMH, PSH, FAMILY HX, current medications (otc or herbal). Allergies to meds, latex or food, Social history (smoking, etoh, drugs, mental health). Review of pertinent systems such as HEENT or review of all symptoms for a comprehensive visit. Physical exam.
What’s included in a focused exam
CC, HPI, PMH, PSH, FAMILY HX, current medications (otc or herbal). Allergies to meds, latex or food, Social history (smoking, EtOH, drugs, mental health). Review of pertinent systems such as HEENT or review of all symptoms for a comprehensive visit. Physical exam.
Define each section of a SOAP note
S - subjective - what the patient reports
O - objective - what the clinician observes and assesses
A - assessment - the diagnosis of diagnostic assessment with rationale
P - plan - the plan of care for the pt including pharmacological and nonpharmacological and patient education
Subjective
Patients point of view. Hx. from the patient, describes patients concerns, symptoms or unexpected findings
Objective
The finding from direct observations, what you smell, see, hear or touch. Objective data is observable and measurable and can be obtained through vital signs, physical examination, labs and diagnostic test.
Assessment
Pulls together the findings and collected in the subjective and objective section to form a diagnosis
*For a sick visit only list pertinent information r/the CC. Do not cover all the systems. Come up w/DD and a working diagnosis.
*For a follow up no DD needed
*For a comprehensive visit - address every system in detail
Plan
Develop a plan for each working diagnosis
Explain Chief Complaint
The main reason for a visit, describes the sx, problem, condition, or diagnosis for the visit - it is in “” and in the patient’s own words
Explain HPI
HPI contains 8 core elements - location, quality, severity, duration, timing, context, modifying factors, associated signs and symptoms. USE OLDCARTSA
Describe reasons for maintaining clear and accurate records
the patients record is a legal document. Court, legal proceedings, as well as incurances can have access to it. It is important to chart in the EMR as soon as possible to maintain information accurately. The patient record provides an opportunity for the clinician to document the care provided at the visit and track how bothe patient
What is the difference between a focused and a comprehensive assessment
the focused and comprehensive assessment have similar components such as demographics, age, gender, ethnicity, CC, HPI, PMH, Social history, etc. However, in the focused visit, only pertinent information will be addressed to the CC and potential body system affected. Comprehensive visits are more in depth and require more detail information to assess or prevent potential medical problems.
Delineate methods for documenting the location and description of findings
Use OLDCARTSA
What are the four classical techniques of physical assessment and proper techniques
Inspection
Palpation
Percussion
Auscultation
Inspection
Process of observation beginning with the initial meeting of the patient and continuing through the history and physical examination. Use adequate lighting, take time to carefully inspect the areas you want to see and validate findings with patient
Palpation
The use of hands and fingers to gather information through the sense of touch. Keep fingernails short, warm hands, be gentle, use correct palpation approach and use appropriate hand surface. Use palmar surface of the hands and finger pads
Palmer and pads - position and texture, size, crepitus, mass or structure
Ulnar - vibration
Dorsal (back of hand) - temperature
Percussion
The use or striking of one object or one finger against another produces vibrations and sound waves. Tapping fingers produces vibrations by impact on underlying tissues
Auscultation
Listening to sounds produced by the body. always do this last in the examination sequence, except with abdominal examination, place the stethoscope on naked skin, listen to one sound at a time, take time to identify characteristics of sound, and do not anticipate the next sound.
What are the different techniques using percussion and when would you use them
- Immediate (direct) - finger strikes directly against body
- Mediate (indirect) Middle finger of dominant hand is hammer; middle finger of non-dominant hand is placed on body and struck.
- Fist-nondominant hand is placed on body and struck with fist of dominant hand. Most commonly used to elicit tenderness from liver, gallbladder or kidneys
Tympany
loud, high drum like Ex. gastric bubble
Hyperresonance
very loud, low, booming Ex emphysematous lung
Resonance
loud, low, hollow. Ex healthy lung tissue
Dullness
soft, moderate, thudlike Ex over liver
Flatness
soft, high, dull Ex over muscle
Gonimeter
Determines degree of joint flexion. Two straight arms that intersect and can be angled and rotated around a protractor
Stethoscope Bell and Diaphragm
Bell - light pressure to hear low frequency sounds
Diaphragm - use pressure to hear high frequencies
Rosenbaugh Eye Chart
Tests for near sightedness
Amsler Grid
used to detect damage to the macula (central part of the retina or optic nerve / macular degeneration. Grid with dot will have blurred area
Ishihara Color Blindness
Color blind chart
Components of a general survey
Systematic assessment of the individual’s health status. The initial general survey includes assessing for problems, instability, or alterations in the airway, breathing, circulation, and neurologic status. Assessment of mental and physical status includes the general survey, measurements of vital signs, habitus, and evaluation of pain.
Normal vital signs for an adult
Temp 96.4 - 99.1
Pulse 60 - 100 bpm
RR 12 - 20 bpm
BP SBP <120 and DBP <80
Child BP
Start at age 3
Components of a general survey
Systematic assessment of the individual’s health status. Initial general survey includes assessing for problems, instability, or alterations in airway, breathing, circulation, and neurologic status. Assessment of mental and physical status include the general survey, measurements of vital signs, habitus, and evaluation of pain.
Pain Scale used with children
Wong/Baker Faces Rating Scale, the Oucher Scale FLACC (nonverbal kids or adults) are examples of faces rating scales reliable for children.
Words a older adult will use for pain
ouchy sore achy
S/S of pain in infant/child
increased pulse and respiratory rate
lower b/p
behavioral cues
less able to modify pain impulses
easily distracted but still have pain
different pain scales
S/S of pain in older population
No diminished perception of pain
Decreased pain threshold
Pain from chronic conditions
What is a general survey?
A general survey is the systematic assessment of the individual’s health status. Initial general survey includes assessing for problems, instability, or alterations in airway, breathing, circulation, and neurologic status. Assessment of mental and physical status include the general survey, measurements of vital signs, habitus, and evaluation of pain.
Underweight BMI
<18.5
Normal BMI
18.5-24.9
Overweight BMI
25.0-29.9
Obesity BMI
I 30-34.9
II 35-39.9
Extreme obesity BMI
III >40
Normal SP02
>95%
Normal HR
60-100
Normal Inspiration
Diaphragm moves down using external intercostal muscles
Normal Expiration
Internal intercostal muscles
Intercostal muscles
External intercostals increase the anteroposterior chest diameter during inspiration.
Internal intercostals decrease the lateral diameter during expiration.
Respiratory Rate (Normal)
12-20
What is pulse pressure
The difference between systolic and diastolic pressures ex: 120/80 Pulse pressure would be 40mm Hg
BP cuff size and position
Width: 40% of upper arm circumference
Length: 80% of upper arm circumference
Apocrine sweat glands
Apocrine sweat glands: think stinky adolescent
Secretion begins at puberty
Secrete thick viscous cloudy fluid in sac of air follicle and eventually to the surface of the skin
Good source for bacteria -> odor
Ears (cerumen), eye lids, Armpits, areola of the breast, anogenital regions.