health history & physical exam

Question 1

what type of data is the majority of the health history

Answer 1

subjective

Question 2

functions of the interview

Answer 2

establish rappor
the foundation of diagnostic process
legal documentation
reimbursement

Question 3

interviewing process

Answer 3

prepare
introduction
review expectations
listen
clarify and summarize
plan
closing

Question 4

most important type of interviewing question

Answer 4

open-ended

Question 5

crying therapeutic communication

Answer 5

pausing, gentle probing, empathy, tissue

Question 6

rule for sensitive subjects

Answer 6

remain non-judgemental

Question 7

common pitfalls of interviewing

Answer 7

focus on data
leading questions
terminology
interjecting personal info
focusing on next question
interrupting

Question 8

3 types of health histories

Answer 8

comprehensive/complete
focused
interim/episodic

Question 9

comprehensive/complete history

Answer 9

most thorough
1st visit - sports, school, employment, well-visit
pre-hospitalization

Question 10

focused history

Answer 10

acute health problem

Question 11

interim or episodic history

Answer 11

follow up on chronic condition & acute illness requiring monitoring

Question 12

biographical data

Answer 12

collected on intake form
contact info

Question 13

chief complaint

Answer 13

main reason for visit, use client’s own words

chose top 2-3

Question 14

HPI

Answer 14

clarify pt story
symptom analysis

well visit- pt perception of health (rate 1-10)

health promotion activities

Question 15

symptom analysis pneumonics

Answer 15

OLD CARTS, PQRST, OPQRST, CLIENT OUTCOMES

Question 16

interim/episodic visit includes

Answer 16

date diagnosed/most recent visit
management initiated
current state of health-tolerating meds, complications?
lifestyle change status
stressors

Question 17

PMH Included in all exams

Answer 17

current medications (dosage, route, when taking) & allergies

Question 18

ROS for type of assessment

Answer 18

comprehensive - all ROS
focused - only pertinent

Question 19

newborn range

Answer 19

0-28 days

Question 20

infant range

Answer 20

1-12 mos

Question 21

toddler range

Answer 21

1-3 years

Question 22

pre-school range

Answer 22

3-5 years

Question 23

school age range

Answer 23

6-12 years

Question 24

adolescence range

Answer 24

12-18 years

Question 25

neonate important questions

Answer 25

prenatal history
apgar score
gestational age
birth weight

Question 26

infant important question

Answer 26

development - rule of 4 3’s

Question 27

rule of 4 3’s

Answer 27

1-3 mos - development of head, eyes
3-6 mos - upper body, arms
6-9 mos - lower body, fingers
9-12 mos - legs

Question 28

toddler motor development

Answer 28

15 mo - walks well, drinks from a cup, stoops
18 mo - runs, walks up steps, uses spoon, tantrums
2 yr - up & down steps, parallel play, puts on clothes
2.5-3 yr - 3-4 word sentences, understand 50% of theirspoken words

Question 29

preschool development

Answer 29

trusting threes
fascinating fours
frustration 5s
sociable 6s

Question 30

school age development

Answer 30

reading, writing, physical activities
school is important
cooperative and team play
social norms/customs
skills/talents begin to show

Question 31

teen development

Answer 31

emotional independence
secondary sex development
peers VERY important

Question 32

diagnostic reasoning process

Answer 32

1. pt experiences a health problem
2. pt engages with health system
3. information gathering - clinical hx and interview
4. information gathering - physical exam & formulate differential diagnosis
5. communicate the diagnosis
6. treatment
7. outcomes

Question 33

frameworks for developing DD

Answer 33

VINDICATE
anatomic
physiologic