History Flashcards
when asking about sleep, how would you differentiate between rib fracture pain and cancer
rib fracture causes pain when rolled over on side
cancer would be deep boring pain that is diffuse
how do you ask the patient about their ADL’s
does your CC affect your ability to go to work, get groomed, dress, sleep, diet, or exercise
what is the difference between arterial insufficiency and venous insufficiency
arterial insufficiency (claudication) will make skin cold
venous insufficiency (DVT) will make skin warm
what types of questions should you ask your patient about their headache
how long do they last how often do they appear any tearing of the eye any visual disturbances any double vision, blurry vision any problems with memory any problems with speech are they related to mens. cycle any nausea/vomiting any trauma
what types of questions should you ask your patient about their abdominal complaints
site? frequency? does eating make it worse or better radiating pain have you noticed any weight loss (is it b/c you want to lose weight or haven't been eating) bowel/bladder changes? feeling tired? nausea/vomiting?
what types of questions should you ask your patient about their CNS
memory trouble?
balance and coordination?
blurry vision/trouble with vision?
bowel/bladder function?
what types of questions should you ask your patient about suspected pulmonary conditions
shortness of breath?
chest pain?
pain with exercise?
Doctor centered case management
7 cardinal features of symptoms
- location and radiation
- quality
- quantity
- chronology
- setting
- modifying factors
- associated symptoms
patient centered case management
NURS- emotion handling
- naming
- understanding
- respect
- support
what are the different types of histories
- problem focused
- comprehensive
beyond “OPQRST” (skeleton for history)
additional areas to include: social history, occupational history, ADL’s, past medical history, review of systems
social history includes
- alcohol consumption
- tobacco use
- recreational drug use
- how do these affect the chief complaint
occupational history includes
- workforce stressors
- mechanical stress
- prior work related injuries
ADL’s include
- dressing, grooming, eating etc
- extended ADL’s
- golf, biking, playing with gkids
past medical history includes
- childhood illnesses
- trauma
- MVA, slips, falls, etc
- work related injuries
- hospitalizations/surgeries
- medications: current, past
what is the review of systems important for
often uncover other area of complaint
what are the 14 steps of an examination
- history
- age of patient, sex of patient
- chief complaint-OPQRST
- social, occupational, ADL, past medical, review of systems
- physical examination
- inspection
- palpation
- percussion
- instrumentation
- ROM
- orthopedic
- neurologic
- exam of related areas
- lab and x-ray
what is the purpose of a patients interview
- doctor patient rapport
- reason for care
- determine if your patient will benefit from chiropractic care
- determine if a referral is needed-red flags
- determine appropriate case management
what is included in a physical examination
- objective portion of case management
- orthopedic testing
- neurologic testing
- visceral examination
hwat is HIPPARONI
history inspection palpation percussion auscultation range of motion orthopedic neurologic instrumentation
what is a clinical impression
- doctors assessment of condition
- diagnosis
- what you think is going to be
- will have a list of differentials
all clinical findings MUST be covered in the clinical impression.
No generic terms are allowed
what is the doctors plan
what are you going to do to help the patient
how are we going to reach this
what type of goals are tehre
short term goals
long term goals
what is a care plan
- frequency
- duration
- adjunct procedures
- patient education
- home exercise plans
what are potential involved tissues (or pain generators)
muscle tendon ligament/joint capsule bursae joint disc nerve visceral referred pain
