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Advanced Health Assessment > History-Taking for Wellness Exams, Episodic Visits, and Chronic Care Management > Flashcards

History-Taking for Wellness Exams, Episodic Visits, and Chronic Care Management Flashcards

1
Q

What does the scope and degree of detail in history-taking depend on?

A

the chief concern
complexity of the medical condition
clinician’s goals for the visit

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2
Q

What is the purpose of a wellness exam?

A

preventing illness, disease, and health problems

detecting problems at an early stage

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3
Q

General components of a wellness exam

A
  • comprehensive, culturally sensitive history and physical
  • anticipatory guidance
  • addressing risk factors
  • motivational interviewing to reduce identified risk factors
  • ordering appropriate immunizations and laboratory/diagnostic procedures
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4
Q

How does a wellness exam differ from a episodic visit or chronic care management visit?

A

wellness exams are focused on risk factors NOT a presenting problem

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5
Q

What should PMH include for a wellness exam?

A
  • past medical conditions, hospitalizations, surgeries, injuries
  • medications or supplements be observant of opiate use
  • allergies
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6
Q

PMH for women should include

A
  • menstrual history
  • gynecological history
  • sexual history
  • obstetric history
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7
Q

Who should be included in a family history?

A

patient’s grandparents, parents, siblings, and children

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8
Q

What should be asked during a menstrual history exam?

A

age of menarche, length and frequency of cycle, type and amount of flow, associated symptoms, FDLMP, menopause, any hormone replacement therapy

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9
Q

What should be asked during a gynecological history exam?

A

last pap smear and results, abnormal vaginal discharge, dryness, lesions

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10
Q

What should be asked during a sexual history exam?

A
  • sexual history: number of partners, preference, abuse history, safety, STI, contraception method
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11
Q

What should be asked during a obstetric history exam?

A

GPA or TPAL, complications during pregnancy or labor, vaginal, induced, or c-section, fertility

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12
Q

What should be reviewed during a family history of a wellness exam??

A

health status of family members, pattern of disease(s), cause of death

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13
Q

What is included in a social history of a wellness exam?

A 
age and gender appropriate review of: 
marital status
living arrangement
home conditions
social support
occupational history
drug use
alcohol intake
smoking/tobacco history
religious/spiritual ideals
cultural preference
sexual history
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14
Q

What is the purpose of a ROS?

A

to gather essential information on current or potential disease processes that may otherwise go unnoticed

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15
Q

What is important to consider when obtaining a history on a patient with a disability?

A

The patient is the expert.

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16
Q

What are special considerations for older adults during a wellness exam?

A 
medication appropriateness
functional assessment (ADLs, fall risk, home safety)
cognitive function
advanced directives/POAs
risk for depression
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17
Q

What is an example of a screening tool for medication appropriatenss?

A

AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adults

18
Q

What are some examples of a model used to assess fall risk for older adults?

A

Hendrick II Fall Model

Fall Prevention Checklist for Older Adults

19
Q

What is an example of a cognitive assessment tool for older adults?

A

Mini-Cog

20
Q

PHQ-9 or PHQ-2

A

A depression screening tool (patient health questionnaire-9 or 2)

21
Q

Where can you find recommendations on preventative care services?

A

www. uspreventiveservicestaskforce.org/Page/Name/grade-definitions
https: //epss.ahrq.gov/PDA/index.jsp

22
Q

What letter grade warrants the highest certainty for net benefit in regards to preventive services?

A

Grade A

23
Q

What type of visit accounts for the majority of visits to a clinician?

A

episodic visit

24
Q

What is the general framework for history taking during an episodic visit?

A 
Chief concern (CC)
History of present illness (HPI)
Past medical history (PMH)
Family history (FH)
Social history (SH)
Review of systems (ROS)
25
Q

How should the HPI begin?

A

with the chief concern (CC)

26
Q

What is the most helpful component of developing a differential diagnosis list?

A

the HPI

27
Q

What are the 8 key elements of the HPI?

A
  1. location
  2. quality
  3. severity
  4. duration
  5. timing
  6. context
  7. modifying factors
  8. associated signs and symptoms
28
Q

What is OLD CARTS?

A

A mnemonic to help remember the 8 key elements of HPI.

Onset, Location, Duration, Character, Aggravating factors/associated symptoms, Relieving factors, Timing, Severity

29
Q

How is the ROS performed during an episodic visit?

A
  1. problem-pertinent ROS
  2. extended ROS
  3. complete ROS
30
Q

What type of physical exam should be performed during an episodic visit?

A

problem-focused
expanded problem-focused
detailed
comprehensive

31
Q

What body areas should be included in a physical examination?

A 
head/face
neck
chest
abdomen
genitalia, groin, buttocks
back/spine
extremities
32
Q

What reference should be utilized when considering laboratory and diagnostic testing?

A

choosingwisely.org

33
Q

What are among the leading causes of death and disability?

A

chronic conditions

34
Q

What are some examples of chronic conditions?

A 
heart disease
cancer
chronic lung disease
stroke
alzheimer's disease
diabetes
chronic kidney disease
35
Q

What should chronic care management include?

A

BOTH face-to-face and non-face-to-face visits

36
Q

What should be the focus of chronic care management?

A

patient’s relationship with the healthcare TEAM
establishing AND achieving health goals
coordination of community and social services
medical, functional, and psychosocial assessment
preventive care

37
Q

What should the treatment plan include for chronic care management?

A

lifestyle modifications
pharmacological interventions
self-management support
education

38
Q

What is a chronic care management visit MOST focused on?

A

lifestyle modifications and counseling

39
Q

What are potential benefits of team-based care?

A

clinician delegation
improvement in quality of care
reduction in healthcare cost
more patient-centered

40
Q

How would a clinician document HPI during a chronic care visit?

A

By utilizing 6 elements: SDT CMA

  1. Severity
  2. Duration
  3. Timing
  4. Context
  5. Modifying factors
  6. Associated S/S
41
Q

How is a PMH, FH, and SH obtained during a chronic care visit?

A

same as wellness and episodic visits

Advanced Health Assessment (7 decks)

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