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PHRM 100 – IMM > IMM 02: Introduction to Clinical Assessment & Head-to-Toe Approach > Flashcards

IMM 02: Introduction to Clinical Assessment & Head-to-Toe Approach Flashcards

1
Q

What are the steps involved in conducting a clinical assessment? (7)

A
  • history taking
  • physical exam
  • develop working diagnosis
  • obtain lab studies
  • develop final diagnosis
  • initiate treatment
  • ongoing evaluation (follow-up)
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2
Q

What are the components of a comprehensive health history? (9)

A

(might not go through everything for every patient)

  • identifying data (ID)
  • chief concern/complaint (CC)
  • history of present illness (HPI)
  • past medical history (PMHx)
  • medication history (MHx)
  • allergies and intolerances
  • family history (FHx)
  • social history (SHx)
  • review of symptoms (RS)
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3
Q

Identifying Data (ID)

What information is classified here? (2)

A
  • date and time of history
  • age (risk factor), gender identity/pronouns, occupation (risk factor), marital status (support system)
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4
Q

Chief Concern/Complaint (CC)

What information is classified here? (2)

A
  • symptoms causing the patient to seek care
  • quote patient’s own words
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5
Q

History of Present Illness (HPI)

What information is classified here? (2)

A
  • complete, clear, chronologic account of presenting problem
  • detailed description of symptoms, treatments, and risk factors
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6
Q

Past Medical History (PMHx)

What information is classified here? (2)

A
  • medical, surgical, obstetric/gynecologic, psychiatric
  • immunizations
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7
Q

Medication History (MHx)

What information is classified here? (1)

A

prescription and non-prescription medications, vitamins and supplements, alternative health products

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8
Q

Allergies and Intolerances

What information is classified here? (2)

A
  • date of reaction
  • symptoms of reaction
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9
Q

Family History (FHx)

What information is classified here?

A

presence or absence of specific illnesses

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10
Q

Social History (SHx)

What information is classified here?

A
  • education level
  • ethnicity (prevalence of condition)
  • current home situation
  • support system
  • personal interests
  • lifestyle (smoking, alcohol, illicit drugs)
  • activities of daily living
  • exercise
  • diet
  • some conditions are more prevalent within certain ethnicities
  • important to not make assumptions
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11
Q

Review of Symptoms (RS)

What information is classified here?

A

documents presence or absence of common symptoms related to each major body system

  • detailed, systematic, and complete review of a patient’s symptoms
  • organizes information head-to-toe according to major body systems
  • takes patient-centred approach (vs. product-centred approach)
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12
Q

What are the components of a head-to-toe review of systems? (10)

A
  • vital signs (VS)
  • psychiatric (PSYCH) and neurologic (NEURO)
  • skin, hair, nails (DERM)
  • head, ears, eyes, nose, throat (HEENT)
  • respiratory (RESP)
  • cardiovascular (CV)
  • gastrointestinal (GI)
  • genitourinary (GU)
    -peripheral vascular system (PVS)
  • musculoskeletal (MSK)
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13
Q

Vital Signs (VS)

A
  • temperature
  • heart rate
  • respiratory rate
  • blood pressure
  • height
  • weight
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14
Q

Psychiatric (PSYCH)

A

(can be a result of side effects of certain drugs)

  • insomnia
  • nervousness or anxiety
  • changes in insight, orientation, memory, or judgement
  • changes in attention or mood
  • unusual or disturbing thoughts
  • hallucinations or delusions
  • suicidal thoughts or attempts
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15
Q

Neurologic (NEURO)

A
  • headache
  • dizziness or vertigo
  • weakness or paralysis
  • numbness or loss of sensation, tingling or ‘pins and needles’
  • change in level of consciousness (LOC)
  • tremors or other involuntary movements
  • convulsions or seizures
  • rigidity
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16
Q

Skin, Hair, Nails (DERM)

A
  • rashes
  • bruises
  • dryness or moistness
  • itching
  • hair loss or growth
  • lesions, masses, ulcers, sores, wounds
  • changes in hair or nails
  • changes in skin colour (ie. erythema), texture
  • changes in mole colour, texture, size
17
Q

Head and Neck (HEENT)

A
  • pain or headache
  • dizziness
  • light-headedness
  • swollen glands
18
Q

Ears (HEENT)

A
  • auditory acuity
  • tinnitus
  • vertigo
  • earaches
  • discharge
19
Q

Eyes (HEENT)

A
  • visual acuity
  • pain
  • spots, specks, flashing lights
  • double or blurred vision
  • tearing or dyrness
  • itching
  • redness
  • discharge
  • blind spots
20
Q

Noses and Sinuses (HEENT)

A
  • itchiness
  • nasal congestion
  • discharge or runny nose
  • nosebleeds
  • sinus pain or pressure
21
Q

Throat and Mouth (HEENT)

A
  • gum soreness or sore throat
  • mouth or tongue sores
  • bleeding gums
  • dry mouth
  • hoarseness of voice
  • loss of taste
  • condition of teeth and gums (ie. cavities)
  • use of dentures
22
Q

Respiratory (RESP)

A
  • difficulty breathing
  • pain on breathing
  • dyspnea
  • cough
  • wheezing
  • sputum
  • hemoptysis
  • snoring or apnea
  • chest wall abnormalities
  • chest pain or chest tightness
23
Q

Cardiovascular (CV)

A
  • rapid or irregular heart beat
  • palpitations or flutters
  • chest pain or pressure
  • high or low blood pressure
  • orthostatic hypotension
  • heart murmur
24
Q

Gastrointestinal (GI)

A
  • difficulty or pain on swallowing
  • heartburn, acid reflux
  • changes in appetite
  • nausea
  • vomiting
  • abdominal pain
  • hematemesis
  • excessive belching or gas
  • diarrhea
  • constipation
  • change in bowel habits
  • pain on defecation
  • rectal bleeding
  • blood in stools or black/tarry stools
  • hemorrhoids
  • jaundice
25
Q

Genitourinary (GU)

A
  • frequency of urination
  • polyuria, nocturia, anuria
  • urgency or dribbling
  • burning or pain during urination
  • hematuria
  • kidney or flank (lower back) pain
  • enlarged prostate
  • dysmenorrhea
  • menstrual regularity and frequency
  • vaginal dryness or itching
  • changes in sexual interest and function
  • discharge or sores
26
Q

Peripheral Vascular System (PVS)

A
  • temperature change (ie. cold or warm extremities)
  • discolouration (ie. cyanosis, pallor)
  • leg cramps
  • varicose veins
  • pain or numbness
  • edema or swelling
  • erythema
  • tenderness
  • reduced pulses
27
Q

Musculoskeletal (MSK)

A
  • muscle cramps or pain
  • joint pain or tenderness
  • joint swelling or redness
  • joint stiffness
  • muscle weakness
  • deformities
28
Q

What are the attributes of a system? (7)

A

SCHOLAR

  • symptoms – what are the main and associated symptoms
  • characteristics – what are the symptoms like
  • history – what has been done so far, has it happened in the past
  • onset – when did it start
  • location – where is the problem
  • aggravating factors – what makes it worse
  • remitting factors – what makes it better
29
Q

What are the steps of conducting a review of symptoms? (3)

A
  1. prepare the patient
  • explain why you are performing ROS
  • ensure patient comfort and privacy
  1. start with general open-ended questions pertaining to each body system
  • ie. do you have any trouble with your heart, do you ever experience any headaches
  1. ask more specific questions (SCHOLAR) as you uncover information
  • ie. where is the chest pain located, does anything make your headaches worse, have you taken any medications that help alleviate the headache
30
Q

How do you use a review of symptoms?

A

as you ask questions from head-to-toe, consider:

  • could this symptom be caused by the patient’s medication(s)
  • does presence of this symptom suggest that the patient’s medication is effective or ineffective
  • does presence of this symptom suggest an undiagnosed condition
  • how do all of the symptoms my patient is experiencing relate to each other
  • what does this symptom tell me about the patient’s overall health status

remember that what you ask in your ROS should be based on your patient history

31
Q

What is a comprehensive assessment? (4)

A
  • best way to assess new patients
  • provides fundamental knowledge about patient
  • helps identify or rule out physical causes related to patient concerns
  • strengthens pharmacist-patient relationship
32
Q

What is a focused assessment?

A
  • efficient way to assess established patients
  • addresses specific concerns and symptoms
  • assesses symptoms restricted to a specific body system
  • applies examination methods relevant to assessment of target problem

PHRM 100 – IMM (22 decks)

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