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Health and Physical Examination > Lecture 1 E1- Patient history pt 1 > Flashcards

Lecture 1 E1- Patient history pt 1 Flashcards

1
Q

what is a comprehensive assessment (3)

A
  • for new patients in office or hospital
  • provides fundamental and personalized knowledge about the patient
    (family history, surgical history, etc)
  • provides baseline for future assessments
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2
Q

what type of assessment strengthens clinician patient relationship

A

comprehensive

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3
Q

what type of assessment helps identify or rule out physical causes related to patient concerns

A

comprehensive

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4
Q

what type of assessment creates a platform for health promotion through education and counseling

A

comprehensive

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5
Q

what type of assessment develops proficiency in the essential skills of physical examination

A

comprehensive

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6
Q

what specialties mainly use comprehensive exams

A

family medicine and internal medicine

new and returning for care patients

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7
Q

what is a focused assessment (4)

A
  • majority of assessments
  • occurs in any specialty of medicine
  • addresses focused concerns or symptoms
  • assesses symptoms restricted to a specific body system
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8
Q

what type of assessment applies exam methods relevant to assessing the concern or problem as precisely and carefully as possible

A

focused

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9
Q

what is a routine assessment

A
  • similar to comprehensive- but done after you’ve done a comprehensive to prevent/screen disease (yearly follow ups)
  • should be performed annually in adults and more frequently in young children
  • review of previously acquired comprehensive history
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10
Q

what type of assessment considers screening exams

A

routine

(testicular, rectal, breast, pelvic exam, PAP)

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11
Q

what is subjective data collection (+2 examples)

A
  • what the patient tells you
  • fever would be subjective if the patient said they had one or if they didn’t have a thermometer
    -labs a patient brought to you that someone else acquired
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12
Q

what is objective data collection

A
  • what you see with exam
  • fever in clinic
  • labs YOU ordered to assess the problem YOU saw
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13
Q

what is the comprehensive health history

A
  • acquiring the health history is one of the most important skills in medicine
  • acquiring all past medical, social, environmental factors in the patients life
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14
Q

what are the benefits of a good health history

A
  • get to know the patient and their health and social concerns
  • gain the patient respect and trust
  • allows you to formulate aa good differential diagnosis
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15
Q

what is a differential diagnosis

A

list of diseases you have comprised as possible diagnoses based on what the patient tells you

(try to think of 5 per chief complaint)

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16
Q

who are the 2 experts in a comprehensive health history

A
  • the patient, an expert on the experience of illness and the unique context in which it has occurred

-the clinician, an expert on the diagnosis and management of illness

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17
Q

what is the history of present illness (HPI)

A

where you tell the patients story
- Chief Complaint goes here
- have to do it well enough that another provider could read and come up with same plan and diagnosis
-subjective info goes here

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17
Q

what is classified as source of history (Ident. data and source of history component)

A
  • patient, family member, friend, police officer, EMS, medical records
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17
Q

what are the 7 components of every comprehensive history?

A
  1. Identifying data/ source of history
  2. chief complaint (CC)
  3. history of present illness (HPI)
  4. past medical history (PMH)
  5. family history (FH)
  6. social history (SH)
  7. review of systems (ROS)
17
Q

what is classified as identifying demographics (Ident. data and source of history component)

A
  • legal name, preferred name, gender, sex at birth, medical record number, DOB
  • usually included on patients chart or EMR
17
Q

what is considered reliability (Ident. data and source of history component)

A

-reliability of information obtained
- varies according to the historians memory, level of honesty, and mood ( or if someone else is speaking for them)

17
Q

What are the two subcomponents of a chief complaint

A
  1. patients words on why they are seeking care
    - quote/ not to quote?
    - quote “my foot hurts” “ I am having a hard time breathing” usually if patient said it themselves
  2. what if patient doesn’t have a complaint?
    - often in routine annual visits or establishing care
    - “I am here for routine checkup”/ “I was admitted for my heart” , annual exam, med refill
18
Q

what is the only section subjective information should go

A

HPI

19
Q

how to document an HPI

A
  • document in paragraph form, using correct english
  • document in chronological order
  • subjective info only
  • be succinct and to the point ( dont repeat words/phrases
  • only use approved medical abbreviation
20
Q

how to open HPI

A

open HPI with patient identifiers and if historian is someone other than patient ( include race only if pertinent to treatment for diagnosis)
(daughter speaking for mom because of dementia)

21
Q

what are the 7 parameters of a symptoms (CC)

A

LOCATES
location, onset, character, factors/symptoms, timing, environment, severity

22
Q

what is Location of a CC

A
  1. where is it?
    - point to location
    - where was it when it started (vs now)
  2. does it radiate
  • has it progressed or changed
  • if no area (nausea) bypass and move on
23
Q

what is onset in CC

A
  1. when did it start
    - numbers of minutes, hours, days ago
    - DO NOT only document specifics dates or times
    - now v then
24
Q

what is character in CC

A
  1. what does it feel like
  2. can you describe the symptom
  3. give examples
    - pain: dull, sharp, stabbing
    - dizziness- room going black or spinning

if pt cant describe the pain chart that and move on

25
Q

what are factors in CC

A

Aggravating and Alleviating factors
1. what makes it better/worse ( space out when asking)
- medication
-food
-sleep
-activity

26
Q

what are associated symptoms in CC

A

1.based upon your differential diagnosis
- do you have….
- are you experiencing…

27
Q

what in timing in CC

A
  1. is it constant
  2. does it come and go (how long does it las then completely go away)
  3. does it wax and wane
  4. how long does it last
28
Q

what is environment in CC

A
  1. what were you doing/where were you at when it started
  2. consider
    - environmental factors
    - personal activities
    - emotional reactions
29
Q

what is severity in CC

A
  1. pain is assessed on numeric scale of 0-10
    - 0 no pain
    -10 worst pain of your life
  2. non pain related symptoms
    - assessed by effect on quality of life
    - anxiety, shortness of breath
  • document things that rule out your differentials
30
Q

what should any provider be able to recognize by the end of your HPI

A

what your differential diagnosis is

31
Q

what is PMH

A

-past medical history

-belong sin past history section

-adult/childhood illnesses, OBGYN, psych, past hospitilizations

32
Q

what is PSH

A

-past surgical history

-belongs in past history section

  • with dates if possible
    ex; laparscopic cholecystectomy 2014
33
Q

what is health maintenance, what section does it belong

A

-belongs in past history section

  • immunizations
    -screening tests (cholesterol, cscope, mammorgram)
34
Q

Where do medications belong

A

past history

-including OTC, herbal
- include name, dosage, route, frequency, compliance

35
Q

where does list of allergies belong

A

-Medical allergies in PAST HISTORY
- Environmental (or food) allergies belong in PMH section

  • with reactions stated if known
  • if unknown write reaction unknown
36
Q

what is family history

A

-document age, health, or age and cause of death of immediate relatives

-parents (father deceased at 57 MI)
- siblings (sister living 42- HTN, DM)
- grandparents (unknown-both parents were adopted)

37
Q

what is included as personal and social history

A

home life
relationship status
support system
occupation
level of education
tobacco
ETOH
illicit drug use
attempts to quit
exercise/activity
sexual history
hobbies
safety measures
ADLs
alternative health practices
religious/spiritual
sources of stress
other healthcare providers
pets
advanced care plan (living will, advanced directives, code status)

38
Q

What is the review of systems

A

-utilized to ensure there are no other symptoms missed when asking HPI
(covers head to toe systems)
(focused on organs related to the CC)

39
Q

in a comprehensive exam how many systems should be reviewed in review of systems part of exam

A

at least 10 systems (NOT body parts)
- ask at least 2 symptoms in each area

-see ROS cheat sheet

40
Q

what are pertinent positives and where do they belong

A
  • in ROS documentation
  • PRESENCE of a symptom that helps substantiate or identify a patients condition

-ex; patient admits to a fever, fatigue, vomiting, diarrhea

41
Q

what are pertinent negatives and where do they belong

A

-in ROS documentation
- ABSENCE of a symptom that helps substantiate or identify a patients condition

-ex; patient denies rash, chest pain, dyspnea, abdominal pain, hematemesis, melena

42
Q

what should be documented in HPI (coming back to it)

A

anything discovered in the ROS, FH, PMH medication history, social history- positive or negative- that is pertinent to the CC should be documented in the HPI

Health and Physical Examination (3 decks)

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