Lecture Material Week 3 Flashcards
How do you transition out of the HPI?
Smooth transition so patient is aware of change
Start with open ended questions
“How is your general health?”
Date gathering, slightly more clinician centered ?s
What mnemonic is used for the PMH?
A: adult illness/allergies H: hospitalizations I: Immunizations S: surgeries T: trauma O: oral meds R: Reproductive (LMP, menopause) Y: youth illnesses
What goes into the adult illnesses section of the PMH?
Anything major and chronic
Avoid self limited like URI
Hospitalizations include
Any stay and why
ED visit, CDU visits, longer stays
Include major diagnoses and year
Many years ago(25+), can say “remote”
Immunization info includes:
What, When, Up to date
Include reactions
What is Guillain-Barré syndrome?
body’s immune system attacks your nerves. Weakness and tingling in your extremities are usually the first symptoms. These sensations can quickly spread, eventually paralyzing your whole body. In its most severe form, Guillain-Barre syndrome is a medical emergency requiring hospitalization.
Although uncommon, can be triggered by severe vaccination reaction to influenza vaccine
What pts should avoid varicella vaccinations?
Those with egg shell allergies/reactions
What gets documented in the surgery portion of the PMH?
Reason, what was done, when
any complications
what bones were broken
residual disabilities
What “rights of medication” must be included?
Drug Dose (with units) Frequency Duration Side Effect
What gets included in the reproductive history?
Women's LMP (last menstrual period) Menopause and year G/P gravid/ parity First menses Contraceptives IPV (intimate partner violence) STD history Fertility (if relevant)
What do you include in the youth illness section of the PMH?
Major conditions (use judgment if relevant)
Particularly those w/long term sequela
Recurrent infections
Could indicate gammopathy (antibody probs)
Record as much as possible for when, circumstances, complications, treatments
Who is included in the FH?
First degree relatives (sibling, parents, grandparents)
Spouse- for fertility & genetic counseling
What is included in FH?
Relationship
Age
Health Status
Diseased** vs. living
**Think he meant deceased….
Billing will not accept “noncontributory”
What is mnemonic for the SH?
F: family/food/faith
L: living arrangements
A: activity
M: marital status
E: education/economic/ exercise/ exposure
S: screenings/ sexual history/ substance abuse/ safety
A comprehensive exam would include ____ of SH
While a focused exam would include____
as many components as possible
those pertinent to condition
What are the 5 Ps?
Sexual History: Partners Practices Prevention of pregnancy Protection from STD Past STD
What are some safety measures screenings?
Seat belt use Drinking/texting while driving Helmet use with motorcycles/bicycles Safety in home: firearms, smoke detector, grab bars in bath Pool fenced, pool alarm Sunscreen Water sports: flotation devices Eye protection
What are some common diseases that increase risk factor based on family health?
Cancers: Breast, Ovarian, Prostate, Colon
Heart: Hypertension, Hyperlipidemia
Psych: Depression, Schizophrenia, Suicide, Alcoholism
Autoimmune: RA, SLE
Endocrine: Diabetes, Thyroid disease
CMS guidelines identifies how many ROS?
How many for highest billing?
14
12 for highest billing
#of symptoms in each discretion of providers
What is ROS? What type of info gets recorded
Inventory of organ system related specific symptoms
Document positives and negatives
ROS Organ/break-up
Constitutional Eyes ENT CV Respiratory GI GU MSK Neurological Psychiatric Endocrine Hematologic/Lymph Allergic/ immunologic Integumentary
What is objective data?
What is observed
What test results would you document?
Pertinent results
What is the MDM?
Medical Decision Making
ED environment
Narrative of hypotheses and deductive process, why you did what you did
