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Clinical Applications > Lecture Material Week 3 > Flashcards

Lecture Material Week 3 Flashcards

1
Q

How do you transition out of the HPI?

A

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

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2
Q

What mnemonic is used for the PMH?

A 
A: adult illness/allergies
H: hospitalizations
I: Immunizations
S: surgeries
T: trauma
O: oral meds
R: Reproductive (LMP, menopause)
Y: youth illnesses
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3
Q

What goes into the adult illnesses section of the PMH?

A

Anything major and chronic

Avoid self limited like URI

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4
Q

Hospitalizations include

A

Any stay and why

ED visit, CDU visits, longer stays
Include major diagnoses and year
Many years ago(25+), can say “remote”

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5
Q

Immunization info includes:

A

What, When, Up to date

Include reactions

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6
Q

What is Guillain-Barré syndrome?

A

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

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7
Q

What pts should avoid varicella vaccinations?

A

Those with egg shell allergies/reactions

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8
Q

What gets documented in the surgery portion of the PMH?

A

Reason, what was done, when
any complications
what bones were broken
residual disabilities

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9
Q

What “rights of medication” must be included?

A 
Drug
Dose (with units)
Frequency
Duration
Side Effect
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10
Q

What gets included in the reproductive history?

A 
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)
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11
Q

What do you include in the youth illness section of the PMH?

A

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

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12
Q

Who is included in the FH?

A

First degree relatives (sibling, parents, grandparents)

Spouse- for fertility & genetic counseling

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13
Q

What is included in FH?

A

Relationship
Age
Health Status
Diseased** vs. living

**Think he meant deceased….

Billing will not accept “noncontributory”

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14
Q

What is mnemonic for the SH?

A

F: family/food/faith
L: living arrangements
A: activity
M: marital status
E: education/economic/ exercise/ exposure
S: screenings/ sexual history/ substance abuse/ safety

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15
Q

A comprehensive exam would include ____ of SH

While a focused exam would include____

A

as many components as possible

those pertinent to condition

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16
Q

What are the 5 Ps?

A 
Sexual History:
Partners
Practices
Prevention of pregnancy
Protection from STD
Past STD
17
Q

What are some safety measures screenings?

A 
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
18
Q

What are some common diseases that increase risk factor based on family health?

A

Cancers: Breast, Ovarian, Prostate, Colon
Heart: Hypertension, Hyperlipidemia
Psych: Depression, Schizophrenia, Suicide, Alcoholism
Autoimmune: RA, SLE
Endocrine: Diabetes, Thyroid disease

19
Q

CMS guidelines identifies how many ROS?

How many for highest billing?

A

14
12 for highest billing
#of symptoms in each discretion of providers

20
Q

What is ROS? What type of info gets recorded

A

Inventory of organ system related specific symptoms

Document positives and negatives

21
Q

ROS Organ/break-up

A 
Constitutional
Eyes
ENT
CV
Respiratory
GI
GU
MSK
Neurological
Psychiatric
Endocrine
Hematologic/Lymph
Allergic/ immunologic
Integumentary
22
Q

What is objective data?

A

What is observed

23
Q

What test results would you document?

A

Pertinent results

24
Q

What is the MDM?

A

Medical Decision Making
ED environment
Narrative of hypotheses and deductive process, why you did what you did

25
Q

How is the A/P set up?

A

All problems listed (most severe to secondary issues)
OAPs after
Appropriate use of suspected or X vs Y
Syncopal event: suspected cardiogenic vs autonomic
Plan of care
Numbered list
Including tests, therapies, consults, etc

26
Q

How do you close interview?

A 
Share info with pt
Collaborate treatment
Answer Questions
Educate/Counseling
     Small increments of info with assessment of understanding
Evaluate & correcting health beliefs
Acknowledge and provide support

Clinical Applications (4 decks)

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