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PHYSICAL DIAGNOSIS > M1: Medical History > Flashcards

M1: Medical History Flashcards

0
Q

First step in establishing patient ________ and building a good _______________.

A

Rapport. Doctor-Patient Relationship.

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1
Q

Can already be made from a good clinical history 80% of the time

A

Diagnosis

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2
Q

Patients report the story of an illness as they have lived and remembered it. Varies with age, socioeconomic status, culture and experiences.

A

History

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3
Q

Are a universal human experience, but often have unique personal meaning.

A

Symptoms

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4
Q

Fact finding & Investigation about the disease. Observation of patient’s behavior and what the illness means to them. A skill and an art.

A

History taking

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5
Q

Requirements for History taking: Ability to _________.

A

Listen

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6
Q

Requirements for History taking: Ask ________ questions.

A

Common sense

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7
Q

Requirements for History taking: Good _________.

A

Intentions

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8
Q

True statement

A

Fact

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9
Q

Consists of facts that are arranged in a useful manner

A

Information

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10
Q

A history is not simply a collection of facts. The facts must be placed in a form that makes them ________.

A

Informative

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11
Q

Is the explanation the clinician brings to the symptoms. Leads tp the diagnosis and management plan.

A

Disease

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12
Q

Is how the patient experience the symptoms shaped by previous experiences, how symptoms affect daily living, culture, age and expectations about medical care. _________ must take into account both.

A

Illness. Health History.

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13
Q

Date and time of examination. Identifying data: name, age, sex, ethnicity, civil status, religion and address. Source of history and reliability. Sources of referral.

A

General Data

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14
Q

Main reason the patient seeks medical attention. Usually have a single symptom, but may be more. Recorded in patient’s own words. Be careful about recording a diagnosis in this areas.

A

Chief complaint

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15
Q

Clear, chronological narrative account of present problem. Detailed progression and regression of symptoms very important. Includes prior investigation, confinements and treatments if any. Sequential presentation.

A

History of Present Illness

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16
Q

HPI: Avoid __________.

A

Medical terminology

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17
Q

HPI: Must be written or presented in ________ & grammatically correct language.

A

Concise

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18
Q

HPI: Ability to discern what is ________ & ________ data will come as you learn more about the pathophysiology of the disease.

A

Essential & Important

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19
Q

Ask about symptoms in the other major body systems NOT mentioned in HPI.

A

Review of Systems

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20
Q

Review of Systems: Identify ________ the patient has not mentioned so that they are not missed.

A

Problem

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21
Q

Review of Systems: Identify ________ of other diseases the patient may not know about.

A

Symptoms

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22
Q

Review of Systems: Identify symptoms which may be _________ for present illness.

A

Risk factors

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23
Q

If symptoms appear to be related to chief complaint, move ROS to

A

HPI

24
Q

Is the key for a good ROS

A

Systematic Approach

25
Q

Controversial position in Health History. May be done during Physical Exam. Include pertinent positives and negatives.

A

Review of Systems

26
Q

Present known medical problems. Note when diagnosed, meds if any & regular check-up. Current medications with doses, previous illness/confinement/surgery/BT, allergies and immunizations.

A

Past Medical History

27
Q

Diseases among first or second degree relatives of the patient, listed according to disease, include age at onset and if cause of death. Review certain conditions (HPN, HD, DM, Ca, Thyroid disease, Seizure & Psychiatric disorders) if considering infectious disease, may require if any family member also have symptoms.

A

Family History

28
Q

Includes smoking, alcohol intake, illicit drug use, work/occupation, diet & exercise, water supply & living conditions if necessary, sexual preference & activity and OB-Gyne History.

A

Personal and Social History

29
Q

Interview sequence: ________ the patient and _______ rapport.

A

Greeting. Establishing.

30
Q

Interview sequence: ________ the patient’s story.

A

Inviting

31
Q

Interview sequence: Establishing the ________ for the interview.

A

Agenda

32
Q

Interview sequence: ________ and ________ the patient’s story, generating and testing diagnostic hypotheses.

A

Expanding & Clarifying

33
Q

Interview sequence: Creating a shared _______ of the problem.

A

Understanding

34
Q

Interview sequence: _________ a plan.

A

Negotiating

35
Q

Interview sequence: Planning for ________ and ________ the interview.

A

Follow-up & closing

36
Q

Interview Strength: Used _______ and allowed patient to _______.

A

Open ended. Talk.

37
Q

Interview Strength: Used ________, ________ and ________.

A

Facilitation, Clarification/Repetition and Summary

38
Q

Interview Strength: _________ led patient to remember certain symptoms or health history.

A

Pertinent questions

39
Q

Interview Strength: ________ & ________ approach.

A

Nonjudgmental & Nonthreatening

40
Q

Interview Strength: Asked for ______ & about patient’s ________.

A

Questions. Concerns.

41
Q

Interview Strength: _________ plans. Time for ________.

A

Well-explained. Patient education.

42
Q

Interview Strength: Make environment as ________ and _______ of distractions as possible.

A

Private & Free

43
Q

Interview Strength: Never make ________.

A

Assumptions

44
Q

Interview Strength: ________! Follow leads given by the patient asking more _______.

A

Listen. Direct question.

45
Q

Interview Strength: Be aware of both ________ and ________ cues from patient & relatives. And beware of your _______ as well.

A

Verbal & Non-verbal. Own.

46
Q

Interview Strength: Be aware of your _________ and _________ at all times.

A

Appearance & Professionalism

47
Q

The more you know, the more _______ your history becomes.

A

Pertinent

48
Q

Let urgency of the patient’s condition be your ______.

A

Guide

49
Q

Documentation of patient’s medical history and care.

A

Medical chart/record

50
Q

For record of patient’s current status, communication with other parties involved in patient’s care, continuity of care, quality assurance, education and research. Always consider patient’s confidentiality.

A

Medical chart/record

51
Q

Guide for Ethics and Professionalism

A

Tavistock Principles

52
Q

Tavistock Principle: People have a right to health and healthcare

A

Rights

53
Q

Tavistock Principle: Care of individual patients is central, but the health population is also our concern

A

Balance

54
Q

Tavistock Principle: In addition to treating illness, we have an obligation to ease suffering, minimize disability, prevent disease and promote health.

A

Comprehensiveness

55
Q

Tavistock Principle: Health care succeeds only if we cooperate with those we serve, each other, and those in other sectors.

A

Cooperation

56
Q

Tavistock Principle: Improving health care is a serious and continuing responsibility

A

Improvement

57
Q

Tavistock Principle: Do no harm

A

Safety

58
Q

Tavistock Principle: Being open, honest and trustworthy is vital in health care

A

Openness

PHYSICAL DIAGNOSIS (5 decks)

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