Patient Assessment 1 Flashcards
1
Q
Clinician centered care
A
“The balance of power was centered on the preferences and values of the doctor” reflects
-“find the broken part and fix it”
2
Q
The biopsychosocial model reflects
A
The complex interaction of biological, psychological and social factors. Not
just bio and medical
3
Q
Pioneer of patient centered care
A
Harvey picker
“improving healthcare through the patient’s eyes”
4
Q
Patient centered care
A
Patients want their clinicians to see them as individuals, to understand their concerns, emotions and challenges
5
Q
Relationship centered care
A
“An expansion of patient centered care”
6
Q
What is incorporated in relationship centered care?
A
-The relationship between caregivers and patients/families
-relationship among members of the healthcare team
-caregiver’s relationship with one’s self
7
Q
General steps of patient assessment
A
Preparation
Health history
Physical exam
Assessment
Plan
Documentation/presentation
8
Q
What are you doing during the preparation for a patient encounter?
A
Review the patient’s name and chief concern
Review past and current medical history
Gather tools
PPE/precautions?
Interpreter?
HIPPA
9
Q
Components of taking an adult patient’s health history
A
Patient identifiers
Source/reliability
Chief concern
HPI
PMH
SH
FH
ROS
10
Q
What is a learned skill that requires practice, like any other clinical skill?
A
Medical interview
11
Q
Two main goals for the medical interview
A
Establish a meaningful and caring relationship with your patient
Be a rigorous diagnostician
12
Q
How accurate were medical internists at making the correct diagnosis after history only
A
75%
13
Q
Allowing patients to tell their symptom story is diagnostically helpful, because it will allow us to arrive
A
At the correct diagnosis more often and more quickly
14
Q
“Listen to the patient. He is telling you the diagnosis” quote by
A
Sir William Osler
15
Q
The sole use of clinician centered interviewing results in poor
A
Patient satisfaction, physician frustration, and worse health outcomes
16
Q
Open ended skills are aimed at
A
Getting the patient to tell their story in their own words in a way they want
17
Q
Examples of non-focusing open ended skills
A
Silence
neutral utterances
Nonverbal encouragement
18
Q
Focusing open ended skills
A
Echoes
Paraphrasing
Requests
19
Q
Components of NURS
A
N-name the emotion
U-understanding
R-respect
S-support
20
Q
Difference between empathy and compassion
A
Empathy = capacity to share/resonate others’ emotional state, suffering, or joy
Compassion = Not “sharing” of suffering, but rather feelings of warmth, concern, and care for the other
21
Q
Respecting the emotion
A
“thanks for sharing this with me”
22
Q
Step one, also called
A
Setting the stage
23
Q
“Small talk before big talk”
A
Stage 1
24
Q
What % of our communication to others is nonverbal?
A
80%
25
Examples of positive non verbal communication
Forward lean
Eye contact
Uncrossed arms and legs
Nod
Sit level with patient
26
Chief concern and agenda, step
2
27
Open ended non focusing, step
3, just listen!
28
How long does it take for a physician to interrupt a patient with traditional clinician centered interview?
Less than 30 seconds
29
Focusing the story, obtaining emotional and personal context, step
4
30
What step do we use NURS in?
Step 4
31
Summarize and transition, step
5
32
What are closed ended data gathering skills?
Questions that produce yes/no answers
Or
Questions that produce brief answers
33
A symptom is objective or subjective
Subjective
(Ex. Nausea, headache)
34
A sign is objective or subjective
Objective
(Ex. Murmur, perforated TM)
35
Where are signs identified in the interview?
Physical exam
36
How many systems are there?
19
37
7 symptom descriptors
Onset/chronology
Position/radiation
Quality
Quantification
Related symptoms
Setting
Transforming factors
38
Expand/clarify HPI, step
6
39
“Pertinent positives and negatives” will be uncovered in which step
6
40
Past medical history, step
7
41
Components of PMHx
Adult illnesses
Childhood illnesses
Medications
Allergies
Health maintenance
42
Social history, step
8
43
Review of system, step
10
44
End of interview, step
11
45
SOAP meaning
Subjective, objective, assessment, plan
46
Health history is mostly covered in the ________ and ___________
HPI, ROS
47
Common concerns/symptoms
Fatigue
Weakness
Fever, chills, night sweats
Weight change
Pain
48
Emphasizes physical, psychological, and emotional safety for patients and providers
Informed care
49
Draping and modesty applies to ________ care
Informed
50
What kind of language do we want to use with patients?
Simple, not medical
51
The general survey begins when
Any time the patient is in your view
52
General survey
“Study the whole person, covering the general health state and any obvious physical characteristics”
53
When does the general survey take place in relation to the interview?
Before
54
What are you looking for in the general survey?
Apparent state of health
LOC
Signs of distress
Skin color
Grooming, hygiene
Facial expressions
Odor
Body structure, gait, posture
55
Low grade fever
99-100.4
56
High fever
>103
57
Extremely high fever
>104
58
Normal temperature
97.8-99
59
Normal HR
60-100
60
Aside from rate, what else are we assessing with pulse?
Rhythm
61
Abnormal RR could be evident by
Prolonged expiration phase
62
Auscultatory office blood pressure pros and cons
Common, cheap
Subject to patient anxiety, observer technique, cuff recalibration
63
Ambulatory blood pressure monitoring
Automated: clinical and research “gold standard”
Average of 24 hr blood pressures
More expensive, may not be covered
64
Hypertension definition for office manual or automated
140/90
65
Hypertension definition home automated blood pressure
<135/85
66
Hypertension definition ambulatory 24 hr avg? Daytime? Nighttime?
>130/80
>135/85
>120/70
67
White coat hypertension
A phenomenon in which patients exhibit elevated blood pressure in the hospital or doctor's office but not in their everyday lives
68
Masked hypertension
Low clinic blood pressure, but elevated ambulatory/home blood pressure
69
Nocturnal hypertension
Nocturnal fall of <10% of daytime values is associated with poor cardiovascular outcomes and can only be identified on 24 hour ambulatory bp monitoring
70
Width of cuff should be about _____ % upper arm circumference
40
71
Pre-measurement BP reading steps for accuracy
-avoid caffeine, smoking, exercise for 30 mins prior
-sits for 5 mins prior
-arm free of clothing
-arm roughly at heart level
72
Nociceptive pain
Somatic
73
Neuropathic pain
Pain from damage to neurons of either the peripheral or central nervous system “burning”
74
Central sensitization pain
Alteration of the CNS processing of sensation amplifying signals
Ex. Fibromyalgia
75
Psychogenic pain
Physical cause for pain cannot be identified (common)
76
Idiopathic pain
Chronic pain in the absence of an identifiable physical or psychological cause or pain perceived as excessive for the extent of an organic pathological condition
77
Four As of pain monitoring
Analgesia
ADLs
Adverse effects
Abberant drug related behaviors
78
Is MRI ioninzing or non-ionizing?
Non-ionizing
79
How does MRI work?
Strong, static magnetic field of radiofrequency energy used to excite free protons (located mainly in water) to a higher energy state
80
Indications for MRI
Soft tissues! (Amongst other things)
81
Limitations of MRI
Size restrictions
Time, availability
Presence of ferrous materials
Pacemaker
Cost
82
Is ultrasound non-ionizing or ionizing?
Non-ionizing
83
How does ultrasound work?
Imaging is made possible by the transmission and return of sound waves of high frequency
84
With ultrasound, which structures are dark and which are light
Fluid, blood = black
Bone = white
Organs = various shades of gray
85
Anechoic
Fluid filled area void of any material
86
Hypoechoic
A darker area compared to surrounding tissue
87
Hyperechoic
A brighter area compared to surrounding tissue
88
Fanning
Tilting the probe while maintaining some position on skin
89
Acoustic shadow
Area on the screen void of ultrasound return due to an overlying obstructive structure
90
Color flow doppler
Used in assessing direction of blood flow (Ex. Cardiac ultrasound)
91
Indications for ultrasound
Point of care: ocular, lung, soft tissue, vascular access, thorax-abdominal trauma
Gallbladder: stones
Pelvic: uterus, ovaries, fetus
Cardiac: wall motion, valves, effusion
Renal: obstruction
Neurologic: nerve blocks
92
Advantages of ultrasound
No radiation
Real-time motion images
Procedural assistance
93
Disadvantages of ultrasound
Body habits restrictions
Availability
Interpretation dependent on radiologist/sonographer abilities
94
Nuclear medicine assesses for
Physiology not morphology
95
Indications for nuclear medicine
Lung: V/Q scan (PE)
Liver: HIDA scan (gallbladder obstruction)
Bone: bone scan
Thyroid: Radioactive iodine uptake
Heart: Myocardial perfusion scintigraphy
PET: Cancer work-ups
96
Advantages of nuclear medicine
Cancer treatment
Head-to-toe scanning
Organ function assessment
Less radiation
97
Disadvantages of nuclear medicine
Small exposure to ionizing radiation
Potential for allergic reactions
Availability
98
Electrocardiogram
Record of the electrical activity of the heart
99
How does x-ray work?
Exposure of silver bromide and silver iodide to x-rays causes deposition of metallic silver, which appears darker on film
100
Standard x-rays are referred to as
Plain films
101
Digital radiography
Uses electronic sensors rather than silver sheets to measure attenuation coefficient of tissue through which x-rays have been passed through.
Data then processed into images on monitor.
102
Fluoroscopy
Uses plates covered with phosphor which fluoresces when exposed to x-rays (cardiac Cath)
103
On x-ray, high density structures are ______, while air appears ________
Radiopaque, black
104
What is the preferred CXR view?
PA view
105
Where is the plate placed in the PA view?
Over anterior aspect
106
Contrast studies, mostly used for which systems
GI, GU, vascular
107
What is a downside to contrast studies?
Reactions
Minor: n/v, flushing
Moderate to severe: pulmonary edema, bronchospasm, apnea
108
What can we do to prevent severe reactions in contrast studies?
Prophylax with steroids or benadryl
109
What are plain films good for?
Skeletal: Fx, alinements
Chest: mass,fluid, air
ABD: air, stool
Soft tissue neck: soft tissue swelling, air/gas, patency
110
What are plain films not too good for?
Ligament/cartilage
Head injury
Non-radiopaque foreign bodies
111
How does a CT scan work?
Highly restricted x-ray beams move 360 around desired area
112
Is CT ionizining or non-ionizing?
Ionizing
113
CT indications
IV and PO contrast
CT angiography
Renal function
114
What is a CT less useful for?
Intracranial pathology
Spinal/nerve
Muscle
Cartilage, ligament
Pregnant or pediatric patient
115
No increase risk of cancer below _____ rads
5
116
What are some questions you should be asking in the history for the dermatology patient?
Why now?
Where did it start?
Does it migrate?
Have you had this before?
Any recent contacts who had something similar?
Associated symptoms?
Medications?
New products?
117
Dermatofibroma
Benign fibrous tumor of the skin
118
Keloid
Hypertrophic scar, elevated beyond site of original injury
119
Purpura
Subdermal bruising
120
Factors that influence severity of burns
Rate of heat transfer
Thickness of affected skin
Temperature
Duration of exposure
121
Deep partial thickness
Blisters, painful to pressure only
Easily unroofed, waxy
122
Full thickness
Not painful
Leathery
May not blanch
123
Moderate burn injury can be treated in what setting
Hospital admission, but not burn center
124
Management of thermal burns
Cooling
Pain management
Fluid management
Airway
Cleaning/debriding
Dressings
Infection
Tetanus prophylaxis
Referral
125
Avoid examining the ______ and then returning to the ______
Feet or pubic area
Face
126
It is conventional for the examiner to be on the patient’s ________ side
Right
127
Four cornerstones of the physical exam
Inspection
Palpation
Percussion
Auscultation
128
The bell of the stethoscope is best for ______ pitched sounds
High
129
The diaphragm of the stethoscope is best for _______
Low
130
OLDCARTS
Onset
Location
Duration
Character/quality
Associated symptoms
Radiation
Timing
Severity
131
Flesh colored
No change from surrounding normal skin
132
Battle’s sign
Bruising behind the ears, indicative of a basilar skull fracture
133
Raccoon eyes
Bruising around the eyes (indicates skull fracture)
134
What viral etiologies could cause enlargement of the salivary glands?
Mumps (parotitis)
135
What bacterial etiologies could cause enlargement of the salivary glands?
Acute parotitis
Tuberculosis
Actinomycosis
136
What pulse site do you want to check on the head?
Temporal
137
Name the lymph nodes of the head and neck
Preauricular
Post auricular
Occipital
Tonsillar
Superficial cervical
Submandibular
Submental
Deep cervical chain
Posterior cervical chain
Supraclavicular
138
What do lymph nodes do?
Act as fighters against foreign invasion of bacteria, viruses, cancer cells or toxins
139
Lymphocytes originate from
Stem cells
140
Amorosus Fugax
Can’t see out of one eye
141
Seat belt sign
Can indicate injury to great vessels
142
Ligature marks
Indicates strangulation or use of restraints
143
Possible cause for tracheal deviation?
Pneumothorax
144
Enlarged supraclavicular node indicative of
Advancing gastric cancer
(Virchow’s node)
145
Enlarged pre-auricular associated with
Otitis externa
146
Enlarged posterior cervical with sore throat may indicate
Mono (EBV)
147
Enlarged epitrochlear node may be early indication of
HIV
148
Two approaches to thyroid exam
Anterior
Posterior
149
If thyroid is enlarged, you should
Auscultate for the presence of a bruit
150
What should you always do before palpating carotid artery?
Auscultate! (Exception to the rules)
151
You should palpate carotid pulse at what 3 locations
Base
Cricoid level
Mandible
152
CMS
Centers for Medicare and Medicaid Services
153
Two components to billing
MDM (medical decision making)
Time
154
4 categories of Medical Decision Making
Straightforward
Low
Moderate
High
155
HPI is more for _______ visits
acute
156
When documenting physical exams, pick either ________ or __________
Body areas
or
Organ systems
157
RVU
Relative value unit
158
Medicare fraud
Providing false information to claim medical reimbursements beyond the scope of payment for actual healthcare services rendered
159
Medicare abuse
Describes practices that, either directly or indirectly, result in unnecessary costs to the Medicare program
160
Both fraud and abuse can expose providers to ______ and ________ liability
Criminal
Civil
161
The patient’s record is a
Legal document
162
The medical record establishes your _______ as a health care provider
Credibility
163
Levels of E/M services are based on 4 levels of history
Problem focused
Expanded problem focused
Detailed
Comprehensive
164
When does comprehensive typically apply?
1st time seeing patient
Inpatient admissions
165
Orders should go under the ______ portion of your SOAP note
Plan
166
Problem list:
Running list of active, remote, or resolved medical complaints that the patient has been evaluated for in office
167
Gravida
G - number of pregnancies
168
Para
Births delivered after 20 weeks (viable or non viable) includes multiples
169
Documentation of OB history usually follows short term notation of
G-P-A
170
LNMP
Last normal menstrual period
171
CAGE questions in context of
Alcohol abuse
172
How many systems should be reviewed according to Dr. Geralds?
14
173
Assessment aka
Differential diagnoses
174
Plan divided into 5 sections
1. Diagnostics
2. Therapeutics
3. Patient education
4. Consents/referrals
4. Disposition plan
175
Alliance=
Compliance!
176
Four steps to a DDx
1. Acquire data
2. Identify key features
3. Develop problem list
4. Create DDx
177
Flourescein stain
Pattern of dendrites associated with herpes zoster opthalmicus
178
Gradual hearing loss could be a ______ etiology
Viral
179
Sudden hearing loss could be a _______ etiology
Vascular or autoimmune
180
Patient will complain of ______ in sensorineural hearing loss
People mumbling
Noisy rooms make it worse
181
Ramsey hunt syndrome
Herpes Zoster oticus
182
Tinnitus associated with hearing loss, think
Meneire’s disease
183
If popping sounds in ear, think
TMJ
184
Dizziness while seated=
Arrhythmia
185
Dizziness while just moving head
Labyrinthitis
186
Dizziness that is worse with movement =
Benign positional vertigo
187
Losing balance sensation
CVA
188
Dizziness at rest
Ménière’s disease
189
Dix-Hallpike maneuver
Rapidly moving the PT from a sitting position to the supine position with the head turned 45 degrees to the right = for benign positional vertigo
190
Whisper test is testing which CN
CN 8
191
Weber test is testing
Lateralization
192
Normal Rinne test
Air condition greater than bone conduction
193
What technique should we use on pediatrics for otoscopic exam?
Pull down and back
194
Pneumatic otoscope tests for
Ability of TM to move
If limited movement = could be fluid/infection etc
195
______ is the most frequent cause of colds
Rhinovirus
196
Hutchinson’s sign
Tip of nose affected by zoster and usually indicates ocular involvement
197
You must use a _______ when inspecting the nose and mouth
Light
198
What can you do to the sinuses to assess for fluid/infection?
Percuss
Transillumination
199
Lips observe
Color and moisture
Symmetry
Edema
200
Can candidal thrush be scraped off
Yes
201
Aphthous ulcers
“Canker sores”
Small painful round ulcers in the oral mucosa of unknown cause
202
Trismus
Inability to open the jaw, can be associated with peritonsillar abscess
203
Ludwig’s angina
Submandibular space infection
Most serious complication is edema of the glottis
Airway compromise can occur
204
Strep throat swab sensitivity
90-95%
205
EBV IGG and IGM is more or less sensitive than mono-spot
More
206
Sinusitis imaging indications
Limited to atypical presentations or treatment failures
207
Soft tissue neck x-ray indications
Epiglottitis
Retropharyngeal abscess
Ludwig’s angina
Foreign body
Croup
208
Normal prevertebral measurements
<6 mm at C2
<22 mm at C6
209
Flexible laryngoscopy
Allows for visualization of airway using a small camera
210
Flexible laryngoscopy indications of
GERD, dysphagia
Stridor
Hoarseness
Inhaled foreign object
211
Barium swallow is a type of
Contrast fluoroscopy
212
Indications for barium swallow
Choking
Dysphagia
Aspiration
Hiatal hernia
GERD
Enlarged veins, tumors, polyps
213
Test for determining the clarity and sensitivity of hearing
Audiometry
214
Indications for audiometry
Routine adolescent screening
Reported hearing deficit
Screening for high risk pt’s
