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SMUPAFall-IPC > Patient-Centered Focus > Flashcards

Patient-Centered Focus Flashcards

Interpersonal patient centered

1
Q

Document Women Pregancy

A

Para- Births include stillborn (P), living children
Gravida- how many times pregnant
Twins= G1, P1 (# not about fetus, about gestational age)
P should = G (except still born, and twins)

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2
Q

Interpret
G4P2113
G3P2TAB1

A 
4 preganance
2 Full term
1 premie
1 Abortion
3 living children

3 pregancy
2 full term
1 elective abortion

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3
Q

TPAL

A

Term Pregnancies
Premature deliveries
Abortions (SAB or TAB)
Living children

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4
Q

WOMEN- add section

A

OB/GYN HX- new subsectioni in PMH

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5
Q

Geriatric-ADD section

A

Comprehensive Assessement
Move after Family HX
Replaces Social HX, include SAFETY section, Paragraph
Functional Assessment

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6
Q

SPLATT

A 
w/in comprehensive assessment- Fall ?
SX- pre and post fall
Previous falls
Location of fall
Activity at time of fall
Time of fall
Traum
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7
Q

Geriatric-ADD section details

A 
Comprehensive Assessement
include: 
DIET
EXERCISE
HABITS
SEXUAL HX
FUNCTIONAL ASMT
SAFETY 
FALLS
TRANSPORTATIN
ACTIVITIES
RELIGION
ADVANCE DIRECTIVES
PT CONCERNS
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8
Q

FUNCTIONAL ASSESSMENT

A 
ADL
IADL
PHYSICAL 
COGNITIVE
PSYCHOSOCIAL
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9
Q

Urinary

A
  1. Dysuria
  2. Urgency
  3. Frequency
  4. Hesitancy
  5. Hematuria
  6. Color changes
  7. Nocturia
  8. Polyuria
  9. Oliguria
  10. Anuria
  11. Change in stream (force amount)
  12. Difficulty emptying
  13. Incontinence
  14. Frequent UTI (>4yr, Y- PMH, N-omit from ROS)
  15. Kidney infection/diseases (Y-PMH, N-omit from ROS
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10
Q

Genital Male

A
  1. Penile discharge
  2. Testicular pain
  3. Masses
  4. Lesions
  5. Semen or ejaculation issues
  6. Impotence (Sexual HX, also HPI if today issues)
  7. Sexual satisfaction (Sexual HX, also HPI if today issues)
  8. Hx STIs (Sexual HX, also HIP if today issues)
  9. Safe Sex px (Sexual HX, also HPI if today issues)
  10. Testicular self exam (HM screen)
  11. Prostate exam (HM screen)
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11
Q

Genital Female

A
  1. Vaginal discharge
  2. Genital pain
  3. Abnormal vaginal bleeding
  4. Dyspareunia
  5. Post-coital bleeding
  6. Age at menarche(OB/GYN HX)
  7. LMP (last menstrual period, date began) (OB/GYN HX)
  8. Flow/timing normal? (OB/GYN HX)
  9. Typical cycle (#days) (OB/GYN HX)
  10. Changes in cycle - duration, frequency (OB/GYN HX)
  11. Dysmenorrhea, pre-menstrual sx’s
  12. Peri – or Post menopausal sx’s
  13. Last PAP (HM screen)
  14. Contraception method (OB/GYN HX)
  15. Sexual satisfaction/Libido (Sexual HX, also HIP if today issues
  16. Hx STI’s (Sexual HX, also HPI if today issues
  17. Safe sex practices (Sexual HX, also HPI if today issues)
  18. Age menopause(OB/GYN HX)
  19. Number of pregnancies (gravida), number of live births (para), number of spontaneous or therapeutic abortions
    Written: G6,P4,SAB1,TAB1**
  20. Delivery type: Spontaneous vaginal delivery (SVD) or C-section (reason) (OB/GYN HX)
  21. Complications during pregnancy or birth(OB/GYN HX)
  22. Breastfeeding (only if relevant) (OB/GYN HX)
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12
Q

Peripheral Vascular

A
  1. Extremity sores (chronic, not healing)
  2. Leg cramps
  3. Varicose veins
  4. Intermittent claudication(YES-PMH, also HPI if today/new issues, NO-STAY IN ROS)
  5. Hx of blood clot in legs (DVT) (YES-PMH, also HPI if today/new issues, NO-OMIT ROS)
  6. Hx of peripheral vascular disease(YES-PMH, also HPI if today/new issues, NO-OMIT ROS)
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13
Q

Musculoskeletal

A
  1. Muscle pain and/or stiffness
  2. Joint pain
  3. Joint swelling
  4. Joint redness
  5. Joint stiffness
  6. Back pain
  7. Arthritis (PMH Illnesses or Injuries/Accidents; N-omit from ROS)
  8. Gout (PMH Illnesses or Injuries/Accidents; N-omit from ROS)
  9. Hx fractures (PMH Illnesses or Injuries/Accidents; N-omit from ROS)
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14
Q

Neurologic

A
  1. Syncope
  2. Focal weakness, paralysis (extremity, face)**
  3. Speech difficulty**
  4. Numbness/decreased sensation**
  5. Paresthesias**
  6. Tremor or involuntary movements**
  7. Seizures**
    All: YES new- HPI, not ROS, Fx Assessment Elders
    YES chronic- PMH, not ROS, Fx Assessment Elders
    N0- INClUDE IN ROS
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15
Q

Hematologic

A
  1. Easy bruising
  2. Bleeding
  3. Hx of anemia (YES-PMH, also HPI if today issues, NO-STAY IN ROS)
  4. Hx past transfusions ((YES-PMH, also HPI if today issues, NO-STAY IN ROS))
  5. HX of Transfusion. Any reactions? (YES-PMH, also HPI if today issues, NO-STAY IN ROS)
  6. Hx hematologic illnesses (YES-PMH, also HPI if today issues, NO-STAY IN ROS)
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16
Q

Endocrine

A
  1. Polyuria (either here or Urinary ROS)
  2. Excessive thirst (polydipsia)
  3. Excessive hunger (polyphagia)
  4. Heat or cold intolerance
  5. Excessive sweating
  6. Change in glove or shoe size
  7. Thyroid disease(YES-PMH, also HPI if today issues, NO-STAY IN ROS
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17
Q

Psychiatric

A
  1. Depression or sadness
  2. Mood changes
  3. Nervousness,
  4. Tension
  5. Stress (recent stressful event) YES-Social HX, also HPI if today issues, NO-STAY IN ROS)
  6. Suicidal ideation (if yes - Hx suicide attempt in past(YES-PMH, also HPI if today issues, NO-STAY IN ROS)
  7. History of mental illness (YES-PMH, also HPI if today issues, NO-STAY IN ROS)
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18
Q
  1. Fever
  2. Chill
  3. Weankenss
  4. Maliase
  5. Fatigue
  6. Sleep Changes
  7. Wt Changes
  8. Appetiti Changes
  9. Recent Trauma
A

General

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19
Q
  1. Rash
  2. Masses
  3. Lesions
  4. Pruritus
  5. Oily or Dry
  6. Changes in color or texture
  7. Changes in temp
  8. Changes in hair
  9. Changes in Nails
A

Skin

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20
Q

Head

A
  1. Cephalgia

2. Trauma

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21
Q
  1. Pain
  2. Discharge
  3. Changes in hearing (hearing aide HM)
  4. Vertigo
  5. Dizziness
  6. Tinnitus
  7. Surgeries (YES-PMH, NO-STAY IN ROS)
  8. Frequent infections (YES-PMH, NO-STAY IN ROS)
  9. Trauma (YES-PMH, also HPI if today issues, NO-STAY IN ROS)
A

Ears

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22
Q

Nose

A
  1. Change in/loss in smell
  2. Pain
  3. Congestion
  4. Rhinorrhea
  5. Pruritus
  6. Epistaxis
  7. Frequent cold or sinus infections (YES-PMH, NO-STAY IN ROS)
  8. Trauma (YES-PMH, also HPI if today issues, NO-STAY IN ROS)
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23
Q
  1. Visual changes
  2. Blurred, partial, double vision
  3. Spots, specks, flashing lights
  4. Pain, redness, discharge
  5. Dry ness or tearing
  6. Photophobia
  7. Icterus
  8. Glass contacts- YES-HM,
  9. Last eye exam- YES-HM,
  10. Eye diseases (YES-PMH, NO-STAY IN ROS)
  11. Trauma surge (YES-PMH, NO-STAY IN ROS)
A

Eye

24
Q

Mouth/Teeth

A
  1. Pain, ulcer, sore
  2. Excess salivation, dry mouth
  3. Change in Taste
  4. Tender or coated tongue, change in appearance
  5. Dental pain , caries, bleeding gums
  6. Halitosis
  7. Sore Throat
  8. Hoarseness
  9. Frequent sore throat (YES-PMH, NO-STAY IN ROS)
  10. Dysphagia
  11. Last dental visit, dentures (HM-any answer)
25
Q
  1. Neck Pain
  2. Stiffness
  3. Lumps or swelling
  4. Lymph nodes pain or swelling
  5. Injury or trauma (YES-PMH, NO-STAY IN ROS)
  6. Goiter (YES-PMH, NO-STAY IN ROS)
A

Neck

26
Q

Breast

A
  1. Lumps
  2. Pain or discomfort
  3. Nipple discharge
  4. Visible Changes
  5. Self exam (HM Y or N) NOT in ROS
    a. When?Frequency? During cycle?
27
Q
  1. Cough, productive
  2. Hemoptysis
  3. Chest pain
  4. SOB
  5. Pleurisy
  6. Wheezing
  7. Hx of Respiratory illness (Asthma, COPD, TB)- (YES-PMH, NO-STAY IN ROS)
  8. Had/Last chest x-ray (YES-HM, NOT-STAY IN ROS)
  9. Had/Last PPD (Results) (+ REAPEAT IN PMH)
A

Respiratory

28
Q

Gastrointesinal

A
  1. Abdominal pain
  2. Nausea, vomiting
  3. Hematemesis
  4. Gas bloating
  5. Melena
  6. Changes in bowel habits-Diarrhea, pain,
  7. Painful BM
  8. Change in color or character of stool
  9. Rectal pain or bleeding
  10. Food intolerance-heartbun, excessive belching, gas
  11. Hemorroids-(YES-PMH, NO-STAY IN ROS)
  12. Jaundice-(YES-PMH, NO-STAY IN ROS)
  13. Gastrointestinal illness- YES-PMH, NO-STAY IN ROS)
29
Q
  1. Chest pain
  2. Palpitations
  3. DOE
  4. Orthopnea
  5. Leg Edema
  6. Paroxysmal Nocturnal dyspnea
  7. Hx of cardia problems- (YES-PMH, NO-STAY IN ROS)
  8. Ever had/last EKG (YES-HM)
  9. Ever had/last heart test (echo , stress) (YES-HM)
  10. Hx of prev cardiac procedures (YES-PMH (or HPI), NO-STAY IN ROS)
A

Cardiovascular

30
Q

Pediatric DOC

A

Birth Hx- prenatal, neonatal, natal, feeding, growth, physical, congitive, social.
Geneitcs in Fam HX
Social Hx- nutrition diet, func/activ, func/psycho
exer/act, school, saftey, Pt and parent concerns

31
Q

Peds ROS

A

Pt actally observes
OMIT test, illnesses, OB, Breast>11, self exams-older adolescents.
PV-Omit

32
Q

ROS Add

A 
General- add alertness energy
Skin- jaundice, rash
Respiratory- add rapid noisy breathing
CV-sweating w/ feeding, cyanosis, edeme, pain in chest
GI- stools issuses
Urinary- issue w/ urine training
Pelvic- foreskin, rash
Neuro- febrile seizures, coordination problems
Endocrine- keep excessvie sweating
33
Q

HEADDSS

A

H- home life; relatiosn foster safety, care, privacy
E- Education, grades, progress, bullying, fighting, adjustments to conflicts, employment goals
A- activities fun, friends, gang, not forced, sports, hobbies, weapons
D- diet, body image, exercise
D- drugs alcohol, caffeine
S- sexual activity, be specific, debut # orientation, assault
S- suicidal idealiton, depression, hurt others

34
Q

Sick Kids

A

Parents- what do you think is going? Concerns?

35
Q

SAFE-DV/IPV

A

S- safety stress- do you feel safe?
A- afraid/Abused
F- Freinds/Family- do they know
E- emergency plan

36
Q

REPEATED HPI

A

PMH, HM, FAMILY HX, OR SOCIAL HX

37
Q

disease vs illness

A 
Disease= our explantin
Illness= patients experience
38
Q

7 Attributs

A 
Location
Quality- description
Quantity(severity) 1-10
Setting- worse with or during?
Time- onset, when, lasting, intermittent?
A- Associated SX. Radiatiing
R- relieving or exacberating factors
39
Q

CAGE

A

Cut back-Have you ever felt the need to Cut down on drinking?

Annoyed-Have you ever felt Annoyed by criticism about drinking?

Guilty- Have you ever felt Guilty about drinking?

Eye opener-Have you ever had to take a drink first thing in the morning (Eye-opener) to steady your nerves or get rid of a hangover?

40
Q

Goal of interview

A
  1. Establish maintain open, trusting, supportive patient provider relastionship
  2. Educate, guide, console, motivate
  3. History to suggest dx
  4. Negotiate a mutual acceptable course of action
41
Q

Patient centerd care

A

Communicate= better outcomes. convery support, care, teamwork
Transparent. Let me research more.
What do you think is going on? Any loved ones w/ similar problem? What have you tried?What are you most concerned about

42
Q

Therapeutic Core

A 
Active listeing
Objectivitiey
Reliability-on time, DO waht you say
RESPECT
GENUINE
EMPATHY
43
Q

RESPECT

A 
Accept them as they are
Nonverbal cues-eye contact
NOn judgemental-tone, face, words
Explain so they understand
THEY watch like a hulk, like you do!
ThINk b4 speak
44
Q

EMPATHY

A

Awareness and insight
listening
AVOID auto-reassuracne

45
Q

ACTIVE Listening

A 
GET out of your head
Step in theirs
BE there. Pt only person in the room
2 min Rule give Pt the floor
IT must have been scary to
IT sounds as thought
46
Q

Addictive questioning

A

reflects what the pt just said and what they didnt say

Sound like your frustrated w/ all these

47
Q

Interchangeable

A

Mirror- This one is the worst

Paraphrasing-Sound like your breathing has gotten

48
Q

adaptive questioning

A

clarification

Do you have the pain when…

49
Q

Facilitation

A

Go on, Tell me more about…

50
Q

Summarize

Transition

A

Summary of pt

Ok, now I’d like to ask about

51
Q

Objectivity

A

separate Pt theaory from sx, but don’t disregard their theory

52
Q

Always ask

A

Have you had other sx
Have had had in the past?
Were you well before this started
Anyone else sick, school, work?
What made you come in today? Any changes?
Is there anything else you like to talk about today?

53
Q

INtro

A

My name is ….
Do you prefer Joe or Mr. Smith
Tell me, what bring you in today.

54
Q

PA

A

We are healthcare professional licenesed in alls states to practice medicine under the supervison of a physician. We perform physic exam, diagnosis, treating, interpret order test, perform procedures, assits in surgery, provide patient education, counsleing, make rounds in clinincs and prescribe mediication..

55
Q

HPI

A

History of present illness
subjective
Pt words only (jargon sometimes) Include 7s each yes to sx ROS, relevant HPI
NO judgemental speech
INclude:
Relevant ROS + and -, PMH, HM, MEDs, Allergies, FH,SH

SMUPAFall-IPC (1 decks)

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