Pt Encounter Script Flashcards
What are the 6 elements of a general health survey?
1) Health
2) Awareness/ LOC
3) Distress
4) Grooming/ hygiene
5) Face
6) Posture/ motor
HAD GFP
General health survey for an average/ well patient
1) Pt is a well-appearing man/ woman who is awake and oriented with no signs of distress.
2) Pt has appropriate grooming and hygiene for this visit and their mood and affect/ facial expression is flat/ cheerful
4) And their posture is upright with appropriate motor activity
ROS: head
Hair loss, scalp pain, and jaw pain (with chewing)
ROS: eyes
Redness, double vision, and blurry vision
ROS: ears
Loss of hearing, ringing in ears, and ear pain.
ROS: nose/ sinuses
Runny nose, stuffy nose, and bloody nose.
ROS: throat
Sore throat, hoarseness, and trouble swallowing
ROS: neck
Stiff neck, changes in ROM of neck, and lumps or bumps in neck.
ROS: cardiovascular
Chest pain, feeling of heart skipping a beat, and heart racing
ROS: respiratory
Shortness of breath, wheezing, and cough.
ROS: GI
Nausea, vomiting, and constipation
ROS: urinary
Difficulty urinating, pain during urination, and change in color or smell of urine.
ROS: genital
Itching, swelling, and pain of genitals
ROS: musculoskeletal
Acute back pain, joint pain, and changes in range of motion of joints.
ROS skin
Rashes, dryness, and itchiness.
ROS: endocrine
Cold or heat sensitivity, excessive thirst, and excessive hunger
ROS: peripheral vascular
Numbness, coldness, and swelling in hands or feet.
ROS: hematologic
Bruising or bleeding, history of anemia, or blood transfusions.
ROS neurologic
Pt denies dizziness, headaches, and changes in memory
ROS: psychiatric
Anxiety, depression, and suicidal thoughts.
Psych exam
-Pt’s fluency and rate of speech are appropriate. She displays logical and organized thoughts.
-Her higher cognitive functioning is intact.
2 depression questions
1) Over the past 2 weeks have you felt down, depressed, or hopeless?
2) Over the past 2 weeks, have you felt little pleasure in doing things?
3 anxiety questions
1) Over the past 2 weeks, have you felt nervous, anxious, or on edge?
2) Over the past 2 weeks, have you been unable to stop or control worrying?
3) Over the past 4 weeks, have you had an anxiety attack; suddenly feeling fear or panic?
What are the social Hx questions?
1) Tobacco
2) Illicit drugs + Rx misuse
3) Alcohol
4) Sexual history
○ Partners (marital status)
○ Protection
○ Preference
5) Home life / abuse
6) Occupation/ military history /travel
7) Exercise and diet + caffeine
What are the 7 attributes of a symptom?
Onset
Location
Duration
Characteristic
Alleviating and aggravating factors
Radiation
Timing
Severity
(OLD CARTS)
List the general order of the steps of a patient exam, before the actual physical exam part
CC
HPI
ROS
Medical Hx
Family Hx
Social Hx
Vital Signs
First 3 (out of 4) steps of a hair/ skin/ nails PE
1) Part hair of scalp and look for lesions, rashes, or infestations
a. No evidence of lesions, rashes, erythema, hypo/hyperpigmentation.
b. And their hair distribution is even
2) Visually assess a patient’s face, ears, and trunk. Turn over arms and move legs to see all sides. Look at palms and soles of feet. Look at and touch their nails and toenails. Look at conjunctiva, lips, oral mucosa using a pen light.
a. No erythema, rashes, lesions, or hypo/hyperpigmentation on the visible skin.
b. No signs of pallor, jaundice, or cyanosis of the oral mucosa, conjunctiva, or palms and soles of the feet.
c. Nail beds are an appropriate color and shape with no lesions or pitting
3) Touch the patient’s arm and leg, and pinch the patient’s skin on their arm and leg
a. Skin is warm and dry with an even texture and has appropriate turgor (mobility and elasticity)
Last step of a hair/ skin/ nails PE
Identify any nevi and counsel patient on ABCDE method to screen for melanoma
a. No nevi identified. You want to look once a month for any suspicious moles or lesions, right when you get out of the shower is a good time to do this, use a hand mirror to look at all the nooks and crannies. When you’re looking at a spot, you want to use the ABCs of melanoma:
i. A: Is it asymmetrical?
ii. B: Are the borders clear or blurry?
iii. C: Is it one color or multiple?
iv. D: Is it bigger than the size of a pencil eraser (about 6mm)?
vi. E: Is it evolving or changing over time?
That’s the most important thing to look out for.
3 steps of a head exam
1) Look at skull and face
a. Pt’s skull is symmetrical + of an appropriate size
b. Face is without involuntary movements, asymmetry, or lesions
2) Palpate skull, face, and mastoid process (posterior auricular) ask if it hurts
a. Mastoid process is without redness or pain
b. Skull is without deformities, hematoma, or inappropriate depressions.
c. Face is without bony deformities, crepitus, or masses
3) Battle sign and raccoon sign are absent with no other signs of trauma