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PNP: Physical Assessment > Session 1: History > Flashcards

Session 1: History Flashcards

1
Q

SHEEADSS I’M Very Good

A

Strengths: strengths or interests

Home: household relationship/family dynamics

Education/employment: school, grade, etc.

Activities

Disabilities/drugs

Sleep/safety/self image/sleep sexuality/suicide/self mutilation

Internet

Media

Violence

Gang

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2
Q

CAGE Questionnaire

A

Four-question screening tool that evaluates substance use

*Can also be used to identify patterns, consequences, and tolerance of alcohol and other drugs

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3
Q

Inventory History

A

Listed problems that the patient is asked and checks off if they have; used more in adult medicine

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4
Q

Problem-focused history

A

Taken for acute illness

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5
Q

Interim History

A

History of what has happened between last visits

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6
Q

Recapitulation

A

Useful when a long complicated history or unusual history is presented
*Summarize frequently, especially with unusual histories

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7
Q

Sentence Completion Game

A

Psychodiagnosis/type of communication tool

*Give the first part of the sentence, child completes the second half of the sentence

Ex: I feel bad when I…

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8
Q

Developmental Considerations when taking history of baby 0-8 Months (3) Overview…

A
  1. Examine the child in the mother’s lap
  2. Once child is able to grasp, give the tongue blade to the child and see what the infant does with it
  3. Show parents how to react to the child
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9
Q

Communication with Child 0-2 months old (3)

A
  1. Note child’s ability to self-quiet and observe tracking behaviors
  2. Engage the infant by being face-to-face
  3. Watch them coo
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10
Q

Communication with Child 3-7 months old (5)

A
  1. Note social responsiveness
    - -Should be very social: smiling, peek-a-boo, etc.
  2. Reaching out play
  3. Mother-child interactions
    - While you watch interactions, note if they are using legs and hands equally
  4. How does child use hands and mouth in exploration?
  5. How does the parent see the child?
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11
Q

Communication with Child 8-12 months old (5)

A
  1. At 8 months –> object permanence and infant hatching occurs (coming in to his or her own)
  2. Greater sense of self
  3. If you take off something, put it back on to make sure infant feels safe
  4. Put stethoscope on mom’s arm first, then infant’s chest
  5. Develops separation anxiety
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12
Q

Communication with Child 12-18 months old (3)

A
  1. Age of separation anxiety
  2. Observe the child’s social distance - the limit of proximity that the child allows you before showing signs of distress
  3. Does child appear depressed? baby’s reflect maternal depression
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13
Q

Communication with Child 18 months-2 years old

A

18 months-2 years old = Toddlerhood

  1. Communication by observation
    - Look for interactions with toys and caretakers
    - Look for aggressive behavior or hyperactivity
  2. Look for maternal-child mismatch
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14
Q

Preschool age

A

2-5 years old

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15
Q

Interviewing the child 2-3 years old (2)

A
  1. Ask the child’s name and age, guess wrong and play game with child
  2. Play with puppets nurse-doctor games; have a medical kit in the office and have the child play with it and a doll
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16
Q

Interviewing the child 3-5 years old (3)

A
  1. Obtain initial history from child; by 2 years old you want to talk to the kid a lot
  2. Draw-a-person test
    - gives idea of how they can handle a pencil and how developed they are
  3. Has no concept of illness
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17
Q

Pre-Schoolers Development (4)

A
  1. Concept of illness is not clear, feel guilty when someone is sick around them
  2. Cannot judge size well
  3. Does not understand concept of time or people permanence
  4. Ask child what they think made them sick
    - introduce germs, give band-aids, allow child to cry if upset
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18
Q

School-Aged Children

A

6-10 years old

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19
Q

Communication with School-Aged Child (6)

A
  1. Sense of mastery and privacy is very important
  2. Oriented toward peer-group
  3. Ask about school life
    - Ask if child wants to stay home or go to school. If wanting to stay home, suspect learning disability, emotional difficulties, or separation difficulty
  4. Very concrete thought processes; tend not to talk and keeps feelings inwards
    - Can be very quiet or introverted
  5. Ask about social life and obtain peer history
  6. Ask about home life (3 wishes)
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20
Q

Communication with Adolescents 11-? (3)

A
  1. It is now time to talk to the child on their own, without a parent present
  2. Confidentiality issues and explanation
    - Set the scene, explain confidentiality and when confidentiality can be breached
  3. Ask about sexuality in private after establishing boundaries
21
Q

Non-consensual sex definition

A

4 years apart is considered not consensual (ex: 9 year old and 13 year old)

16 years old is age of consent with adults

22
Q

The Five P’s in Sexual History

A
  1. Partners
    - amount, type
  2. Prevention of Pregnancy
    - preventative measures?
  3. Protections from STDs
    - preventative measures?
  4. Practices
    - Vaginal, anal, oral?
    - do you use condoms?
  5. Past history of STDs
23
Q

Edinburg Postnatal Depression Scale (EPDS)

A

Screening for post-natal depression should be done 2 weeks, 6-8 weeks
*Designed for use at 6-8 weeks

24
Q

HITS Screening tOOL

A

HITS = hurt, insulted, threatened with harm, partner violence

How often does your partner:

  1. Physically hurt you?
  2. Insult or talk down to you?
  3. Threaten you with harm?
  4. Scream or curse at you?

Answers: 1=never, 5=frequently

Range is 4-20, and greater than 10 is positive

25
Q

CRAFFT Questionnaire

A

For Alcohol use

CRAFFT –>

  1. CAR – have you ever been in car with someone under the influence?
  2. RELAX – do you use drugs or alc to relax?
  3. ALONE – do you use drugs or alc when you’re alone?
  4. FORGET – do you forget things while using drugs or alc?
  5. FRIENDS –do they ever tell you to cut down or quit?
  6. TROUBLE – do you ever get into trouble?
26
Q

Patient Health Questionnaire-2 (PHQ-2)

A

Over past 2 weeks, how often have you been bothered by any of the following:
1. Little interest or pleasure in doing things
2. Feeling down, depressed or hopeless
(range is 1-3 points per question)

A score of 3 or more means you need to do PHQ-9

27
Q

History of Present Illness OPQRST

A 
O = onset
P = Promoting, preventing, precipitating, palliating factors
Q= Quality or quantity 
R = Region or radiation
S= severity, setting, simultaneous symptoms
T= temporal factors
28
Q

Pre-natal history cfDNA screening

A

10 week cell-free DNA screening; identifies trisomy, Down syndrome, fetal sex

29
Q

15-20 weeks gestation prenatal Quad screen

A

Risk of down syndrome (trisomy 21), trisomy 18, and open neural tube defects such as spina bifida

30
Q

High Grade Ultra Sound Pre-natal screen

A

Done at 16-18 weeks

31
Q

Genogram (4)

A
  1. Male = square
  2. Female = circle
  3. Male is placed to the left of the female in the father/mother dyad
  4. Children are noted oldest to youngest, left to right
32
Q

Genogram: Liason

A

Denotes a couple living together, unmarried

*Denoted by a dotted line between the male and the female, rather than a solid line

33
Q

Genogram: Separtism

A

Marked with one slashed line

34
Q

Genogram: Divorce

A

Marked by two slashed lines

35
Q

Genogram: death

A

Indicated by an “x” through the shape. the birth date and death date are recorded

36
Q

Genogram: remarriage

A

Remarriage is shown to the side with a smaller shape

37
Q

Heritability

A

Measures the contribution of genetics (compared to environment) in development of a particular disorder

38
Q

Recurrence risk

A

Likelihood that a trait or disorder present in one family member will occur again in other family members in the same or subsequent generations

39
Q

NEEDSS in history taking

A 
Nutrition
Elimination
Education, environment
Development, daycare
Sleep, sexuality (if adolescent)
Safety
40
Q

Environmental Health Anticipatory Guidance Topic at prenatal or first visit (5)

A
  1. Home,
  2. ETS,
  3. mold,
  4. occupational exposures,
  5. breast/bottle issues
41
Q

Environmental Health Anticipatory Guidance Topic at 2 months (3)

A
  1. ETS,
  2. Sun exposure,
  3. mold
42
Q

Environmental Health Anticipatory Guidance Topic at 6 months (3)

A
  1. poisons,
  2. household pesticides,
  3. lead
43
Q

Environmental Health Anticipatory Guidance Topic at preschool

A

arts and crafts

44
Q

Environmental Health Anticipatory Guidance Topic for seasons (4 summer/spring, 2 fall/winter)

A

Spring/Summer: lawn, garden products, services

Fall/winter: wood stoves/heating

45
Q

Interval history must include… (6)

A
  1. Chief complaint
  2. HPI
  3. Brief significant past medical history
  4. All meds/confirm allergies
  5. Activities of daily living
  6. NEEDS
46
Q

Interpretation

A

Move beyond clarification to an inference that can be made from the circumstances presented

47
Q

Confrontation

A

Pointing out contradictions between actions and feelings

48
Q

Perinatal history includes (7)

A
  1. Birth history (type of delivery, problems?, Apgar)
  2. Ease or difficulty of labor
  3. Duration of labor
  4. Type of anesthesia
  5. Attendance by other family members
  6. Birth order if multiple births
  7. If C-section, why?

PNP: Physical Assessment (21 decks)

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