Skills Lab Flashcards
Points to touch on during General-ROS questioning
Weight changes Fevers/chills Problems with sleep Fatigue Night sweats Headaches
Systems involved in ROS questioning
Skin HEENT/Neck Respiratory Cardiovascular Gastrointestinal Peripheral vascular Urinary Musculoskeletal Psychiatric Neurologic
BP Questions prior to starting vitals
Before I take your BP…
Have you had any caffeine or nicotine within the last 30 minutes or so?
Have you exercised today?
Do you know what your BP is normally?
Do you take any medications, even over the counter?
Points to discuss during Social History questioning
Alcohol Tobacco Recreational drugs Employment Diet Exercise Living situation Sexual history Marital status Children
7-Attributes of a symptom
Prompt with open-ended question first! Location Quality Severity Timing Setting Exacerbating factors Associated symptoms
Skin question
Any changes in your skin hair or nails?
HEENT/Neck questions
Any changes in vision?
Any stiffness of the neck?
Respiratory question
Any shortness of breath or changes in breathing patterns?
Cardiovascular question
Have you noticed any changes in your heart beat or pain in your chest?
Gastrointestinal question
Have you had any problems with bowel movements, your stomach hurting, or any nausea or vomiting?
Peripheral vascular questions
Have you noticed any swelling in your ankles? Any changes in temperature?
Why do we ask the questions that we ask when reviewing the peripheral vascular system during our ROS?
We are looking for signs of clots:
- Swelling may be present
- A venous clot will be warm
- A arterial clot will be cold
Urinary questions
Have you experienced any difficulty in urination? Any pain, color change, or change in odor?
Musculoskeletal questions
Do you have any problems with pain in your joints or muscle weakness?
Psychiatric questions
Have you noticed any changes in your mood or experienced any undue anxiety?
Neurologic question
Do you feel any numbness or weakness?
Questions for the 7-Attributes
Open with open-ended question: Can you tell me a little more about ( )? Then fill in the gaps:
Can you show me where you typically experience this?
Can describe what it is like to me a little differently?
How bad would you say it is on a scale from 1-10?
Can you tell me about when it starts, how long it lasts, and so on?
Are there any other circumstances that you feel bring it on?
Are there any other symptoms that you notice come along with it?
Questions for General-ROS
Have you had any recent changes in weight that weren’t intentional?
Have you recently experience any of the following symptoms: fever or chills, problems sleeping, fatigue, night sweats, or headaches?
Questions for Social History
Can you tell me about your use of alcohol, nicotine, or recreational drugs?
Do you currently hold a job?
Would you say that you eat a well-balanced or generally healthy diet?
Do you exercise, or participate in anything strenuous regularly?
Can you describe your current living situation?
* In order to get a complete picture of your health, I need to ask a personal question, if you are okay with it… Have you had sexual relations or intercourse with someone within the last 6-months?
- Does your sexual activity include men, women, or both?
- Do you use protection?
Are you currently married or single?
Do you have any children?
Components of the Closeout
Intro
- Knock, Introduce, Wash
Interview
- Open-ended Q’s
- 7-Attributes
- Past Medical/Surgical Hx
- Social History
- Family History
- Meds and Allergies (HOW)
- General ROS
- ROS
- BP Questions
Vitals
- BP
- Pulse Oximeter
- Respiratory Rate
- Pulse
- Temperature
Professionalism
- Dress, empathy, confidence, reflection.
