Week 1

Question 1

Components of a comprehensive history

Answer 1

Chief complaint
History of present illness
Allergies
Medications
Past history
Family history
Personal/social history
Review of systems
Physical exam (all systems)
Assessment plan

Question 2

Components of a focused history

Answer 2

Chief complaint
History of present illness
Allergies
Meds
Past history
Pertinent family history
Pertinent social/personal
Pertinent review of systems
Physical exam of pertinent systems
Focused assessment
Focused plan

Question 3

Objective

Answer 3

Vitals
Lab values
Imaging
MY physical exam

Question 4

Subjective

Answer 4

Whatever the patient says
Up to and including review of systems

Question 5

Chief complaint

Answer 5

Always use the patients own words

Question 6

OLDCARTS

Answer 6

onset
Location
Duration
Characteristics
Aggravating/alleviating
Radiation
Timing
Severity

Question 7

OPQRST

Answer 7

onset
Provocation
Quality
Radiation
Severity
Timing

Question 8

History of present illness

Answer 8

An expansion of the chief complaint
Paints a picture of why the patient is seeking medical treatment

Question 9

Examples of allergies

Answer 9

Medications
Food
Environmental
Latex

Question 10

Components of the past history

Answer 10

Medical history (childhood and adult)
Surgical history
Traumatic history
OBGYN
Psychiatric history

Question 11

Family history

Answer 11

Parents, grandparents, siblings, children
Age with health status
Age of death and cause
General medical history in family

Question 12

Personal and social history

Answer 12

Health promotion and maintenance
Tobacco use (pack years)
Alcohol use
Illicit drug use
Sexual history
Home/living situation

Question 13

Concerning health history findings

Answer 13

Changes in weight- rapid or gradual
Nutrition vs medical causes vs psychosocial
Fatigue and weakness
Fever, chills, night sweats

Question 14

Nociceptive (somatic) pain

Answer 14

Damage to tissue or viscera but sensory nerves intact
Dull, pressing, pulling, throbbing, boring, spasmodic, colicky

Question 15

Neuropathic pain

Answer 15

Direct trauma to the peripheral or central nervous system
Shock-like, stabbing, burning, pins and needles

Question 16

Idiopathic pain

Answer 16

No identifiable etiology

Question 17

Psychogenic pain

Answer 17

Related to factors that influence the patients report of pain (psych conditions, personality and coping styles, cultural norms, social support system)

Question 18

Chronic pain

Answer 18

Not due to cancer or illness lasting >3-6 months
Lasting >1 month beyond the course of an illness
Recurring at intervals over months or years

Question 19

Purpose of a clinical note

Answer 19

A way to accurately record information
Assists provider in making an accurate diagnosis and provide the best treatment plan
A written record that provides interprofessional communication

Question 20

SOAP format for comprehensive and focused notes

Answer 20

Subjective
Objective
Assessment
Plan

Question 21

Optimal Bp conditions

Answer 21

Avoid smoking or drinking caffeine 30 min prior
Seated in chair w feet on ground for 5 min
Quiet warm room
Bare arm

Question 22

How to get orthostatic BP

Answer 22

measure BP and HR with patient supine, wait 3 minutes, then have patient stand up, now repeat the measurements

Question 23

Orthostatis

Answer 23

Systolic BP drops >20 mmHg or diastolic BP drops >10 mmHg

Question 24

General survey

Answer 24

Paint the picture of what you see when you enter the patients room and as you observe the patient
Must be completed of every clinical note

Question 25

General appearance (paint the description)

Answer 25

Apparent state of health
LOC
signs of distress
Skin color/obvious lesions
Dress, grooming, personal hygiene
Facial expression
Odor or body/breath
Posture, gait
Height weight