Week 1 - EBP Flashcards
Giving Bad News - we use SPIKES, stands for…?
S: set up the interview P: perception I: invitation K: knowledge E: emotions with empathy S: strategy and summary
What are part of the Health History you should collect?
HEALTH HISTORY
CC: the reason for coming in- in the patient’s words
HPI: History of Present Illness
ROS: Review of Systems (how extensive, depends on type of visit)
Personal/Soc Hx: Substance use, sexual hx & gender identity, exercise/activities, career, living
Medical Hx: chronic problems, childhood illnesses
Surgical Hx: past surgeries/procedures
Family Hx: first-degree, vs. second-degree
Gyn Hx: menarche, regularity, #days menstruation #days between menses, pregnancies, live births, abortions, c-sections, vaginal birth
HPI - history and present illness
objective or subjective
subjective data
ROS - review of system
objective or subjective
subjective
PE - physical exam
objective or subjective
objective
OLDCARTS - what does it stand for?
Onset, location, duration, character, aggravating factors/associated symtpoms, relieving factors, timing, severity
What is the difference between somatic pain and visceral pain?
When nociceptive pain develops in your skin, muscles, ligaments, tendons, joints, or bones, it’s known as somatic pain.
When it develops in your internal organs, it’s known as visceral pain
What is consist in ROS?
Constitutional: fever, body aches, chills
HEENT: runny nose, sinus pain, sore throat, cough
Neuro: vision changes, aura, dizziness, tinnitus, numbness/tingling of face or extremities, difficulty speaking, focal weakness, hx of TBI, thunderclap
MSK: neck pain, neck injury/accident, weakness, difficulty walking
GI: n/v
Skin: rash?
Psych: anxiety, depression, stress, insomnia, mood changes?
Social hx: any changes w/work, relationship, do you feel safe in current relationship, substance use/abuse
PMH: have you had these h/a before? Are these like h/a you’ve had in the past? If yes, what do you usually do to treat them?
What is consist in ROS?
Constitutional: fever, body aches, chills
HEENT: runny nose, sinus pain, sore throat, cough
Neuro: vision changes, aura, dizziness, tinnitus, numbness/tingling of face or extremities, difficulty speaking, focal weakness, hx of TBI, thunderclap
MSK: neck pain, neck injury/accident, weakness, difficulty walking
GI: n/v
Skin: rash?
Psych: anxiety, depression, stress, insomnia, mood changes?
Social hx: any changes w/work, relationship, do you feel safe in current relationship, substance use/abuse
PMH: have you had these h/a before? Are these like h/a you’ve had in the past? If yes, what do you usually do to treat them?
What is consist in ROS?
Constitutional: fever, body aches, chills
HEENT: runny nose, sinus pain, sore throat, cough
Neuro: vision changes, aura, dizziness, tinnitus, numbness/tingling of face or extremities, difficulty speaking, focal weakness, hx of TBI, thunderclap
MSK: neck pain, neck injury/accident, weakness, difficulty walking
GI: n/v
Skin: rash?
Psych: anxiety, depression, stress, insomnia, mood changes?
Social hx: any changes w/work, relationship, do you feel safe in current relationship, substance use/abuse
PMH: have you had these h/a before? Are these like h/a you’ve had in the past? If yes, what do you usually do to treat them?
What is SOAP and when is it being used?
S: subjective data (CC, HPI, PMH, Med List, Allergies)
O: Objective Data (P.E., lab findings, test reports)
A: Assessment- Impression, Differential Diagnosis/Diagnosis
P: Plan, including follow up & often “verbalized agreement” of any precautions such as ER or need for f/u
What is in family history?
Family History Parents Siblings Children Paternal & Maternal Grandparents *Occasionally, aunts/uncles may be important, as in Cancer risk assessments and/or genetic counseling etc.
How do you take a sexual history?
Sexual Hx: Are you sexually active? With males, females or both?
Practices: type of contact
Oral, vaginal or anal?
If same sex male partners, are you the “giver or the receiver?”
Protection: STI prevention
Do you use condoms? Every time? Sometimes?
HPV immunizations?
Past hx of STI
Have you ever been treated for STI (if yes, which and when?)
Pregnancy: Birth control
Are you interested in preventing pregnancy? If yes, how are you preventing pregnancy?
Are you on birth control? (do not use “contraception”) what type?
Do you ever miss doses? What do you do if that happens?
Plus: Safety & other concerns
Do you feel safe in your current relationship
Have you ever been forced to have sex or perform sexual acts?
Have you ever had sex under the influence of drugs or etoh? If yes, was it consensual?
Do you have any concerns or problems or need support?
How do you take menstral history?
Menstrual/Gynecology/Obstetric Hx
Menarche: age of your very first period
Length of Menstruation: how many days does it last?
Frequency: # days between cycles
Regular/Irregular: does the number of days between cycles vary (do you skip months)?
Heavy, light, regular- heavy first 2 days, then tapers.
How many pads/tampons do you use on “heavy days” (per hour) i.e. 1 every 4 hours?
Do you “leak through” pads/tampons during the day/night, clots?
