Week 1: Intro to HA

Question 1

What are the two types of visits we conduct as FNPs?
When would you conduct each?
What are the components of each?

Answer 1

The two types of visits we conduct as FNPs are comprehensive and focused/problem-oriented.

Comprehensive: new patients, in-depth knowledge of a patient, provides a baseline for future visits, health promotion and education

Focused/Problem-oriented: appropriate for established patients, addresses focused concerns or symptoms, addresses symptoms related to specific body systems, focused exam utilizing specific techniques or maneuvers

Question 2

What is the difference between subjective and objective data?
What are some examples of each?

Answer 2

Subjective: symptoms, what the patient tells you, data source/reliability, chief complaint, HPI, past history, family history, personal/social history, review of systems

Objective: signs, vital signs, physical exam findings, diagnostic tests

Question 3

What is a differential diagnosis and how is one formulated?

Answer 3

A differential diagnosis is a list of potential causes for the patient’s problems and the length of the list will reflect your uncertainty about the possible explanation for a given problem

It is formulated with the most likely explanation, but will also include other plausible diagnoses, particularly those that have serious consequences if undiagnosed and untreated

Question 4

What is the HPI?

How would the FNP obtain one?

Answer 4

The HPI (history of present illness) is a summary (the onset, setting, manifestations, and treatments to date), 7 attributes of a symptom, relevant risk factors, all medications, allergies, tobacco use, alcohol use. It is the expansion upon the chief complaint, includes individual’s thoughts and feelings about the illness, contains pertinent positives and negatives from the ROS

FNP would consider the reliability of the historian

Question 5

What are the seven attributes of a symptom?
How do you define each?
What is the difference between onset and timing?

Answer 5

The seven attributes of a symptom are onset, location, duration, characteristics, aggravating factors, relieving factors, timing, and severity(OLDCARTS)

Onset (setting in which symptom occurs) - include environmental factors, personal activities, emotional reactions, or other circumstances that may have contributed to the illness

Timing - when does/did it start? How long does it last? How often does it come?

Question 6

What does OLDCART stand for?

How is onset in OLDCART different from the onset in the seven attributes of a symptom?

Answer 6

OLDCART stands for

Question 7

What is leading question?

Should these be used when obtaining a history from a patient?

Answer 7

A leading question already contains an answer or suggested response. It may limit the information provided to what the patient thinks you want to know.

“Has your pain been improving?”

“Is your pain like a pressure?”

Question 8

How should the FNP quantify tobacco use?

Answer 8

The FNP should quantify tobacco use in pack years.

One pack = 20 cigarettes
Number PPD x Number of years smoking = pack years

Question 9

How would you approach the silent patient?
What should you consider as part of your DDx for the silent patient?
Why are periods of silence important?

Answer 9

• Try not to feel uncomfortable with silence
• Patients may use periods of silencfe to collect their thoughts, remember details, or decide if they can trust you with certain info
• Watch patient closely for nonverbal cues, such as difficulty controlling emotions
• Being comfortable with periods of silence may be therapeutic, prompting the patient to reveal deeper feelings
• Silence may indicate depression or dementia: can try guided questioning, direct inquiry about depression/mental status examination
• Depressed patients: slow, monotone speech with long pauses
• If silence may be in reaction to something you have done, ask

Question 10

How would you approach the confusing patient?

What should you consider as part of your DDx for the confusing patient?

Answer 10

Focus on the context of the symptom, emphasizing the patient’s perspective, and guide the interview into a psychosocial assessment- shift to mental status exam, focusing on level of consciousness, orientation, memory, and capacity to understand.

Consider…
Mental status change: psychosis
Mental illness: schizophrenia or a neurologic d/o
Delirium: acutely ill or intoxicated patients and dementia in the elderly

Question 11

How would you approach the talkative patient?

What are some strategies that you can use during a visit with a talkative patient?

Answer 11

• No perfect solution
• Give them free reign to talk for a certain amount of time (5-10 min)
• Focus on what seems important to the patient
• Avoid interrupting or showing impatience
• Be honest about your time restrictions
• If time runs out, explain the need for a second visit

Question 12

How would you approach the patient with a language barrier?

What would you look for in the ideal interpreter?

Answer 12

Make every effort to find a trained interpreter - “cultural navigator” who is neutral and trained in both languages and cultures

Don’t rely on family and friends

When using an interpreter…
1) Ask interpreter to translate everything, not to condense or summarize

2) Make your questions clear, short, and simple
3) Speak directly to the patient

INTERPRET: Introduction, Note goals, Transparency, Ethics, Respect beliefs, Patient focus, Retain control, Explain, Thanks

Question 13

How would you approach the patient with a low literary or low health literacy?
What are some strategies that you can use during a visit with this patient?

Answer 13

Assess patient’s ability to read

“How is your reading?”
“How comfortable are you with filling out health forms?”

One rapid screen is to hand the patient a written text upside down

Explore reasons for impaired literary—language barriers, learning disorders, poor vision, or level of education

Question 14

How would you approach the patient with hearing loss?

What are some strategies that you can use during a visit with this patient?

Answer 14

To approach the patient with hearing loss is to learn whether the patient belongs to the deaf culture of the hearing culture, when the hearing loss occurred relative to the development of speech and language, and the kinds of schools the patient attended

• Find out patient’s preferred method of communication
• If patient has a hearing aid, make sure it is working correctly
• Sit on hearing side for unilateral hearing loss
• Eliminate background noise, face patients directly, have patients put on glasses to see cues to help them understand, speak at a normal volume and rate

Question 15

How should you approach the history of the patient with an altered mental status or delirium?

Answer 15

May need additional historians. Consider HIPAA restrictions unless informant is proxy/durable power of attory for health care/permission from patient

Capacity: clinical designation and can be assessed by clinicians
Competence: legal designation and can only be decided by a court
Decision-making is “temporal and situational”

Question 16

What are some questions you should ask the depressed patient?

Answer 16

Some questions you should ask the depressed patient are
“Over the past 2 weeks, have you felt down, depressed, or hopeless?”
“Over the past 2 weeks, have you felt little interest or pleasure in doing things?”

If signs and symptoms of depression, always ask about suicide
Assess the severity of depression

Question 17

What are some questions you can use and questions that you might ask when taking a sexual history?

Answer 17

“When was the last time you had intimate physical contact with someone?”
“Did that contact include sexual intercourse?”
“Do you have sex with men, women, or both?”
“How many sexual partners have you had in the last 6 months? In the last 5 years? In your lifetime?”
“Have you had any new partners in the past 6 months?”
“How often do you use condoms?”
“Do you havge any concerns about HIV infection or AIDS?”

Question 18

What are some questions that you might ask when taking a mental health history?

Answer 18

Open-ended questions initially:
“Have you ever had any problem with emotional or mental illnesses?”

More specific:
“Have you ever seen a counselor or psychotherapist?”
“Have you ever taken medication for a mental health condition?”
“Have you ever been hospitalized for an emotional or mental health problem?”
“What about members of your family?”

Question 19

When considering alcohol and illicit drug use, what are some screening strategies that the FNP might use?
What questions should the FNP ask?

Answer 19

CAGE questions are the most widely used screening questions:
Cutting down, Annoyance when criticized, Guilty feelings, and Eye-openers —two or more affirmative answers suggest alcohol misuse

For illicit drugs, ask a highly sensitive and specific single question: “How many times in the past year have you used an illegal drug or used a prescription medication for non-clinical reasons?”
-if answer is one or more, ask about specific drugs

Question 20

Who should be screened for IPV?

What is the best approach to IPV screening?

Answer 20

IPV screening should be done on all women of childbearing age. Even with skilled inquiry, only 25% of patients diclose their abuse experience.

Question 21

What is a health care proxy and who should have one?

Answer 21

A health care proxy is one who can act as the patient’s health decision maker.

Question 22

What is the difference between weakness and fatigue?

When is fatigue an expected finding?

Answer 22

Fatigue—nonspecific symptom with many causes; refers to a sense of weariness or loss of energy that patients describe in various ways… because fatigue is a normal response to hard work, sustained stress, or grief, elicit the life circumstances in which it occurs; it is a common symptom of depression and anxiety. It can also be caused by infections, endocrine d/o, HF, chronic dx of the lungs, kidneys, or liver, electrolyte imbalance, moderate-severe anemia, malignancies, nutritional deficits, and medications

Weakness—denotes a demonstrable loss of muscle power; if localized, can be related to neuropathy or myopathy

Question 23

How do we define weight loss? Overweight? Obesity?

What are some etiologies that we would consider?

Answer 23

Weight loss is defined as loss of 5% or more of usual body weight over a 6-month period.
Overweight is BMI of 25.0-25.9
Obesity class 1 is 30.0-34.9
Obesity class 2 is 35.0-39.9
Extreme obesity is > 40

Etiolgoies to consider are…

• hitting a plateau due to feedback physiologic systems that maintain body homeostasis
• poor adherence to diet due to increasing hunger over time as weight declines
• inhibition of leptin

Question 24

What determines the validity of a test?

Answer 24

The validity of a test is determined by accurately identifying whether a patient has a disease

Question 25

What is the difference between sensitivity and specificity?

Answer 25

Sensitivity - the probability that a person with disease has a positive test… known as true positive rate

Specificity - the probability that a non-diseased person has a negative test… known as true negative rate

SnNout: Sensitive test with a Negative result rules OUT disease

SpPin: Specific test with a Positive result rules IN disease

Question 26

What type of routine screening do older adults need?

Answer 26

Older adults need

Question 27

What geriatric syndromes should the FNP assess for in the older adult?

Answer 27

The FNP should assess geriatric syndromes (multifactorial condition that involves the interaction between identifiable situation-specific stressors and underlying age-related risk factors, resulting in damage across multiple organ systems) such as falls, delirium/cognitive impairment, dependence, and urinary incontinence in every patient

Question 28

What environmental changes should we consider in the office to make a history and examination as comfortable as possible for the older adult?

Answer 28

Adjust the office environment

• bright light
• warm temperature
• face patient directly
• eliminate background noise
• pocket talker (small portable microphone)
• make sure patient is using glasses, hearing aids, and dentures to assist with communciation
• high chairs, handrails

Question 29

How and why would you approach a pediatric or adolescent history/exam differently than an adult?

Answer 29

Pediatrics

• direct questions to child first
• review purpose of visit with child
• examine child on parents lap
• distract, play, patience
• engage child with questions about their interests
• move from least invasive to most invasive (save ears, mouth, abdomen for last)

Older children

• may be modest
• parents should stay up until 11 years old

Adolescent

• comfortable, confidential environment
• focus on adolescent, not their problems
• behavior is based upon their developmental stage, not their chronological age
• always consider confidentiality but never make confidentiality unlimited, particularly relating to safety
• topics: puberty, growth, development, family and peer relationships, sexuality, healthy decision masking, and high-risk behaviors
• encourage adolescents to discuss sensitive issues with parents, offer to guide these discussions

Question 30

When observing the parent-child interaction during an exam, what would the FNP be looking for?

Answer 30

The FNP would be looking for “goodness of fit” between parents and child… observe unstructured play in the exam room—abnormalities in physical, cognitive, and social development or issues with parent-child relationship