1. Describe the differences between
a. A comprehensive health history/exam
Includes all the elements of the health history and the complete physical examination.
- Provides fundamental and personalized knowledge about the patient
- Strengthens the clinician-patient relationship
- Helps identify or rule out physical causes relate
b. A focused health history/exam
Assesses symptoms restricted to a specific body system (eg. sore throat or knee pain)
Applies examination methods relevant to assessing the concern or problem as thoroughly and carefully as possible
The patient's symptoms, age, and health history help det
2. Identify examples of when you would obtain (2 examples for each):
a. A comprehensive health history/exam
Is appropriate for new patients in the office or hospital
b. A focused health history/exam
Is appropriate for established patients, especially during routine or urgent care visits
Addresses focused concerns or symptoms
( eg. sore throat or knee pain)
3. Discuss the differences between subjective and objective data
Subjective data: is what the patient tells you
Objective data: what you detect during the examination, laboratory information and test data
a. Provide examples of what would constitute Subjective data
The symptoms and history, from Chief Complaint through Review of Systems
Example: Mrs. G. is a 54-year-old hairdresser who reports pressure over her left chest "like an elephant sitting there," which goes into her left neck and arm.
b. Provide examples of what would constitute Objective data
All physical examination findings, or signs
Example: Mrs. G. is an older, overweight white female, who is pleasant and cooperative. Height 5?4??, weight 150 lbs, BMI 26, BP 160/80, HR 96 and regular, respiratory rate 24, temperature 97.5 �F
4. Identify what goes into each section of the comprehensive health history
a. Identifying data and source of history
Identifying data�such as age, gender, occupation, marital status
Source of the history�usually the patient, but can be a family member or friend, letter of referral, or the clinical record
If appropriate, establish the source of referral, because a writte
b. Chief complaint
The one or more symptoms or concerns causing the patient to seek care.
Note: make every attempt to quote the pt's own words. Eg. "my stomach hurts and I feel awful
c. History of present illness
Is a complete, clear, and chronologic description of the problems prompting the patient's visit, including the onset of the problem, the setting in which it developed, its manifestations, and any treatments to date.
Pulls in relevant portions of the Revie
d Past history
Lists childhood illnesses
Lists adult illnesses with dates for events in at least four categories: medical, surgical, ob/gyn, & psychiatric Includes health maintenance practices such as immunizations, screening tests, lifestyle issues, and home safety
e. Family history
Outlines or diagrams age and health, or age and cause of death, of siblings, parents, and grandparents
Documents presence or absence of specific illnesses in family, such as hypertension, diabetes, or type of cancer
f. Personal and social history
- Describes educational level, family of origin, current household, personal interests, and lifestyle.
- occupation & health promotion
- hx of tobacco, drug & alcohol use.
(Health Promotion/Maintenance Activities: screenings, immunizations, sleep, exercis
g. Review of systems
Documents presence or absence of common symptoms related to each of the major body systems
Bonus : Cardinal techniques of Examination
1. Inspection
2. Palpation
3. Percussion
4. Auscultation
5. Explain each of the components for identifying problems and making diagnoses (what occurs in each component)?
a. Identify abnormal findings
Make a list of the patient's symptoms, the signs you observed during the physical examination, and any laboratory reports avail- able to you.
b. Localize findings anatomically
Clearly localize the symptom to either an organ, location or system. When localizing findings, be as specific as your data allows, however you might have to settle for a body region such as the chest or a body system such as the musculoskeletal system.
Eg
c. Cluster the clinical findings
Pt age: eg. younger adults are more likely to have a single disease, whereas old adults tend to have multiple diseases.
Timing of symptoms
Involvement of different body systems: may help group clinical data ( if S &S occur i a single system, one disease m
d. Search for the probable cause of the findings
Pt c/o often stem from a pathologic process involving diseases of a body system or structure. These processes are commonly classified as congenital, inflammatory or infectious, immunologic, neoplastic, metabolic, nutritional, degenerative, vascular, traum
e. Cluster the clinical data
...
f. Generate hypotheses about the cause of the patient's problem
Read Steps for Generating Clinical hypotheses table on page #27
Draw on the full range of your knowledge and experience, and read widely ( about diseases & abnormalities). By consulting the clinical literature, you embark on the lifelong goal of evidence-based decision making and clinical practice.
g. Test the hypotheses and establish a working diagnosis
You are likely to need further history, additional maneuvers on physical examination, or laboratory studies or x-rays to confirm or r/o your tentative diagnosis or to clarify which of two or three possible diagnoses are most likely.
A hypothesis is a theory without confirmatory evidence
A diagnosis requires evidence to support the theory
Chapter 3 (p 65-86)
INTERVIEWING AND THE HEALTH HISTORY
1. Review the techniques for guided questioning to expand and clarify the patient story
? Moving from open-ended to focused questions.
? Using questioning that elicits a graded response: rather than a yes-no answer.
? Asking a series of questions, one at a time
? Offering multiple choices for answers
? Clarifying what the patient means
? Enc
2. Identify 2-3 examples for each type of questioning:
a. Open-ended questions
Tell me about your chest discomfort"
"What brings you here today?"
"Tell me more about that
b. Closed-ended questions
Has your pain been improving?
"Is your pain like a pressure?
c. A question eliciting a graded response
How many steps can you climb before you get short of breath?
d. A question asking for clarification
Tell me exactly what you mean by 'the flu'"
" You said you were behaving just like your mother. What did you mean?
3. Identify the sequence and context of the interview process
a. What do you do to prepare for the interview?
- Reviewing the clinical record.
- Set goals for the interview ( balance these provider-centered goals with patient-centered goals, weighing multiple agendas arising from the needs of the patient, the patient's family, and health care agencies and facilit
b. What is the correct sequence of the interview process?
Greeting the patient and establishing rapport. Establishing the agenda for the interview.
Inviting the patient's story.
Exploring the patient's perspective.
Identifying and responding to emotional cues. Expanding and clarifying the patient's story. Genera
c. How does culture play into this process?
Cultural competency and cultural humility is needed.
4. Identify the components of the OLDCARTS mnemonic
Onset , Location, Duration, Character, Aggravating/Alleviating factors, Radiation, and Timing, Severity
5. Identify the components of the OPQRST mnemonic
Onset, Palliating/Provoking factors, Quality, Radiation, Site and Timing
Chapter 4 (p 111-138)
BEGINNING THE PHYSICAL EXAMINATION: GENERAL SURVEY, VITAL SIGNS, AND PAIN
1. Compare BMI readings
a. Identify the BMI range for an underweight patient
<18.5 kg/m2
b. Identify the BMI range for a healthy/normal weight patient
18.5-24.9 kg/m2
c. Identify the BMI range for an overweight patient
25.0-29.9 kg/m2
d. Identify the BMI range for an obese patient (class I)
30.0-34.9 kg/m2
e. Identify the BMI range for an obese patient (class II)
35.0-39.9 kg/m2
f. Identify the BMI range for an extremely obese patient (class III)
>40 kg/m2
2. Discuss the education/counseling you would provide to a patient based on their BMI
a. Identify what education/counseling you would provide to a patient who is determined to be underweight
Nutritional education
b. Identify what education/counseling you would provide to a patient who is determined to be overweight
Walk 30 to 60 minutes 5 or more days a week, or a total of at least 150 minutes a week. The total calorie deficit goal, usually 500 to 1,000 kilocalories a day, is more important than the type of diet. Portion-controlled meals, meal planning, food diaries
c. Identify what education/counseling you would provide to a patient who is determined to be obese (class I, II or III)
Nutritional referral, counseling, personal trainer or exercise programs
3. What components are included in the general survey?
? Apparent state of health
Acute or chronically ill, frail
Posture, gait and motor activity
? Level of consciousness
Awake, alert, responsive or lethargic, obtunded, comatose
? Signs of distress
Cardiac or respiratory; pain; anxiety/depression
? Skin colo
4. Discuss the steps to ensure accurate blood pressure measurement
Avoid smoking or drinking caffeinated beverages 30 minutes prior to measurement
Ensure that the room is quiet and comfortably warm
Patient should be seated quietly in a chair with feet on the floor for at least 5 minutes
Use patient's bare arm
Using the r
5. Identify how to obtain and document the following
a. Heart rate and rhythm
From powerpoint
Radial pulse is commonly used to measure the heart rate
Use the pads of the index and middle fingers
Count 30 seconds (if rate is 50-90 and rhythm regular)
Count
Count the heart rate for one minute by palpating the radial pulse with your fingers, or by listening for the apical pulse with your stethoscope at the cardiac apex.
With the pads of your index and middle fingers, compress the radial artery until a maximal
b. Respiratory rate and rhythm
fyi: Prolonged expiration is common in COPD.
Count the number of respirations in 1 minute either by visual inspection or by subtly listening over the patient's trachea with your stethoscope.
Normal rate: ~20 breaths/minute
Count for a full 60 seconds
Observe
Rhythm: regular, irregular
Depth: shallow
c. Temperature (oral and rectal)
The core body temperature, measured internally, is approximately 37�C (98.6�F) and fluctuates approximately 1�C over the course of the day. It is lowest in the early morning and highest in the afternoon and evening. Women
Average oral temperature : 37�C (98.6�F)
Diurnal variation: 35.8�C (96.4�F) to 37.3�C (99.1�F)
Rectal: 0.5�C (1�F) > oral temperature
Axillary: 0.5�C (1�F) < oral temperature
Tympanic: 0.8�C (1.4�F) > oral temperature
6. Describe how you would assess a patient's pain level (severity of pain)
Use a consistent method to assess pain severity. Three scales are common:
1. Visual Analog Scale and two scales using ratings from 1 to 10
2. Numeric Rating Scale
3. Wong- Baker FACES Pain Rating Scale.
7. Define the types of pain
a. Nociceptive or somatic
Tissue damage
Pain linked to tissue damage to the skin, musculoskeletal system, or viscera (visceral pain), but the sensory nervous system is intact, as in arthritis or spinal stenosis. It can be acute or chronic. It is mediated by the afferent A-delta and C-fibers of
b. Neuropathic
Direct trauma to the peripheral or central nervous system
Mechanisms postulated to evoke neuropathic pain include central nervous system brain or spinal cord injury from stroke or trauma; peripheral nervous system disorders causing entrapment or pressure
c. Idiopathic
pain without an identifiable etiology.
d. Psychogenic
pain involves the many factors that influence the patient's report of pain�psychiatric conditions like anxiety or depression, personality and coping style, cultural norms, and social support systems.