Clin apps midterm study guide

Comprehensive healthy history encounter

New patient establishing care

Focused health history encounter

Established patient with specific concern

Health history includes

Identifying data

reliability

chief complaint/concern

present illness (HPI)

allergies/medications

past medical and surgical history

family history

social history

review of systems

health maintenance

Physical exam includes

General survey

vitals

skin

HEENT

neck

chest/respiratory

breasts

cardiovascular system

abdomen

peripheral vascular system

musculoskeleton system

neurological system

genitalia/rectal

Written patient record

Serves as primary communication method between health care team.

Written patient record types

Outpatient history and physical

admission history and physical

consultation note

focused outpatient office visit note (SOAP)

subsequent day inpatient note (SOAP)

Soape

Subjective, objective, assessment, plan, education.

How do you start the patient encounter

Open ended questions.

Subjective symptom

feeling reported by patient that cannot be directly measured, ex: SOB

Objective symptom

Medical fact in which can assist clinician in diagnosis. Example irregular heart rhythm.

Assessment portion of soap notes

Aims to answer: what is wrong with the patient.

Soape note

Subjective objective assessment, plan, education.

Subjective

Pertinent positives and negatives in ros include in hip and in portions of history.

Objective

Diagnostic tests and completed labs.

vital signs

pertinent portions of physical exam

Chief concern

• Reason patient is seeking medical care

• use patients words when possible

• include duration of symptoms

• may not be a specific complaint but a statement

HPI

• complete, clear, chronological, account of problem for why pt is seeking medical care (expands cc)

• full description of acute problem

• includes pertinent positives and negatives

• if multiple symptoms present, each need to be detailed separately and completely

Timing of illness

When did it start

how long have you had it

when did you first notice it

intermittent or constant

how long is each episode

do symptoms vary with time of day

have you ever experienced this before.

Oldcarts

Onset, location, duration, characteristics, aggregate or alleviate, radiation, timing, severity.

What should you have after completing the HPI

• Good idea of potential diagnosis

• the exam/testing to be performed to refine list

Adverse drug reaction

• Unwanted reaction to a medication that is unintended

• occurs at normal doses of a drug

Type A ADR

Side effect expected

known effect of a drug that is not its intended outcome

Type B ADR

Mediated by immune response.

Importance of true allergy

Cannot give patient this drug.

Where to find individuals immune records

Michigan care improvement registry (MCIR).

Medications

Ask about various types and classes of medications including prescriptions, over the counter, herbs, supplements, and vitamins.

Review of systems purpose

• Identify symptoms that may have been overlooked in cc

• Trigger past medical history, symptoms patient may have overlooked.

General review of symptoms

Fever chills, body aches, sleep disturbances, unexplained weight loss or appetite changes.

Definition of heavy drinking

Males: 14 drinks a week or more than 4 drinks on occasion

Females: 7 drinks a week or more than 3 drinks on occasion

Single item screening

Do you sometimes drink beer, wine, or other alcoholic beverages.

How many times in the past year have you had more than

• 5 drinks for males and 4 for females in a day.

Cage question

Not as good as identifying all spectrum of unhealthy alcohol use.

Nondependent alcoholism

Should receive brief counseling during the encounter.

What to do when patient evades questions on substance use

Return to topic at a later time by asking to discuss manner in a non threatening way.

Substance abuse or dependence

Should be referred for further care.

Why do we ask about military service

Can have important implications on health status of patient.

Baseline level of function

Assess patients ability to

• care for self

• capacity to perform ADL

• cook

• clean

• laundry

What is the 5th leading cause of death

Accidents.

When to gather sexual satisfaction

Not routinely is patient guided.

5 P's of sexual history

Partners

practices

protections from STD

past history of STD

prevention of pregnancy

Opening statement for discussing sexual health

May I ask you a few questions regarding your sexual health and practice. I understand these questions are personal but they are important to your overall health; I ask them to all adult patients.

What do you need to do before switching to the physical exam

Ask for permission.

What side do we exam patients from

Right.

BMI calculation

(weight kg)/(height m^2) or

(weight lb x 705.4)/(height in inches) over (height in inches).

What is the first step in ensuring accurate blood pressure

Ensuring correct cuff size.

Width of blood pressure cuff

Should be 40% of upper arm

length of inflatable bladder should be 80% of upper arm

Orthostatic blood pressure

Have patients lie down for 10 minutes, take blood pressure

Have the patient stand up within three minutes and take blood pressure.

If a change in 20 systolic and 10 diastolic, positive orthostatic.

What temperature source is most accurate

Rectal.

Pain scale

0 being no pain, 10 being worst pain of your life.

When does the general survey begin

The second you walk into the room takes shape as you move into physical exam.

Jaundice

Sclera and skin are a yellowish tinge

Pattern with alcoholic liver disease.

Lesions of melanoma we are most concerned about

Are those greater than 6mm in diameter

asymmetrical irregular borders

color variations

Clubbing

Distal phalanx of each finger is rounded

The nail plate is more convex

Feels spongy/flattening

Causes of hypoxia

copd or hypoxia from heart or lung disease, hepatic cirrhosis.

Palpate lymph nodes technique

Move skin over underlying tissue and do a gentle rotatory motion.

Lymph nodes to palpate

Occipital, post auricular, pre auricular, submandibular, tonsillar, submental, anterior cervical, posterior cervical, deep cervical, suprascapular.

20/200 vision

Patient can see at 20 ft what a normal person can see at 200 feet.

Consensual reaction

Pupillary constriction in opposite eye.

Near reaction

• Aka accommodation

• have patient look at finger and then wall behind you;

• pupils should dilate as looking farther away

Lighting for fundoscopic exam

Dark.

Normal color of tympanic membrane

Pearly gray.

Palpation in the ear

Auricle, pinna, mastoid process.

Inserting otoscope

Forward and down.

Whisper voice test

Have patient cover 1 ear and stand 1-2 ft away and whisper a two syllable word;

they should be able to repeat the word you said 50% of the time with normal hearing

Testing nasal patency

Have patient cover one ala and breathe in.

Testing CNXII

Have patient stick out tongue and move it back and forth; assess symmetry.

Inspecting oropharynx

Say ahh and watch uvula rise; CNX.

Normal breath rate and sound

12-18 breaths per minute, quiet and non-labored.

AP diameter

1:2 ratio; anterior and posterior thoracic width is 1 to that of transverse (2).

Normal percussion sounds in lung

Resonant healthy lung.

Percussions on the back

In a ladder-like fashion comparing one side to the other.

Auscultating lungs

Instruct patient on how to breathe.

Assessing auscultation triangle

Have patient abduct shoulder via hugging their arms.

Vesicular auscultation sounds

Soft and low pitched

heard through majority of lung fields

inspiration continues without pause

expiration fades ⅓ of the way through

Bronchovesicular sounds

Inspiration then expiration sound equal; may be a brief pause.

Bronchial sounds

Loud and high pitched

expiration is longer and inspiration