Clin Studies week 1

intercourse history

partners, practices, protection from STI, past history of STI, pregnancy, plus

ROS

general, skin, HEENT, neck, breasts, respiratory, cardiovascular, GI, peripheral vascular, urinary, genital, musculoskeletal, psychiatric, neurologic, hematologic, endocrine

IPPA

inspection, palpation, percussion, auscultation

lithotomy

pt lies on their back with hips and knees flexed, feet resting in stirrups

CC

in the pt words, how long Sx, ‘I have a sore throat” x2 days

OP4QRST

onset, precipitating, palliative, provocative, progression, quality, radiation, severity, timing, associated symptoms

associated symptoms

those things, that are related to CC

PMH

medications, allergies, diagnoses, surgeries, hospitalizations, health maintenance, childhood diseases, OB/GYN history

diagnoses

psychiatric illnesses, trauma history

medications - includes vitamins

include dosage and directions, Lisinopril 10mg 1 tab PO daily

allergies

list allergy and reaction, penicillin - rash

allergy = rash, itching, tongue swelling

side effect = nausea, diarrhea

diagnoses

anything long term, includes mental and trauma, childhood diseases, include status of condition

type 2 diabetes mellitus diet controlled

surgeries

include dates

hospitalization

what for and when

health maintenance

immunizations, routine cancer screenings, routine health screenings, date and interval of when next screening due

FH

indentifies pt high risk for disorder, include relative, age (when diagnosed), living or passed, chronic disorders

only grandparents to grandchildren

ex: mother - 72 living, hypertension

nociceptive pain

dull, throbbing pain

neuropathic pain

burning, stabbing, related to diseases

O - onset

sudden, gradual

P - precipitating

what was happening when the symptoms started

P - palliative

what makes it better

P - provocative

what makes it worse

P - progression

how has it changed

Q - quality

what type of pain

R - radiation

does it go anywhere other then primary location

S - severity

scale one to ten

T - timing

does it come and go

Wong-Baker Faces pain rating scale

pain scale for children

social history

can play a role in functional medicine, integrative medicine, mindfulness and alternative medicine

social history includes

who do you live with, are you safe, who are the people in your life, tobacco use, drug use, alcohol use, intercourse, what form of protection and birth control, what/where do you work, what do you do in your free time, what kind of diet, what do you do for exercise, how do you de-stress

ROS

review of systems, each organ system has a list of symptoms common within that system, do another OP4QRST on each added symptom

ROS includes

General, HEENT, neck, lymph, heart, lungs, dermatologic, GI, genitourinary, musculoskeletal, neurologic, psychiatric, endocrine, breasts

ROS - general

weight change, fatigue, fever/chills

ROS - skin

rash, sores, growths, dry, itching, color change, hair change, nail change

ROS - head

pain, injury, enlargement

ROS - eye

vision change, pain, redness, drainage (including eyelids)

ROS - ear, nose, throat

hearing change, tinnitus, pain, drainage, nasal congestion, runny nose, nosebleed, altered smell, sore throat, pain to swallow, hoarse voice, exudate, dental changes

ROS - neck

pain, stiffness, swelling

ROS - lymph

adenopathy, pain

ROS - breasts

masses, nipple changes, pain

ROS - pulmonary

cough, hemoptysis, DOE, SOB, wheezing, pleuritic pain

ROS - cardiac/peripheral vascular

pain, palpitations, edema, temp change, claudication, varicose veins

ROS - GI

appetite changes, nausea/vomiting, dysphagia, indigestion, abdominal pain, bloating, belching, flatus, diarrhea, constipation, bowel change otherwise, hemorrhoids, melena, hematochezia, food intolerance

ROS - urinary

dysuria, frequency, urgency, nocturia, incontinence, hematuria, hesitancy, dribbling

ROS - genital

pain, discharge, sores, odor, testicular pain/mass, dryness, dysmenorrhea, meno/metrorrhagia, itching, irregular bleeding

ROS - muculoskeletal

joint pain, muscle pain, swelling, cramps

ROS - neurological

syncope, seizures, dizzy, weak, paralysis, numb, tingle, tremor, involuntary movements, speech change, memory change

ROS - hematology

bleeding, bruising

ROS - endocrine

heat/cold intolerance, sweating, polyuria, polydipsia, polyphagia

ROS - psych

nervous, excessive worry, sad, suicidal ideation, homicidal ideation, apathy, sleep disturbance, hallucination (think of any signs or symptoms in a psych disorder)

components of a general survey

health, consciousness, grooming, distress, movement

components of behavioral health

appearance, speech, mood, thoughts, insight, cognition

components of derm exam

inspect, palpate, hair and nails

general survey - apparent state of health

how does the pt look, well nourished, healthy

general survey - consciousness

is the pt awake, alert, responsive

general survey - grooming

dressed weather appropriate, clean, groomed, no odor

general survey - discomfort

is pt visibly uncomfortable, showing signs of pain

general survey - movement

posture, gait, balance, walking

derm - inspect

look at skin on head, neck, back, abdomen, shoulders, arms, fingers, behind ears, legs, feet, toes

looking for color, lesions, rash

derm - palpate

palpate temp with back of hand

palpate moisture and texture with fingers

skin lesions should be evaluated using number, size, color, shape, texture, etc.

derm - hair and nails

look for color and density of hair (clumping, evenly spread),

look for pink colored nail beds, shape, condition

behavioral health - appearance

LOC, posture, hygiene, dress, expression

behavioral health - speech

quantity, rate, volume, articulation, flow

behavioral health - thought

organized thoughts, coherence, content of thoughts

behavioral health - mood

emotion displayed, appropriate emotion for setting

behavioral health - cognition

orientation to time, place, person, focused on questions/tasks, memory, abstract thinking

behavioral health - insight

pt aware the they have issues, processing things correctly, interpreting environment, decisions

FIFE

feelings and fears, ideas, function impact, expectations from provider

NURSE

name, understanding, respect, support, explore

skilled interviewing

Active listening, Guided questioning, Empathic responses, Summarization, Transitions, Partnering, Validation, Empowering the patient, Reassurance, Appropriate verbal communication, Appropriate nonverbal communication

verbal communication

Understandable language: simple, clear, every day terms

One question at a time

Non-stigmatizing language

non-verbal communication

Calm and unhurried, Focused, Eye contact, Posture and position, Movements, Arm/leg placement

why document everything

Chronology of care, Communication, Credibility, Legal, Accountable care, Research