[01.01] CMD - Approach to the Adult Patient V2.pdf

Subjective

What part of the patient encounter flow includes history taking and lifestyle vital signs?

Objective

What part of the patient encounter flow includes physical examination and laboratory results?

Assessment

What part of the patient encounter flow includes the problem list, primary impression, and differential diagnosis?

Plan

What part of the patient encounter flow includes diagnostic and therapeutic plans, patient education, and supportive plans?

Lifestyle interventions

What is the number one preventive measure for a hypertensive patient?

Identify a health problem

Why do most adult patients seek consult at a primary care setting?

Annual check up

How often should a well patient ideally have a check up?

Comprehensive Health History

What kind of health history is obtained for new patients, annual physical examinations, or general check ups?

Focused or Problem Oriented History

What kind of health history is based on a specific chief complaint, such as in an outpatient department?

Follow up History

What kind of health history focuses on ongoing treatment, response to treatment, and quality of life?

Health Maintenance Visits

What kind of visits address concerns about smoking, alcohol use, weight loss, and sexual behavior?

RESPECT

What mnemonic is used for approach considerations like rapport, empathy, and trust?

Rapport

What is built to make a patient comfortable sharing information and following advice?

Red flags

What is the term for conditions that necessitate immediate or emergent medical attention?

Slurred speech

Which red flag involves difficulty with articulation?

Facial Asymmetry

Which red flag might indicate a neurological event involving the face?

Not oriented to time person or place

What red flag describes a state of confusion regarding surroundings?

Act of self harm or suicide

Which red flag involves a mental health emergency?

Profuse bleeding

Which red flag involves significant blood loss?

Open ended questions

What type of questions should a clinician use to start a history taking session?

Specific questions

What should be used to clarify and probe symptoms after starting with open ended questions?

Active listening

What skill involves listening to the patient without interrupting?

Date and time

What logistical information must be documented for every history taking session?

Communication with other doctors

Besides medicolegal protection, why is thorough documentation necessary?

Identifying data

What category of history includes name, age, gender, and occupation?

Source of information

What part of the history identifies who is providing the details, such as the patient or a family member?

Memory trust and mood

What three factors can influence the reliability of a patient's information?

Subjective percentage

Besides using terms like poor or good, how might reliability be reported?

Chief Complaint

What is defined as one or more symptoms or concerns prompting the consultation?

Cough of 3 days duration

What is an example of a specific and qualified chief complaint?

Patient's own words

What should a clinician attempt to quote when documenting the chief complaint?

Symptoms based

What type of chief complaint focuses on presence, progression, and persistence?

Came in for a wellness visit

How do you report a visit when the patient has no specific chief complaint?

History of Present Illness

What part of the history provides a chronological description of how each symptom developed?

Pertinent positives and negatives

What relevant portions of the Review of Systems are included in the HPI?

What happened during the interim

What must a clinician identify when documenting the development of symptoms over specific days?

Dosage route and frequency

What three details must be included for every medication listed in the history?

Home remedies and supplements

Besides prescribed drugs, what other substances should be recorded?

Manifestations

When documenting allergies, what must be recorded along with the allergen, such as rash or nausea?

Pack years

How is tobacco use quantified in the history?

Past Medical History

Where should tobacco use be recorded if it is not relevant to the present illness?

Onset

In the mnemonic OLDCAARTS, what does the O stand for?

Location

In the mnemonic OLDCAARTS, what does the L stand for?

Duration

In the mnemonic OLDCAARTS, what does the D stand for?

Character or Quality

In the mnemonic OLDCAARTS, what does the C stand for?

Aggravating or Alleviating factors

In the mnemonic OLDCAARTS, what do the two A's stand for?

Associated symptoms

What is the third A in the expanded OLDCAARTS?

Radiation

In the mnemonic OLDCAARTS, what does the R stand for?

Timing

In the mnemonic OLDCAARTS, what does the T stand for?

Severity

In the mnemonic OLDCAARTS, what does the S stand for?

Parang tinutusok or pinipiga

What are two Tagalog descriptors for the character of pain?

Appendicitis

Radiation of pain to other quadrants might lead a clinician to consider what condition?

Pancreatitis

Radiation of pain to the back might lead a clinician to consider what condition?

Function of the patient

Severity of a symptom like fever might be related to the patient's ability to do what?

Fishbone diagram

Which HPI documentation tool is used for quick note taking but is not for official write ups?

Temporal profile

What is the official documentation of the HPI that graphically represents symptom changes?

Worsening symptoms

In a temporal profile, what does a line going up represent?

Improving symptoms

In a temporal profile, what does a line going down represent?

Remittent or intermittent

What types of febrile patterns can be seen in a temporal profile?

Day of Consult

What does DOC stand for in HPI documentation?

Review of Systems

What section elicits the presence or absence of common symptoms related to each organ system?

Do not repeat symptoms

What is the main rule for the ROS regarding information already mentioned in the HPI?

Comorbidities

The ROS may uncover symptoms related to what existing patient conditions?

Nahihilo na parang umiikot ang mundo

How do you ask about vertigo in Tagalog?

Nahihilo na parang lumulutang

How do you ask about lightheadedness in Tagalog?

Bukol

What is the Tagalog term for lumps?

Tulo

What is the Tagalog term for discharge?

Plema

What is the Tagalog term for sputum?

Huni or hapo

What are the Tagalog terms for wheezing?

Putol putol na ihi

What is the Tagalog term for intermittency?

Gumuguhit na sakit ng dibdib

What is the Tagalog term for heartburn?

Naduduwal

What is the Tagalog term for belching?

Ari

What is the Tagalog term for penis or vagina?

Kasu kasuhan

What is the Tagalog term for joint and tendons?

May plano po ba kayong kunin ang buhay niyo

How do you ask about suicidal ideation in Tagalog?

Pamamanhid

What is the Tagalog term for numbness?

Madaling mamasa

What is the Tagalog term for easy bruising?

Past Medical History

Where are childhood illnesses, such as measles or mumps, recorded?

Tigdas

What is the Tagalog term for childhood measles?

Tigdas hangin

What is the Tagalog term for Rubella?

Beke

What is the Tagalog term for Mumps?

Kumakahol na ubo

What is the Tagalog term for pertussis?

Bulutong

What is the Tagalog term for Chicken pox?

Hika ng pagkabata

What is the Tagalog term for childhood asthma?

Usual and highest BP recorded

When documenting hypertension, what two specific BP values should be asked for?

Surgical history

Which section of PMH includes dates, indications, and types of operations?

Adhesions

If pain at a surgical site occurs after 1 year, what might it be due to?

Obstetric and gynecologic

Which history section includes menstrual history and contraceptive use?

Psychiatric

Which history section includes hospitalizations and treatments for mental illness?

Health maintenance practices

Which section of PMH includes immunizations and screening tests?

0, 1 to 2, and 6 months

What is the 3 dose schedule for the HPV vaccine?

Annual

How often should a patient receive the flu vaccine?

PPSV 23

Which pneumococcal vaccine should be given no earlier than 5 years after the first dose?

6 months to 1 year

Screening tests taken within what timeframe before the consult should be in the history?

Unrecalled medication

What should you document if a patient doesn't remember the name of their maintenance drug?

Menarche

What is the term for the age of the first menstrual period?

Dysmenorrhea

What is the medical term for painful menses?

3 generations

How many generations should ideally be included in a family genogram?

Rectangle

What shape represents a male in a genogram?

Circle

What shape represents a female in a genogram?