General Survey, HPI, PMH, FH, SH, ROS, Documentation

Disease

Focuses on clinicians' organization of symptoms and developing a clinical diagnosis

Illness

Focuses on how the patient perceives his or her illness and its effects on relationships, function, and overall well-being

Steps to physical encounter

initiation, information gathering, physical exam, explanation/planning, closing the session

3 multiple choice options

Explanation/planning

Provide appropriate amount and type of information, discuss next steps/plan of action, and employ shared decision making

Steps of initiating the encounter (general)

Set stage/adjust environment

Review clinical record

Greet patient/establish rapport

Identify patient title

3 multiple choice options

How to establish rapport (newborns & infants)

Hold baby however they are most comfortable

Feed child during the encounter if needed

Ask parents how they are doing

How to establish rapport (young & school-aged children)

Introduce yourself to the child, THEN to family/caregiver

Beginning with play

Ask age-appropriate questions

How to establish rapport (Adolescent)

Direct questions to the patient but ensure caregivers concerns are heard

Spend time with the patient alone (acknowledge confidentiality)

How to establish rapport (older adults)

Provide enough space for them to maneuver

Decrease background noise

Keep room at comfortable (warm) temperature

Allow time for open-ended questions/reminiscing

How to establish rapport (Patients with Physical and Sensory Disabilities)

“people-first” language

Speak directly to patient (not to caregiver)

Avoid assuming need for assistance..

Ask how you can help

How to establish rapport (Patients with Physical and Sensory Disabilities) - Persons who are blind or have low-vision

Announce yourself and introduce others in room

Notify them when you plan to leave the room

Explain what you are about to do when examining them

How to establish rapport (Patients with Physical and Sensory Disabilities) - Persons who are deaf or hard of hearing

Consider sign language interpretation or writing

Do NOT use family members for interpretation

Ensure mouth is not covered & look directly at patient when speaking

Minimize background noise

How to establish rapport (Patients with Physical and Sensory Disabilities) - LGBTQIA+ Adults

Anxiety/fears about being accepted

Fluctuating in their sexual identify

Unlikely to reveal their sexual identity or health concerns if they experience any perceived bias or discrimination

What is included in the information gathering section of steps of initiating encounter?

establish an agenda for the encounter

invite patient's story/perspective of illness

identify/respond to emotional cues

gather info by exploring biomedical perspective

Ask specific questions (HPI, PMH, FH, SH, ROS)

What does FIFE stand for when gathering patient perspective of illness

Feelings, Ideas, Function, Expectations

3 multiple choice options

Identify & respond to emotional cues using ________

NURSE

What does NURSE stand for?

Name ("that sounds like a scary experience")

Understand/legitimize ("i understand why you feel...")

Respect ("you've done better than most people")

Support ("I will continue to work with you on this")

Explore ("how else were you feeling about it")

3 multiple choice options

Physical examination is done ______

head to toe

What do you denote during a physical exam

presence or absence of disease/illness

What should be done during the explanation & planning section of patient encounter

provide useful information & verify patient understanding

negotiate a plan using shared decision making

Components of shared decision making

introduce choices & describe options

explore patient preferences

move toward decision of patient choosing

Steps of closing an patient encounter

let patient know time is concluding

ask if they have any final questions

if new concern is brought up assure them of you interest

summarize plan from visit & plan for future

mention potential follow-up

self-reflect!

Components of skilled interviewing

active/attentive listening, empathetic responses, summarization, transitions, partnering, validation, empowering patient, reassurance, guided questioning

Empathetic responses

capacity to identify with the patient and feel the patient's pain as your own, then respond in a supportive manner

What should you not assume when creating empathetic responses?

how the patient feels

Non-stigmatizing language = _____________

"people first" language

subjective = ____________

symptoms; what patient tells you

1 multiple choice option

objective =

signs; physical exam findings & diagnostics

Chief complaint

Primary symptom or concern causing the patient to seek care

How to document a chief complaint

"Chief Complaint" x duration

3 multiple choice options

Where are additional complaints beside CC addressed

HPI

3 multiple choice options

What is abbreviation for HPI

OP5QRS2T

O of OP5QRS2T

onset

P5 of OP5QRS2T

Precipitating, Palliative, Provocative, Progression, Prior Episodes

3 multiple choice options

O, Q, R, & T of OP5QRS2T

onset, quality, radiation, timing

2s of OP5QRS2T

site, severity

Example of onset (OP5QRS2T)

When did _______ start?

What does a long time mean to you?

Does a long time mean a few days, months, years?

3 multiple choice options

Example of precipitating (OP5QRS2T)

What were you doing when ___________began?

Was anything unusual going on in your life when this started?

Specific risk factors for diagnoses on your differential

3 multiple choice options

Example of Palliative & Provocative Factors (OP5QRS2T)

Does anything make the _______ better? Worse?

Did you take anything for your pain? Did it help?

Specific palliative/provoking qualities to help narrow your differential

3 multiple choice options

Example of progression (OP5QRS2T)

Has the _____ changed since it began?

How has _____ changed since it started?

Have the episodes lasted longer, become more frequent or severe?

3 multiple choice options

Example of prior episodes

Have you ever experienced this before?

if answer to above is, "Yes"....

What was the cause at that time?

2 multiple choice options

Examples of quality

Can you describe ________ for me?

What does dizziness mean for you?

Is it aching, burning, sharp, pressure, squeezing?

3 multiple choice options

Radiation

Does the pain move/travel anywhere else?

Chest pain: Does it travel to your neck, jaw, arm?

Abdominal pain: Does it travel to your back?

2 multiple choice options

Example of site

Where is _____ occurring?

Can you point with one finger to the area you feel the pain?

Where is the weakness you are feeling?

3 multiple choice options

Example of severity

On a scale from 1 to 10 (ten being the worst) how severe is your pain?

How is _______ affecting your ability to complete your normal activities?

Ask for general categorization: mild, moderate, severe

3 multiple choice options

what do you ask about in timing (OP5QRS2T)

time of day, frequency, duration, pattern

Positive associated symptoms are everything patient says ________ to

Negative associated symptoms are everything patient says ________ to

"yes", "no"

1 multiple choice option

Adult illness includes DATES/YEARS since diagnosis of:

medical, surgical, hospitalizations, trauma/serious injuries, obstetric/gynecologic, psychiatric

Components of PMH

Adult illness, childhood illness, health maintenance, medications, allergies

What do you include when asking about past surgeries?

type of surgery, date of surgery, surgeon's name

3 multiple choice options

What to include when asking about hospitalizations

date, hospital, diagnosis, treatment, studies performed, outcomes

3 multiple choice options

Examples of acute childhood illness

MMR, chicken pox, whooping cough, rheumatic fever, scarlet fever, polio

What is included under health maintenance (PMH)

immunizations, screening tests

What to include when asking about medications?

name, dose, route, frequency, indication (why?)

correct way to shorthand allergies

Penicillin - hives (1978)

2 multiple choice options

For family history you ask about _____ generations above & below as well as _________

2, siblings

3 multiple choice options

What to include in social history

tobacco use, alcohol use, drug use, job/education, marital status, lifestyle habits (diet, exercise, supplements, caffeine, sleep), safety measures, SOGI, birthplace, personal environmental map, ADLs

What is included in the personal environmental roadmap of SH

significant relationships, safety in those relationships, home environment, important life experiences, hobbies, sexuality, spirituality, support system

Alcoholism for:

Men is more than _____ drinks a day/_____ a week

Women is more than ______ drinks a day/______ drinks a week

4, 14, 3, 7

What is considered a drink?

8 oz of malt liquor

12 oz of beer

5 oz of wine

1.3 oz of 80 proof distilled liquor

3 multiple choice options

What does CAGE stand for in the questionnaire for alcohol use

Cutting down, Annoyance when criticized, Guilty feelings, Eye openers

CAGE questionnaire (alcohol use)

Yes = _____ point(s)

No = ______ point(s)

score of _______ or more = lifetime alcohol abuse & dependence

1, 0, 2

3 multiple choice options

What does SOGI stand for

sexual orientation & gender identity

5Ps of sexual history

partners, practices, protection from STIs, past history of STIs, Pregnancy prrevention

What does FICA stand for (spiritual history)

Faith/belief, Importance/influence, Community, Address

Use "_________" statements when asking about abuse

ex: "Because abuse is common in many patients' lives, I've begun to ask about it routinely"

normalizing

2 multiple choice options

For ROS, questions ask yes or no questions in _________ format

head to toe

2 multiple choice options

First step of physical examination

hand hygiene, observe signs related to contact precautions & don PPE if needed

IPPA of Physical exam

Inspection, Palpation, Percussion, Auscultation

3 multiple choice options

IPPA for physical exam is always in this order except for ______ exam

abdominal

3 multiple choice options

Constitutional Symptoms

Fatigue, Weakness, Fever/Chills/Night Sweats, Energy Level, Pain, Current weight/height (in last 6 months)

3 multiple choice options

What is malaise

generally feeling unwell

Shivering/shaking chills/goosebumps = _________ temp

sweats/hot = __________ temp

rising, falling

3 multiple choice options

If someone has a fever ask them about

travel, exposure, medications

Rapid changes to weight over a few days suggests changes to _________

body fluid

2 multiple choice options

RED FLAGS during ROS

Unilateral weakness, Sudden weight loss or gain

3 multiple choice options

Goal of general survey

describe distinguishing features of patient so clearly that colleagues can identify the patient in a crowd

Components of general survey

Apparent state of health, LOC, Apparent state of discomfort/distress, Skin color/lesions, Dress/grooming/ hygiene, Facial Expression, Odors of body/breath, Posture/gait/motor activity

3 multiple choice options

What to observe in apparent state of health

acutely or chronically ill, frail, & robust

Alert

eyes opened, looks at examiner, & responds fully & appropriately to examiner

3 multiple choice options

Lethargy

Appear drowsy, opens eyes & looks at examiner, responds, then falls asleep

3 multiple choice options

Obtunded

Opens eyes & looks at examiner, responds slowly & confused; alertness & interest decreased

3 multiple choice options

Stupor

Arises from sleep only after painful stimuli; verbal responses slow; minimal awareness of self or environment

3 multiple choice options

Coma

Unarousable with eyes closed; no response to inner need or stimuli

3 multiple choice options

Signs of anxiety or depression

psychomotor slowing, poor eye contact, fidgety movements

Fruity smelling breath is indicative of _______________?

diabetic ketoacidosis

If preferred position of posture is:

sitting up = _________

leaning forward with braced arm = ____________

lying supine & still = _______________

heart failure, respiratory difficulty, acute abdominal pathology

3 multiple choice options

Height & weight are part of _______, but recorded with ______

general survey, vital signs

Height is measured in

stocking feet

weight is measured in

kg

1 multiple choice option

If BMI greater than or equal to ________kg/m^2, measure _______ circumference

35, waist

3 multiple choice options

BMI measured & then waist is measured

Excess body fat & risk for DM, HTN, & cardiovascular disease if waist is greater than:

_______ inches for men

_______ inches for women

35, 40

3 multiple choice options

BMI classifications

Underweight: <____

Normal: ______

Overweight: ______

Obesity: _______

Extreme Obesity: > & equal to ______

18.5

18.5 - 24.9

25.0 - 29.9

30.0 - 34.9

35.0 - 39.9

40

3 multiple choice options

What is BP

tension exerted by blood against arterial walls

BP physiologically can be affected by

ventricular contraction, arteriolar & capillary resistance, elasticity of arterial walls

What are Korotkoff sounds

five phases of sound that occur due to disruption of blood flow in an artery

Before measuring BP

1. No caffeine, exercise or tobacco 30 minutes prior

2. Sit quietly for 5 minutes in a chair with feet on floor in a quiet and warm comfortable room.

3. Arm should be free of clothing, fistulas for dialysis or lymphedema and at heart level

4. Select appropriate cuff - size matters!

3 multiple choice options

Rule with cuff size

Width of the inflatable bladder of the cuff should be about ______% of upper area circumference (about 12 to 14 cm in the average adult)

Length of the inflatable bladder should be about _____% of upper arm circumference

40, 80

3 multiple choice options

If BP cuff is too _____, BP will read high

If BP cuff is too _______, BP will read low

small, large

1 multiple choice option

What is auscultatory gap?

interval of pressure where Korotkoff sounds indicating true systolic pressure fade away and reappear at a lower pressure point during the manual measurement of blood pressure.