EPC Exam 2

Subjective

Information reported by the patient.

HPI through ROS

Chief Complaint (CC)

Patient's primary concern, documented in their words.

“Theme” of the pt’s story

History of Present Illness (HPI)

Narrative detailing the patient's current issue.

Start with pt age and sex

OPQRST

OPQRST

A mnemonic for assessing symptoms: onset, provocation, quality, radiation, severity, time.

Past Medical History (PMH)

Patient's medical history from birth to present.

Trauma, major injuries

Past Surgical History (PSH)

Record of all surgeries patient has undergone.

Find out if any rxns to anesthesia

Pt can forget small surgeries (e.g. wisdom teeth, tonsils, etc.)

Medications

List of prescribed and over-the-counter drugs.

Include dosage

Allergies

Documented reactions to medications, foods, and environmental factors.

Include rxn

Family History

Health history of first-degree relatives.

If other inherited diseases are prevalent/pertinent in other distant relatives, this can be mentioned (ex: cancers, clotting disorders)

include the age and status of family member

Social History

Patient's lifestyle factors, including tobacco alcohol, and drug use.

Assessment

Identification of patient's problems and differential diagnoses.

Plan

Strategy for diagnosis confirmation and treatment.

Global Appearance of Note

Proper grammar and terminology in documentation.

Only document what YOU found

Complete H&P

Comprehensive HPI, ROS, PE including full medical history.

Problem + >9 subjects for complete ROS

goal = to gain complete pic of pt’s med hx from birth to date of encounter

indication = new patient, hospital admission or consult

Problem Focused Encounter

Specific to patient issues.

Pertinent ROS + 2-6

Pack Years

Tobacco use quantified as packs per year.

Physical Exam

Objective assessment of the patient's physical condition.

What must always be in your note?

Subjective: CC, HPI, PMH, PSH, All, Meds, Social History, ROS

Objective: PE, Vitals. general statement, Osteopathic exam

Assessment

Plan

Differential Diagnosis

List of potential conditions causing symptoms.

Patient Understanding

Ensure patient comprehends and agrees with the plan.

Apparent Age

Can be a marker of chronic disease and overall health status

Levels of Consciousness

Different states of awareness and responsiveness of the patient

Alert (awake), Responsive (conversing), Oriented (know where they are), Cooperative (follow commands)

Alert

Patient opens eyes, looks at you, responds fully and appropriately

Lethargy

Patient appears drowsy but opens eyes and responds to questions

Obtundation

Patient opens eyes, looks at you but responds slowly and confused

Stupor

Patient arouses from sleep after painful stimulus but lapses into unresponsiveness when stimulation stops

Signs of distress

Respiratory: Tripoding

Cardiac pain: clutching chest

Anxiety

Depression

Tripoding

Patient positions hands on knees, gasping for air

General Skin Colors

Includes pallor, cyanosis, jaundice, diffuse rashes, bruises, mottling

Grooming/Personal Hygiene

Is their attire clean and appropriate for the weather and setting?

Vital Signs

Temperature, pulse, respirations, blood pressure, pulse oximetry, BMI

Pulse Measurement

Count for 30 seconds and multiply by two; if HR is fast or slow count for an entire minute.

Radial A.

If irregular rhythm, must measure for full 60.” Best to determine with cardiac auscultation and feeling pulse

Normal Pulse Rate

60-100 bpm for adults

Respiration

Rate is only part recorded in vitals

Assess Rate + Rhythm, depth, effort

Temperature Measurement

Tympanic membrane is most commonly done; average normal temp is 98.6 F

Fever

Elevated temperature > 100.4 F

Hyperpyrexia

>106 F, can cause seizures

Hypothermia

<95 F

Blood Pressure Measurement

Requires proper cuff size and technique to obtain accurate reading

What happens to blood pressure if the cuff is too small

Pressure higher

What happens to blood pressure if the cuff is too big

Pressure lower

Korotkoff Sounds

First sound indicates systolic pressure; disappearance of all sound indicates diastolic pressure

past history of skin & related disorders

skin cancer, acne, psoriasis

family history for general overview of skin

particularly skin cancer and what kind (melanoma, squamous cell, basal cell)

effect of the disease on the pt for general overview of skin

wakes them up at night, can't do their job

skin examination overview

overview first (location, “big picture” pattern), then individual lesions

color

increased pigmentation, loss of pigmentation, redness, pallor, cyanosis, yellowing

moisture

dryness, sweating, oily

temperature

generalized warmth, local warmth, coolness

texture

roughness, smoothness

mobility & turgor

decreased mobility, decreased turgor

primary skin lesions

macules, papule, patch, plaque, vesicle, bullae, wheal, nodule, erosion, ulcer, purpura

primary lesion description

number, size, color, shape, texture, primary lesion, location, configuration

size

measure in millimeters or centimeters, NO MEASUREMENTS IN INCHES

shape

circular, annular, nummular, oval, linear, target

Flat texture skin findings

macule, patch

Raised texture skin findings

Papule, Plaque, Vesicle, Bulla

macule

less than 1 cm

patch

greater than 1 cm

papule

<1 cm, not fluid filled

plaque

>1 cm, not fluid filled

vesicle

<1 cm, fluid filled

bulla

>1 cm, fluid filled (aka blisters)

Primary leisons

Erosions, Ulcer, Nodule, Purpura, Wheal

Erosion

Loss of superficial layers of upper epidermis by wearing away as from friction or pressure

Ulcer

Loss of epidermis and dermis

purpura

discoloration of the skin due to blood vessels leaking blood under the skin (4-10mm)

ecchymosis

>1 cm (aka most bruises)

Type of purpura

petechiae

<4cm

Type of purpura

wheal

evanescent rounded or flat topped elevation of the skin that is edematous and often erythematous (hives)

What are the disease odors of the body and breath

Uremia, Acetone, GI bleed, Malodorous

What is uremia’s smell

Sulfur

What does Acetone’s smell mean

DKA

What does GI Bleed smell

Pennies

What does Malodorous

“Bad Smell”

function of skin

protection, slow fluid loss, sensory input, produce vitamin D, regulate blood pressure, excrete sweat, urea, & lactic acid, express emotions

Hypothetico-deductive reasoning

the method of proposing hypotheses and testing the acceptability of each hypothesis

scheme-inductive reasoning

algorithmic process of evaluating a condition in a patient

non-analytic clinical reasoning

pattern recognition based on experience only

diagnostic hypothesis

set of possible diagnoses

Final Diagnosis

Conclusive identification of a patient's condition.

Working Diagnosis

Initial hypothesis based on available evidence.

Therapeutic Threshold

Point where treatment risk(s) is lower than disease risk(s).

Diagnostic Hypothesis List

Set of possible diagnoses formulated by clinician.

Clinical Reasoning Process

Systematic approach to diagnosing patient conditions.

Problem Focused History

Detailed patient history regarding acute issues.

Heuristics

Experience-based rules for clinical diagnosis.

Confirmation Strategy

Questions aimed at confirming primary diagnosis.

Protect the pt

“Big Nasties”

Failure to ID harmful dx is the top cause of malpractice claims

Use elimination strategy to do this

Elimination Strategy

Method to rule out harmful diagnoses.

Pertinent Negatives

Documentation of absence of findings in diagnosis.

Top Misdiagnosed Conditions

Commonly misidentified diseases like cancer, infections, pulmonary embolism, CAD, fractures, Appendicites.

Rule out dx’s

Infection: Sepsis, meningitis, pneumonia

Vascular: MI, Stroke, PE

Female Specific: Pregnancy, ectopic pregnancy

Cancer

Analytical Clinical Reasoning

Focus on crafting potential diagnostic hypotheses.

Use prevalence of disease when creating differential dx list

Prevalence

Number of disease’s cases in a population.

Anatomic Approach

Diagnosis based on nearby anatomical structures.

Good for pain

Category/System Based Approach

Systematic coverage of diagnostic possibilities.

(ROS for us)

VINDICATE

Mnemonic for various diagnostic categories.

• Vascular

• Infection/Inflammation

• Neoplasm

• Degenerative

• Iatrogenic

• Congenital

• Autoimmune

• Toxic/metabolic

• Endocrine

Probabilistic Approach

Determining most likely diagnosis based on evidence.

Does the evidence match?

What dx is MOST LIKELY

Causal Reasoning

Exploring cause-effect relationships in diagnosis.

Can anatomy and physiology explain findings

Often used to validate dx hypotheses from probabilistic method of reasoning