MIDTERM REVIEW SKILLS V

Humanistic Domain…

1. Non-verbal skills 

2. Verbal skills 

3. Listening skills

4. Education and instructional skills

Empathy, respect, professionalism

HEALTH HISTORY

1. Patient demographics 

2. PAST MEDICAL HISTORY 

3. Chief complaint (CC)

4. HISTORY OF PRESENT ILLNESS (HPI)

5. Family history 

6. Social history 

7. REVIEW OF SYSTEMS (ROS)

Medication History 

1. allergies/adverse drug reactions 

2. Current prescription medications 

3. Current NON-prescription medications 

4. Immunizations 

5. Medication ADHERENCE 

6. Effectiveness 

7. Pass medications

History of Present Illness (HPI)

= symptom analysis 

More detailed description of the CC, used to narrow down and confirm cause of CC

• SUBJECTIVE story given by patient 

• PPQRSSTA

REVIEW OF SYSTEMS

focused problem → focuses on a specific organ system

• Aimged to triage a patient to appropriate level of care

• “Red flag” symptoms 

General, cardiac, respiratory, GI, musculoskeletal, neurologic, endocrine, peripheral vascular, skin/hair/and nails

allergies/adverse events…

→ includes drug, immunization, food, and environmental 

• DESCRIBE THE TYPE OF REACTION 

• Differentiate between allergy and adverse reaction 

General Assessment

..7 elements PRIOR to checking vital signs 

1. Level of consciousness

2. Nutritional status 

3. distress/position of comfort 

4. Comparison to stated age 

5. Development 

6. Skin coloration 

7. Hygiene  

Level of Consciousness 

The state of arousability, behavior, and response to stimuli

• Eye opening 

• Verbal response 

• Motor response → do they respond to light touch/painful stimuli 

Nutritional Status

Approximation of the level of nutrition of the patient 

1. Overnourished 

   1. Caloric intake greater than overall energy expenditure 

2. Well nourished 

   1. Caloric intake just over overall energy expenditure

3. Undernourish 

   1. Less than energy expenditure

Comparison of Stated Age

Subjective measure of cumulative state of health

1. Appears YOUNGER than stated age 

   1. Higher state of health than others the same age

2. Appears stated age 

3. Appears OLDER than stated age

   1. Lower state of health than others the same age

Distress/Position of Comfort

Distress: state of mental or physical suffering 

Position of comfort: body position employed by patient to lessen discomfort

1. Physical pain  

   1. Somatic (sharp/stabbing) 

   2. Cardiac (diffuse, vague, pressure)

   3. ACUTE VISCERAL (abdominal orgain pain upon palpation)

2. Respiratory distress 

3. Emotional pain 

Development

Comparison of musculoskeletal symmetry in relation to sex, age, race

• Heady to body proportion 

• Extremity length 

• Muscle mass 

• Height 

Skin Coloration

1. Yellow discoloration (jaundice) 

2. diffuse pallor (anemia, pale skin) 

3. Blue discoloration (hypooxygenation, cyanosis)

4. Redness (erythema): infection, drug reaction, etc

BMI:

estimates of the amount of body fat someone has

1. Underweight < 18.5 

2. Health weight 

   1. 18.5 - 24.9

3. Overweight 

   1. 25 - 29.9

4. Obesity > 30

Converting between F and C

Pulse:

palpable perception of throbbing as blood moves through arterial system because of  left ventricular contraction 

1. Bradycardia pulse rate < 60 BPM

2. Tachycardia pulse rate > 100 BPM

Pulse Rhythm…

1. Regular: regular intervals between each beat → AV nodal or junctional rhythms 

2. Regular irregular: irregular beats occur with predicted regularity → bigeminy and trigeminy

3. Irregularly irregular: no pattern of beats is present → classic for atrial fibrillation 

Respirations

breath consisting of inspiration and expiration (rate, depth, and pattern)

• Eupnea → normal respiratory rate 12 - 20 bpm 

• Bradypnea < 12 bpm 

• Tachypnea > 20 bpm (rapid breathing) 

Blood Pressure:

pressure of the blood against aterial vascular system

• Systolic - pressure at the peak of left ventricular contraction

• Diastolic  - pressure during left ventricular relaxation

Auscultatory Gap: period of silence where first beat is heart at systole, period of silence follows, then return of audible pulse + second disappearance of pulse representing diastole 

Muffling Point: strength of pulse is significantly muffled but continues and disappears at lower measurement  

interpreting BP

SAVED: Red flags and high risk patients…

• S - severe, strange, suspicious symptoms

• A - age 

• V - veracity 

• E - emotional status 

• D - debilitation and distance  

What is triage

process of classifying patients to specific levels of care to meet their medical needs

• BASED ON

  • Medical acuity 

  • Available resources 

  • Patient expectations 

Medical Acuity 

Severity of the chief complaint: if, when, and where patient needs to be seen

1. HIGH → emergent care

2. Medium/Low → provider care today or tomorrow 

3. Vey low → self care

Loss of life or limb = call EMS NOW

Emergency Treatment

1. MI

2. TIA/Stroke

3. Severe pain

   1. Trauma 

   2. Abdominal pain: pancreatitis, appendicitis 

4. Bleeding

   1. Intracranial 

   2. GI bleed

5. Suicidal/homicidal 

6. Severe infection 

   1. Sepsis

Triage PROCESS…

1. ASK QUESTIONS - COLLECT DATA

   1. CC, HPI, Patient HX, ROS, physical exam 

2. WORKING HYPOTHESIS 

3. TRIAGE - Assessment and Plan

Collecting Data

…working hypothesis occurs the whole time

1. Initial patient impression 

2. Chief complaint

3. HPI (PPQRSSTA)

4. ROS

5. Patient History 

6. Physical Exam

7. Assessment/Triage Decision 

8. Plan of Care

Purpose of a pharmacist physical exam?

• To very or elaborate on information obtained from patient history and ROS (subjective)

• To screen for adverse drug events or disease conditions 

• Preventative health 

Pharmacist Role

• Health and medication history 

• General Survery (ROS)

• Vital signs

• Focused physical exam (targeted)

  • Triage recommendations: self care, provider care, emergency care 

  • Exam the primary area of concern then move outward

Methods of Assessment:

1. Function 

2. Inspection 

3. Auscultation 

4. Palpation

5. Percussion

Inspection

…initial impression: visualization and smell 

• Assess:

  • Age

  • Skin color

  • Facial features 

  • Posture 

  • Body structure 

  • Emotional status 

Auscultation

…listening to sounds of the body using stethoscope 

• Organ systems

  • Pulmonary

  • Abdominal 

  • Cardiovascular 

Bare skin is best for accurate assessment 

Stethoscope Parts:

1. Diaphragm for HIGH PITCHED SOUND

   1. Breath sounds, bowel sounds, regular heart sounds (S1, S2)

2. Bell for LOW PITCHED SOUND

   1. Heart murmurs, bruits, friction rubs, abnormal heart sounds (S3, S4)

Palpation

…touching or feeling with hand

Pads of fingers > fingertips

Assess:

1. Heat - inflammation 

2. Integumentary - surface lesions, rashes, vesicles

3. Pain

Light → medium → deep

Pads of fingers: general palpation

MCP JOINTS: vibrations 

Dorsum of Hand: temperature (back of hand) 

Percussion

… tapping to determine positions of organs, fluid, and air 

1. Respiratory - loud, low, hollow, resonant 

   1. Dull - mass, fluid, pneumonia 

   2. Hyperresonant - emphysema, pneumothorax

2. Abdomen - hollow, resonant, air filled bowels liver (dull)

   1. Dull - fluid collection (ascites) 

Which Ellipta inhalers require post-administration mouth rinsing

Breo, Arnuity, Trelegy

asthma

1. arnuity ellipta

2. spiriva respimat

3. breo ellipta

4. pro-air

short acting insulins

• lispro

• aspart

• glulisine

• human insulin

long acting insulin

• glargine

• detemir

• glargine

• degludec

• glargine-yfgn

correcting insulin dose

(current BG - goal BG)/correction factor = x units of insulin required

once daily GLP

• saxenda (liraglutide) —> weight loss

• victoza (liraglutide) —> T2DM

• Byetta (exenatide) BID —> T2DM