question

Comprehensive assessment

answer

includes all the elements of the health history and the complete physical examination seeing patients for first time in office or hospital provides fundamental and personalized knowledge about the patients strengths the clinician-patient relationship provides baseline for future assessments helps identify or rule out physical causes related to patient concerns creates platform for health promotion through education and counseling develops proficiency in the essential skills of physical examination

question

focused or problem-oriented assessment

answer

appropriate for patients you know well who are returning for routine office care or for patients with specific "urgent care" concerns like sore throat or knee pain adjust scope of history and physical examination to the situation at hand keeping in mind: magnitude and severity of the patient's problems; need for thoroughness; clinical setting

question

Why is the health history important?

answer

history of the past shapes who are are today past and present lifestyle choices affect our health today gives valuable info about patient Example: smoking

question

holistic

answer

physical, mental, spirit

question

assessment database

answer

health history physical examination patient records (laboratory and diagnostics)

question

Patient records

answer

laboratory and diagnostics look at different tests

question

Nursing Process

answer

assessment, past medical, physical exam

question

Goal of Assessment Database

answer

proactive, not reactive (catch something early)

question

Subjective data

answer

things that the patient says history-from chief complain to Review of System

question

Objective data

answer

concrete evidence that is measured what is detected during the examination all physical examination finding

question

comprehensive examination

answer

source of fundamental and personalized knowledge about the patient that strengthens the clinician-patient relationship provides a more complete basis for assessing these concerns and answering patient questions

question

focus examination

answer

select methods relevant to thorough assessment of the targeted problem patient's symptoms, age, and health history help determine scope of focus exam multi-task: vital signs while asking about pain

question

What are some objective findings?

answer

BP 140/90 CXR shows cardiomyopathy lesion noted right hand lungs clear to auscultation

question

What are some subjective findings?

answer

chief complaint father decreased due to lung cancer

question

routine clinical check-up periodic physical examination

answer

studies have scrutinized the usefulness of the comprehensive physical examination for the purposes of screening and prevention of illness, in contrast to evaluation of symptoms

question

7 components of Comprehensive Health HIstory

answer

1. Identifying Data and Source of History; Reliability 2. Chief Complaint(s) 3. Present Illness 4. Past History 5. Family History 6. Personal and Social History 7. Review of Systems

question

Initial Information

answer

Date and time of history identifying data reliability

question

Date and Time of History

answer

date is always important document time you evaluate patient

question

Identifying Data

answer

includes age, gender, martial status, and occupation

question

Source of History or referral

answer

can be patient, a family member or friend, an officer, a consultant, or the medical record type of info provided and any possible biases

question

Reliability

answer

document this information if relevant

question

Chief Complaint(s)

answer

make every attempt to quote the patient's own words report patient's goals why the patient is seeking care -brief statement or short phase

question

History of Present Illness

answer

describes the CC in more detail is a chronological account of the problem includes onset, setting, and manifestations

question

Seven attributes of Problem

answer

1. location (point to pain) 2. quality (what type: throb, burn) 3. quantity (how bad: pain scale) 4. time (onset, duration, frequency: acute/chronic) 5. setting (where did this occur/what were you doing) 6. alleviating and aggravating factors (make better/taking anything that helped) 7. associated manifestation/symptoms (anything else associated like fever)

question

Medications

answer

be noted, including name, dose, route, and frequency of use also list home remedies, nonprescription drugs, vitamins, mineral or herbal supplements, oral contraceptives, and medicines borrowed from family members, or friends

question

allergies

answer

NKA (no known allergies) NKDA (no know drug allergies) specific reactions to each medications, foods, insects, or environmental factors

question

how many cigarettes in a cigar?

answer

1 cigar = 17 cigarettes

question

Past Medical History (PMI)

answer

childhood illnesses medical history surgical history obstetric/gynecologic psychiatric health maintenance

question

Childhood illnesses

answer

measles rubella mumps whooping cough chickenpox rheumatic fever scarlet fever polio

question

Adult Illnesses

answer

medical surgical obstetric/gynecologic psychiatric

question

medical

answer

diabetes hypertension hepatitis asthma HIV hospitalizations number and gender of sex partners risky sexual practices

question

surgical

answer

dates indications types of operations problems with anesthesia

question

Obstetric/Gynecologic

answer

obstetric history menstrual history methods of contraception sexual function number of pregnancies and births

question

psychiatric

answer

illness and time frame diagnoses hospitalizations treatments

question

Health Maintenance

answer

immunizations up to date screening testings: TB test, pap smears, mammograms, colonoscopy

question

Family History

answer

who is the family had what illness and/or disease what illness and/or disease cause who in the family's death

question

Personal and Social History

answer

occupation level of education spiritual beliefs/religious affiliation leisure activités activities of daily living (ADL's) alcohol/tobacco/drugs exercise and diet alternative health care

question

Calculating Pack-Years of Smoking

answer

20 cigarettes = 1 pack # of cigarettes smoked per day/20 X # of years smoking

question

Review of Systems (ROS)

answer

-asking questions "from head to toe" -review systems not related to history of present illness -may discover overlooked problems or concerns -ask "yes/no" questions if "yes" go into detail (7 attributes) -look for "positives and negatives"

question

Major Health events should be moved to the ____.

answer

Present Illness or Past History in your write-up.

question

When do some clinicians do ROS?

answer

during the physical examination

question

ROS

answer

General Skin Head, Eyes, Ears, Nose, Throat (HEENT) Neck Breasts Respiratory Cardiovascular (CV) Gastrointestinal (GI) Urinary Genital Peripheral Vascular Musculoskeletal Psychiatric Neurological Hematological Endocrine

question

Approach to the Interview

answer

Chart review self reflection and acceptance -no bias, prejudice convey professionalism

question

Set the Tone

answer

make patient comfortable -privacy -note taking Write down everything but make eye contact, make sure they can see what you are typing (its their care)

question

Preparing for the Physical Examination

answer

reflect on approach to the patient adjust lighting and environment check your equipment make patient comfortable choose sequence of examination

question

tangential lighting

answer

casts light across the body surfaces that throws contours, elevations, and depressions whether moving or stationary into sharper relief optimal for inspecting structures such as the jugular venous pulse, the thyroid gland, and the apical impulse of the heart

question

equipment for the physical examination

answer

ophthalmoscope and otoscope flashlight or penlight tongue depressors rule and flexible tape measure, in cm thermometer watch with second hand sphygmomanometer stethoscope gloves and lubricant for oral, vaginal, and rectal examinations vaginal specula reflex hammer tuning fork Q-tips, safety pins cotton two test tubes paper, pen, pencil or computer

question

Organize your comprehensive or focused exam around 3 general goals:

answer

1. maximize the patient's comfort 2. avoid unnecessary changes in position 3. enhance clinical efficiency

question

The key to a thorough and accurate physical exam is ____.

answer

developing a systematic sequence of examination

question

What can dictate changes in sequence of examination?

answer

patient at bed rest where can't sit up or stand

question

Cardinal Techniques of Exam

answer

inspection (look) palpation (feel/touch) percussion (tap) auscultation (listen)

question

Standard and Universal Precautions

answer

Standard and MRSA precautions: all blood, body fluids, secretion, excretions except sweat, nonintact skin, and mucous membranes may contain transmissible infectious agents Be sure to wash your hands before and after examining the patient Universal precautions: prevent transmission of HIV, hepatitis B, and other blood-borne pathogens

question

Important goal of physical exam

answer

minimize how often you ask the patient to change position

question

Which side do you examine patient from?

answer

Patient's right side b/c estimates of jugular venous pressure are more reliable, palpating hand rest more comfortably on the apical impulse, right kidneys is more frequently palpable than left, and examining tables are frequently positioned to accommodate right-handed

question

General Survey

answer

continues throughout the history and examination state of health height build sexual development weight not posture motor activity gait dress, grooming, personal hygiene odors of body or breath facial expression speaking manner state of awareness or level of consciousness

question

Vital Signs

answer

BP pulse and respiratory rate (have patient sitting on edge of bed/table and stand in front)

question

Skin

answer

look at skin of face skin moisture or dryness and temperature identify lesions, note location, distribution, arrangement, type, and color inspect and palpate hair and nails

question

Head, Eyes, Ears, Nose, Throat (HEENT)

answer

Head: examine hair, scalp, skull, face Eyes: (room darken)visual acuity, screen the visual fields. Note position and alignment of eyes. Observe eyelids and inspect each cornea, iris, lens. Compare pupils, test reaction to light. Asses extra ocular movements. W/ ophthalmoscope, inspect ocular fundi Ears: Inspect auricles, canals, and drums. check auditory acuity; lateralization (weber test) and compare air and bone conduction (Rinne test) Nose and sinuses: examine external nose; use light and nasal speculum-inspect nasal mucosa, septum, and turbinates, palpate for tenderness for frontal and maxillary sinuses Throat (mouth and pharynx): inspect lips, oral mucosa, gums, teeth, tongue, palate, tonsils, and pharynx

question

Neck

answer

move behind sitting patient to feel thyroid gland and examine back, posterior thorax, and lungs inspect and palpate the cervical lymph nodes, notes any masses or unusual pulsations in the neck; feel for any deviation of trachea; observe sound and effort of patient's breathing; inspect and palpate the thyroid gland

question

Back

answer

inspect and palpate the spine and muscles of the back; observe shoulder height for symmetry

question

Posterior Thorax and Lungs

answer

Inspect and palpate spine and muscles of upper back inspect, palpate, and percuss chest listen to the breath sounds

question

Breasts, Axillae, and Epitrochlear Nodes

answer

still sitting, move to front inspect breasts with arms relaxed, the elevated then with her hands on her hips inspect axillae and feel for axillary nodes, feel epitrochlear nodes

question

Anterior Thorax and Lungs

answer

supine with you on right side of patient inspect, palpate and percuss chest, listen to breathing sounds

question

Cardiovascular System

answer

elevate head of bed to 30 degrees observe jugular venous pulsations and measure JV pressure inspect and palpate carotid pulsations, listen for carotid bruits inspect and palpate precordium, note location, diameter, amplitude and duration of apical impulse; listen to diaphragm, apex and lower sternal border; listen for abnormal heart sounds or murmurs (patient roll partly onto left side when listening to apex for mitral stenosis [S3]; patient should sit, lean forward, exhale when listening for murmur of aortic regurgitation)

question

Abdomen

answer

lower bed; patient is supine inspect, auscultate, and percuss abdomen, palpate lightly then deeply asses liver, spleen by percussion and then palpation try to feel kidneys and palpate aorta and its pulsations, if suspect kidney infection, percuss posteriorly over costovertebral angles

question

Lower extremities

answer

patient is supine still examine legs, assessing 3 systems while pt. supine; 3 systems can be further assessed when pt. stands

question

Peripheral Vascular System (pt. supine)

answer

palpate femoral pulses, popliteal pulses; palpate inguinal lymph nodes inspect lower extremity edema, discoloration, ulcers

question

Musculoskeletal System (pt. supine)

answer

note any deformities or enlarged joints; palpate joints; check range of motion

question

Nervous System (pt. supine)

answer

assess lower extremity muscle bulk, tone, and strength; assess sensation and reflexes; observe abnormal movements

question

Peripheral Vascular System (pt. standing)

answer

inspect varicose veins

question

Musculoskeletal System (pt. standing)

answer

examine alignment of spine and its range of motion, alignment of legs, and feet

question

Genitalia and Hernia in Mens

answer

pt. standing examine penis and scrotal contents and check for hernias

question

Nervous System (pt. standing)

answer

observe pt. gait and ability to walk heel-to-toe, walk on the toes, walk on the heels, hop in place and do shallow knee bend; Romberg test and check for pronator drift

question

Nervous System (sitting or supine)

answer

can be done at end of exam consists of 5 segments: mental status cranial nerves motor system sensory system reflexes

question

Mental Status

answer

assess pt. orientation, mood, thought process, thought content, abnormal perceptions, insight and judgment, memory and attention, information and vocabulary, calculating abilities, abstract thinking, and constructional ability

question

Cranial Nerves

answer

check sense of smell, strength of temporal and masseter muscles, corneal reflexes, facial movements, gag reflex, and strength of the trapezia and sternomastoid muscles

question

Motor System

answer

muscle bulk, tone, strength, of major muscle groups Cerebellar function: rapid alternating movements (RAMs), point-to-point movements, such as finger-to-nose (F-->N) and heel-to-shin (H-->S), gait

question

Sensory System

answer

pain, temperature, light touch, vibration, and discrimination; compare right with left sides and distal with proximal areas on the limbs

question

Reflexes

answer

including biceps, triceps, brachioradialis, patellar, achilles deep tendon reflexes; plantar reflexes or babinski reflex

question

Rectal Exam in Men

answer

pt. lying on his left side for rectal (or standing and bending forward) inspect sacrococcygeal and perianal area palpate anal canal, rectum and prostate if pt. can't stand, examine genitalia before doing rectal exam

question

Genital and rectal exam in Women

answer

pt. is supine in lithotomy position; RN is seated w/ speculum, then standing during bimanual exam of uterus, adnexa examine external genitalia, vagina, and cervix obtain pap smear palpate uterus and adnexa bimanually

question

Sequence to the Interview

answer

Initial contact -introduce your self, tell them who you are always address as Mr./Ms. unless they say otherwise Invite the patient's story Establish an agenda

question

Building a Therapeutic Relationship

answer

active listening -listen to what they say (don't let mind wander) expanding and clarifying the patient's story -find out problem in story and expand on that (lump in breast/trouble shallowing) -clarify what mean to pt. (heartburn; different to each pt.)

question

Therapeutic Communication

answer

Nonverbal Communication Empathy Reassurance Validation Partnering Summarization Transitions Empowering the patient

question

process of interviewing is primarily _____.

answer

patient-centered "encourages patients to express what is most important to them. They express their personal concerns in addition to symptoms" -creates a narrative that includes- "personal context of the patient's symptoms and disease"

question

Experts define patient-centered interviewing as ____.

answer

"following the patient's lead to understand their thought, ideas, concerns, and requests, without adding additional information from the doctor's perspective"

question

More symptom-focused, clinician-centered approach, the clinician _____.

answer

"takes charge of the interaction to meet her or his own need to acquire the symptoms, their details and other data that will help her or him identify a disease" --which can overlook the personal dimensions of the illness

question

Caring attributes are

answer

respect empathy humility sensitivity

question

Interview process

answer

consists of more than just asking a series of questions requires a highly refined sensitivity to the patient's feelings and behavioral cues generates pt. story is fluid and requires, empathy, effective communication, and relational skills to respond to pt. cues, feelings, and concerns

question

Health History Format

answer

provides an important framework for organizing the patient's story into various categories pertinent to the patient's present, past, and family health focuses your attention on specific kinds of info you need to obtain, facilitates clinical reasoning, and clarifies communication of pt. concerns, diagnoses, and plans to other health care providers involved in pt. care

question

Interviewing process is "open-ended" drawing on a range of techniques that ___.

answer

affirm and empower pt.--active listening, guided questioning, nonverbal affirmation, empathic responses, validation, reassurance, and partnering

question

"Clinician-centered", closed-ended "yes-no" questions are more pertinent to ____.

answer

Past Medical History Family History Personal and Social History Review of Systems

question

For patient's who seek care for ongoing or chronic problems, an interviewing focusing on ___.

answer

pt. self-management, response to treatment, functional capacity and quality of life, is most appropriate

question

Primary care clinicians frequently schedule visits specifically for health maintenance to address _____.

answer

screening and issues, like smoking, weight, or high-risk sexual behaviors

question

A specialist may need a ____.

answer

more comprehensive history to evaluate a problem with numerous possible causes

question

Techniques of Skilled Interviewing

answer

active listening empathic response guided questioning nonverbal communication validation reassurance partnering summarization transitions empowering the patient

question

Active Listening

answer

listen to what pt. says - don't let mind wander allows you to understand the meaning of those concerns at multiple levels of pt. experience

question

Empathic Responses

answer

identify with the pt. and feel the pt. pain as the clinician's own -to express empathy, you must first recognize the patient's feelings hard to empathize if you don't understand -For a response to be empathetic, it must convey that you feel what the patient is feeling

question

Guided Questioning: Options for Expanding and Clarifying the Patient's Story

answer

find out problem in pt. story and expand on that (lump in breast/trouble shallowing) clarify what means to the patient (heartburn) -different to each patient

question

Types of Guided Questioning

answer

1. Moving from open-ended to focused questions 2. using questioning that elicits a graded response 3. asking a series of questions, one at a time 4. offering multiple choices for answers 5. clarifying what the patient means 6. encouraging with continuers 7. using echoing

question

Moving from open-ended to focused questions

answer

question should proceed form general to specific -begin with a truly open-ended question AVOID: leading questions that include the answer in question

question

Questioning that Elicits a Graded Response

answer

ask questions that require a graded response rather than a single answer "how many steps can you climb before you get short of breath?" vs. "Do you get short of breath climbing stairs?"

question

Asking a Series of Questions, One at a Time.

answer

ask one question at a time "Any TB, pleurisy, asthma, bronchitis, pneumonia? instead ask "Do you have any of the following problems? (Pause for answers)

question

Offering Multiple Choice for Answers

answer

use when patient is unable to describe symptoms and needs help 1. "Which of the following words best describes your pain: aching, sharp, pressing, burning, shooting, or something else?" 2. "Do you bring up any phlegm with your cough, or is it dry?"

question

Clarifying What the Patient Means

answer

request clarification when answer vague 1. "Tell me exactly what you meant by 'the flu' 2. "You said you were behaving just like your mother. What did you mean?"

question

Encouraging with Continuers

answer

without speaking you can use posture, gestures, or words to encourage the patient to say more Example: nod of head, remaining silent, yet attentive and relaxed, leaning forward, make eye contact, using phrase like "Mm-hmm" or "Go on" or "I'm listening"

question

Echoing

answer

repetition of pt. last words, encourages pt to expand on factual details and feeling

question

Nonverbal Communication

answer

body language is important -don't realize sometimes pay attention to eye contact, facial expression, posture, head position and movement such as shaking or nodding, interpersonal distance, and placement of arms or legs (crossed, neutral, or open) can be universal or culturally bound

question

paralanguage

answer

qualities of speech such as pacing, tone, and volume

question

Validation

answer

important to validate pt. Example: Pt. trying to get pregnant; doing everything right, but parental pressure legitimate and understandable emotion the pt is experiencing

question

Reassurance

answer

not good if it is false Example: Stage 4 cancer --it will be "ok"--not really - can mistakenly reassure pt. about wrong thing - may block further disclosures 1. 1st step to effective reassurance is simply identifying and acknowledging pt. feelings- feeling of connection comes from making pt. feel confident that problems have been fully understood and are being addressed

question

Partnering

answer

be explicit about your commitment to on ongoing partnership make pt. feel regardless of what happens w/ illness, you envision continuing their care.

question

Summarization

answer

give capsule summary of pt. story during course of interview serve several functions 1. communicated to pt. you listened 2. identifies what you know and don't know 3. lets pt. add other info and correct misunderstandings 4. summarize at different pt eps during transitions

question

Transitions

answer

tell pt. when changing directions during interview - give pt. greater sense of control Example: "Now I'd like to ask some questions about your past health" or "Before we move on to reviewing all your medication, was there anything else about past health problems?"

question

Empowering the Patient

answer

clinician-patient relationship unequal pt may feel vulnerable Differences of gender, ethnicity, race, or class may also contribute to power differentials ULTIMATELY, patients are responsible for their own care -tell pt. before that you are going to asking personal questions - ask if ok if other people are present (same when talking about meds [viagra])

question

Empowering the Patient: Principles of Sharing Power

answer

evoke the patient's perspective convey interest in the person, not just problem follow patient's leads elicit and validate emotional content share information with the patient, especially at transition points during visit make your clinical reasoning transparent to patient reveal the limits of your knowledge

question

Sequence and Context of Interview

answer

Preparation Sequence of Interview Cultural Context of the Interview

question

Preparation

answer

reviewing the medical record setting goals for interview reviewing your behavior and appearance adjusting the environment

question

Reviewing the Medical Record

answer

before seeing pt., helps gather info and pan the areas you need to explore look at age, gender, address, and health insurance, peruse the problem list, medication list, details like allergies

question

Setting Goals for the Interview

answer

before talking to pt., clarify your goals for interview goal as student: complete a comprehensive health history goal as clinician: assessing new concern, follow-up treatment, completing forms clinician must balance these provider-centered goals with patient-centered goals

question

Reviewing Your Clinical Behavior and Appearance

answer

posture, gestures, eye contact, and tone of voice all convey extent of your interest, attention, acceptance, and understanding appear calm and unhurried even when time is limited appearance matters

question

Adjusting the Environment

answer

setting as private and comfortable as possible -adjust room temp when needed as the clinician, it is part of your job to make adjustments to the location and seating that make the patient more comfortable

question

Throughout the sequence of the interview, as the clinician, you must always _____.

answer

Be attuned to the patient's feelings, help the patient express them, response to their content, and validate their significant.

question

Sequence of the Interview

answer

1. greeting the patient and establishing rapport 2. establishing the agenda for the interview 3. inviting the patient's story 4. exploring the patient's perspective 5. identifying and responding to emotional clues 6. expanding and clarifying the patient's story 7. generating and testing diagnostic hypothesis 8. sharing the treatment plan 9. closing the interview and the visit 10. taking time for self-reflection

question

Greeting the Patient and Establishing Rapport

answer

greet pt. by name and introduce yourself, give your own name - if possible, shake hands with patient - explain your role, including status and how involved in pt. care use formal title to address pt. (Mr./Ms.) ask if don't know how to pronounce name, then repeat it always be attuned to the patient's comfort adjust lighting

question

Taking Notes

answer

jot down short phrases, specific data, or words rather than attempting a final format don't let note taking distract you from pt. maintain good eye contact

question

Establishing the Agenda

answer

chief complaint presenting problem(s) begin with "open-ended questions"

question

Inviting the Patient's Story

answer

by asking about the foremost concern, "Tell me more about...?" Continue to encourage pt. to tell their story in own words, using open-ended approach avoid biasing the pt. story-inject no new information and don't interrupt use active listening skills follow pt. leads using additional guided questioning helps you avoid missing any of pt. concerns

question

Exploring the Patient's Perspective

answer

explore deeper meaning pt. attach to their symptoms disease/illness distinction model acknowledges different yet complementary perspectives of the clinician and pt. melding of these two perspectives forms the basis for planning evaluation and treatment

question

Disease

answer

explanation that the clinician brings to the symptoms way clinician organizes what he or she learns from the pt. that leads to a clinical diagnosis

question

Illness

answer

how patient experiences all aspects of the disease, including its effects on relationships, function, and sense of well-being may factors shape this experience like prior personal or family health, effect of symptoms on everyday life, individual outlook and style of coping and expectations about medical care

question

Exploring the Patient's Perspective (F-I-F-E)

answer

pt. FEELINGS, including fears or concerns, about the problem pt. IDEAS about the nature and cause of the problem effect of the problem on the pt. life and FUNCTION pt. EXPECTATIONS of the disease, of the clinician, or of health care, often based on prior personal or family experiences

question

Identifying and Responding to the Patient's Emotional Cues

answer

emotional distress is associated with illness respond immediately when observe an emotional cue -Naming -Understanding or legitimization -Respecting

question

Expanding and Clarifying the Patient's Story

answer

guide pt to elaborate on areas of health history that seem most significant clarify the attributes of each symptom including: context, associations, and chronology use pt. words when possible establish sequence and time course of symptoms

question

Seven Attributes of a Symptom

answer

Location Quality Quantity or severity Timing Setting in which it occurs Alleviating or aggravating factors Associated manifestations

question

Generating and Testing Diagnostic Hypotheses

answer

generate and test diagnostic hypotheses about what disease process might be present

question

Sharing the Treatment Plan

answer

shared planning plays important role in building rapport

question

Behavior Change and Motivational Interviewing

answer

drinking, exercise, diet, meds, sleep motivational interviewing makes assumption that many pt already know what is best for them and helps them confront their ambivalence to change

question

Closing the Interview

answer

let pt know end of interview is coming and allow time for final questions

question

Taking Time for Self-Reflection

answer

self-reflection is a continual part of professional development in clinical work. It brings a deepening personal awareness to our work with patients. This personal awareness is one of the most rewarding aspects of pt. care

question

Cultural Competence

answer

"capacity to function effectively as an individual and an organization within the context of the cultural beliefs, behaviors, and needs" presented by patients and their communities

question

Cultural humility

answer

self reflection continual learning mutually respectful and dynamic partnerships

question

Culture

answer

shared, learned, symbolic system of values, beliefs and attitudes that shapes and influences perception and behavior

question

Silent Patient

answer

watch for nonverbal cues have you offended the patient? Asking too many questions?

question

Special Situation

answer

silent patient confusing patient patient with altered capacity talkative patient crying patient angry or disruptive patient language barrier hearing impaired visually impaired cultural differences

question

decision-making capacity

answer

ability to understand information related to health, make medical choices based on reason and consistent set of values, and to declare preferences about treatments

question

Approaching Sensitive Topics

answer

be non-judgmental explain why you are asking start with broad open-ended questions and proceed to more focused self reflect and acknowledge feelings

question

Sensitive Topics: Alcohol/Drug Abuse

answer

CAGE questionnaire: C- "have you ever tried to CUT back on your drinking and couldn't" A- "have you ever felt annoyed by criticism of your drinking?" G- "have you ever felt Guilty about drinking?" E- "have you ever taken a drink first thing in the morning (eye opener) to help your hangover?" If "yes" to any question then might have a problem

question

1 drink is defined as

answer

12 oz of beer 5 oz of wine 1.5 oz of liquor

question

Sensitive Topics-Domestic Violence

answer

RADAR -R: routine screening -A: ask about abuse -D: document -A: assess for safety -R: refer

question

Ethics and Professionalism

answer

autonomy: self, patient have right to determine what best for them beneficence: do good for patient non-maleficence: do no harm confidentiality

question

Preparing for the PHysical Exam

answer

reflect on your approach to the patient adjust lighting and environment determine scope of exam choose sequence of exam observe correct examining position and handedness make patient comfortable

question

Reflect on Your Approach to the Patient

answer

wash your hands in front of the patient it is normal to be nervous identify yourself as student appear calm, cool, and collected on outside explain you may spend extra time as you are learning be thorough, systematic and gentle be selective about sharing information with patient

question

Lighting and Environment

answer

set the stage for comfort (for patient and nurse) adjust the bed height ask the patient to move into optimal position (goal is to have patient move as little as possible) adjust lighting remove unnecessary sounds

question

Sequence of Exam

answer

maximize patient's comfort avoid unnecessary changes in position enhance clinical efficiency Start "head to toe"

question

"Head to Toe" order of 4 things

answer

Inspection: look Palpation: touch Percussion: tap Auscultation: listen

question

Order with abdomen:

answer

Inspection Auscultation Percussion Palpation

question

Position and Handedness

answer

Examine from the patient's right side -more reliable to estimate jugular venous pressure -palpating hand rests more comfortably on the apical pulse -right kidney is more frequently palpable than left -exam tables are more commonly positioned for right-handed approach

question

Patient Comfort

answer

show concern for patient privacy/modesty drape the patient visualize one area at a time keep the patient informed provide clear, courteous directions be sensitive to the patient's feelings and physical comfort share general impressions lower the bed when finished wash your hands with finished

question

Components of the Physical Exam

answer

General Survey Vital Signs Skin HEENT Neck Lymph nodes Thorax and lungs Cardiovascular Abdomen Peripheral vascular Musculoskeletal Neurological Breast Genitalia

question

Framework for Assessment and Documentation of Finding

answer

SOAP Note S: subjective O: objective A: assessment P: plan E: evaluation (plan helped patient) help you think

question

c/o

answer

complains of

question

cc

answer

chief complain

question

PMH

answer

past medical history

question

HTN

answer

hypertension

question

DM

answer

diabetes mellitus

question

ROS

answer

review of systems

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