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What are the two scopes of patient assessment?
What are the factors that help you determine how much needs to be done within the patient assessment?
- Comprehensive and Focused (problem oriented)
- Magnitude of severity of patient’s problem
- Your need for thoroughness
- The clinical setting
- Impatient or outpatient
- Time available
Comprehensive Assessment useful for:
- Appropriate for new patients in office or hospital.
- Provides fundamental and personalized knowledge about the patient.
- Strengthens the clinical-patient relationship.
- Helps identify or rule out physical causes related to patient concerns.
- Provides baselines for future assessments.
- Creates platform for health promotion through education and counseling.
- Develops proficiency in the essential skills of physical examination.
Focused Assessment useful for:
- Is appropriate for established patients, especially during routine or urgent care visits.
- Addresses focused concerns or symptoms.
- Assess symptoms restricted to a specific body system.
- Applies examination methods relevant to assessing the concern or problem as precisely and carefully as possible.
Subjective vs. Objective Data
- Subjective Data
- What the patient tells you
- The history, from chief complaint through review of systems
- Objective Data
- What you detect during the examination
- All physical examination findings
What is the purpose of a Health History?
Purpose to establish a relationship and to learn about the patient, so that you might discover issues and problems that need attention and the assignment of priority.
What are the seven components of an Adult Health History?
- Identifying Data and Source of the History
- Chief Complaints (s)
- Present Illness
- Past History
- Family History
- Personal and Social History
- Review of Systems
Steps taken while taking the history:
- Introduce yourself
- State your role
- Be certain that you understand the patient’s full name and pronounce it correctly.
- Address the patient properly (i.e. Mr. Mrs.)
- Never use surrogate terms.
- If possible be seated at a comfortable distance from the patient without furniture barriers between you.
- Ask patient to state the reason for the visit.
Components of Identifying Data:
- Source of history
- Referral source
What is a Chief Complaint (CC), and what are some steps you can in order to can an accurate account of a patients CC?
- CC: Is a brief statement of the reason the patient is seeking health care.
- Make every attempt to quote the patient’s own words i.e. “I have a sore throat and I feel awful.”
- Ask probing questions to seek for underlying concerns i.e. Patient concerned because a relative developed rheumatic fever.
What is a History of Present Illness (HPI), and what should the narrative of an HPI include?
- HPI: Is a complete, clear, and chronologic account of the problems prompting the patient to seek care.
- Narrative should include the onset of the problem, the setting in which it has developed, its manifestations, and any treatment.
- The medical history goes beyond this to an exploration of the patient’s overall health before the present problem, including all the patient’s past medical and surgical experiences.
In an HPI each principle symptom should be well characterized with a description of:
- Quantity or severity
- Timing, including onset, duration, and frequency
- The setting in which it occurs
- Factors that aggravate or relieve symptoms
- Associated manifestations
Within an HPI ________ and ________ should be noted and recorded.
- Should be noted including name, route, and frequency.
- Also list home remedies, nonprescription drugs, vitamins, minerals or herbal supplements, oral contraceptives, medications borrowed.
- Brown bag
- Must be recorded
- Include specific reactions to each medications i.e. rash, nausea, anaphylactic.
- Include allergies to food, insects, or environmental factors.
A past medical history should include:
- Childhood illnesses
- Major adult illness
- Health maintenance
Surgical History should include:
What does a Family History consist of?
- Outline or diagram the age and health, or age and cause of death, of each immediate relative to include:
A Social History should include:
- Personal status
- Religious affiliation and Spiritual beliefs
- Important life experiences
- Activities of daily living (ADLs)
- Bad Habits
- Sexual History/ Preference
- Home conditions
- Ethnic background
What is a Review of Symptoms(ROS)?
- A screening device to uncover potentially significant symptoms not otherwise elicited.
- Symptoms related to the history of present illness
- Other active problems
- Determine the pertinent positives and negatives which will aid in making a diagnosis.
- A series of questions going from “ head to toe.”
Where does the Review of Symptoms Go?
- It is usually performed as the last part of the medical history.
- It can sometimes be given to a patient in written form to complete before they see you.
- It can be performed during the physical exam, once you are more experienced.
What are some statements used in order to begin the transition to the ROS?
- “I’d like to ask some general questions about your health to make sure I haven’t missed anything.”
- “The next part of the history may feel like a million questions, but they are important and I want to be thorough.”
Hints on how to take the ROS:
- Ask a general question about each system followed by more specific yes/no questions as needed.
- For example, “Are you having any trouble with your vision?”
- If the answer is yes, “Are you having double vision? Is your distance vision worsening?”
- You need enough detail to indicate if each positive response is significant or not.
- For example, “Has this change in your vision been sudden or gradual?
- Has the vision changed in both eyes? Can you read? Can you see the television?”
- You may elicit information that belongs in the HPI.
- You may elicit information that belongs in the Past Medical History.
Order of the Review of Systems:
- Peripheral Vascular
Things to question in the General ROS:
- Weight loss or gain
- Fever or chills
- Trouble sleeping
Things to question or look out for in the Skin ROS:
- Color Change
- Change in Hair or Nails
Things to question or look out for in the Head ROS:
headache, head injury, dizziness, lightheadedness
Things to question or recognize in the Eyes ROS:
- Glasses or contact lenses
- Last eye exam
- Double vision
- Blurred vision
- Flashing lights
Things to question or recognize in the Ears ROS:
- Decreased hearing
- *If hearing is decreased use or non use of hearing aids.*
Things to question or recognize in the Nose and Sinuses ROS:
- Hay fever
- Sinus pain
- Frequent colds
Things to question or recognize in the Throat and Mouth ROS:
- Condition of teeth
- Bleeding gums
- Last dental exam
- Sore tongue
- Dry mouth
- Sore throats
Things to question or recognize in the Neck ROS:
- Swollen glands
- Goiter (large thyroid)
Things to question or recognize in the Breasts ROS:
- Self breast exams?
- Nursing a child?
Things to question or recognize in the Respiratory ROS:
- Sputum (color and amount)
- Painful breathing
- Exposure to tuberculosis
Things to question or recognize in the Cardiovascular ROS:
- Chest pain or tightness
- Paroxysmal nocturnal dyspnea
Things to question or recognize in the Gastrointestinal ROS:
- Trouble swallowing
- Loss of appetite
- Change in bowel habits
- Blood in stool
- Dark tarry stools
- Abdominal pain
- Rectal bleeding
Things to question or recognize in the Urinary ROS:
- Frequency of urination
- Burning or pain
- Kidney stones
Things to question or recognize in the Male Genital ROS:
- Penile discharge
- Testicular mass or pain
- Erectile dysfunction
- Condom use
Things to question or recognize in the Female Genital ROS:
- Onset, length, frequency, duration
- Vaginal discharge, itching or rashes
- Birth Control
Things to question or recognize in the Peripheral Vascular ROS:
- Leg cramps
- Varicose veins
- Blood clots
- Swelling in calves, legs, or feet
- Color change in fingertips or toes during old weather; swelling with redness or tenderness.
Things to question or recognize in the Musculoskeletal ROS:
- Muscle or joint pains
- Back pain
- Swelling of joints
- Timing of symptoms
Things to question or recognize in the Neurologic ROS:
- Dizziness, lightheadedness
- Weakness, paralysis
- Change in mood, attention, speech
- Change in orientation, memory, insight, or judgment
Things to question or recognize in the Hematologic ROS:
- Easy bruising
- Easy bleeding
- Blood Clots
- Transfusion history to include reactions
Things to question or recognize in the Endocrine ROS:
- Heat or cold intolerance
- Excessive sweating
- Change in glove or shoe size
Things to question or recognize in the Psychiatric ROS:
- Depressed mood
- Memory loss
- Disturbing thoughts
- Suicide attempts, if relevant
How do you record the Review of Symptoms?
- Include symptoms relevant to the HPI in the HPI.
- DO NOT repeat HPI information in the ROS.
- Include what you consider major health events in the Past Medical History.
What are the purposes (3) of a clinical examination?
- 1. Gather information about the patient.
- 2. To give information to the patient.
- 3. To establish a patient rapport.
What is clinical reasoning?
- It’s a critical skill for health professionals and is central to the practice of professional autonomy.
- It’s “the thought process that guides practice.”
- Clinical reasoning has been likened to the process of learning to ride a bike.
- Once the learning is done, the knowledge becomes tacit (a fancy word that means it’s engrained and you don’t have to consciously think about it).
How do you obatin a better understanding of the clinical reasoning?
- Life long learning, and pursuit of the clinical literature
- Collaboration with colleagues
Steps in Clinical Reasoning:
- Identify abnormal findings.
- Localize findings anatomically.
- Interpret findings in terms of probable process.
- Make hypotheses about the nature of the patient’s problem.
- Test the hypotheses and establish a working diagnosis.
- Develop a plan agreeable to the patient.
True or False:
All findings should be unified under one diagnosis.
- More than one disease process can exist at one time.
- An acute illness can be imposed on a chronic one, and a chronic disease can cycle endlessly through remission and relapse.
- You must be sure that all of the information is logically explained by your ultimate conclusion.
A _________ may be defined as anything that will nedd further evaluation and/or attention.
It might be related to one or more of the following:
- An uncertain diagnosis
- New findings related to previous diagnosis
- New findings of unknown cause
- Unusual findings revealed in the clinical examination or by laboratory tests
- Personal or social difficulties
Why is the validity of the clinical examination important?
Reduce health care cost by limiting the indiscriminate use of expensive technology.
What is required for the validity of the clinical examination?
- Some assurance and reliability of your observation.
- Clinical data, including laboratory work.
- Learning more of the sensitivity and specificity of your findings.
the ability of an observation to identify correctly those who have a disease.
the ability of an observation to identify correctly those who do not have the disease.
an expected observation that is found when the disease characterized by that observation is presents.
an expected observation that is not found when the disease characterized by that observation is not present
an observation made that suggest a disease when that disease is not present.
a disease is present, the observation is there to be made, and it is not appreciated
Indicates how well a given symptom, sign, or test result-either positive or negative- predicts the presence or absence of disease.
Positive predicted value:
the proportion of persons with an observation characteristic of a disease who have it.
Negative predicted value:
the proportion of persons with an expected observation who ultimately prove not to have the expected condition.
Things to question or recognize when forming a Differential Diagnosis:
- V = Vascular___________ VINDICATE
- I = Infection (e.g. viruses, bacteria and fungal)
- N = Neoplasm
- D = Drugs (medications or illicit drugs)
- I - Inflammatory/Idiopathic
- C = Congenital
- A = Autoimmune
- T = Trauma
- E = Endocrine/metabolic
Process of making the Management Plan:
- Ok now that you decide what you think is going on ( the diagnosis) and what are you going to do about it (the management plan).
- Develop a plan agreeable to the patient. Identify and record a plan for each patient problem.
- Your plan flows logically from the problems or diagnosis you have identified.
Considerations to approach making the management plan may include:
- Laboratory studies
- Consultation requested
- Medication or appliances prescribed
- Special care to be provided (i.e. nursing, PT, OT, RT)
- Diet Modification
- Activity Modification
- Follow-up visit schedule
- Patient education needs
You need to decide the degree of urgency of each of these items and what it is that underlies the issues in terms of _______, ________, and ________ considerations.
- social, economic, and pathophysiologic
- Priorities must be set.
- The patient, surely must be actively and positively involved if an optimal outcome is to be achieved.
Problem- Oriented Medical Record (POMR):
- A commonly used process to organize patient data gained during the history and physical exam.
- Used after the history and physical examination is completed.
Six components of a problem-oriented medical record:
- 1. Comprehensive health history
- 2. Complete physical exam
- 3. Problem list
- 4. Assessment and plan
- 5. Baseline and problem-directed labs and radiologic images
- 6. Progress notes
Sometimes the term “_______” note is only applied to short notes but the format is used throughout medical practice for communication. What does the acronym stand for?
Includes information you have learned from the patient or people caring for the patient.
- This section includes observations and measurements that you have made during the physical examination.
- Includes the vital signs.
- Includes a general description of the patient.
- Results of diagnostic testing also go here.
- Laboratory results
- Pathology reports
- What do you feel is the patient’s differential diagnosis and why?
- This is organized by problem or organ system.
- For each problem what diagnostic testing will you order?
- How will you treat each problem?
- Lifestyle change
- Tincture of time
What is the primary goal of a Health History Interview?
- Primary goal “Is to improve well-being of the patient.”
- Conversation with a purpose.
- Establish a supportive interaction.
is a structured framework for organizing patient information in written or verbal form for other health care providers.
Requires not only knowledge of the data that you need to obtain, but the ability to elicit accurate information and the interpersonal skills that allow you to respond to the patient’s feeling and concerns.
What are the interviewing milestones(6)?
- Getting Ready: The Approach to the Interview
- Learning About the Patient: The Sequence of the Interview
- Building the Relationship: The Techniques of Skilled Interviewing
- Adapting Your Interview to Specific Situations
- Sensitive Topics that Call for Special Skills
- Societal Aspects of Interviewing
In building a theraputic relationship what are some of the techniques used in the interviewing process?
- Active Listening
- Guided questioning
- Non-Verbal Communication
- Empathetic responses
- Empowering the Patient
What are some forms of guided questions?
- Moving from open-ended to focused questions
- Using questioning that elicits a graded response
- Asking a series of questions, one at a time
- Offering multiple choices for answers
- Clarifying what the patient means
- Encouraging with continuers
- Using echoing
When using an interpreter explain how you should arrange the room?
Arrange the room so that you and the patient have eye contact and can read each other’s nonverbal cues; Seat the interpreter next to the patient
What is the CAGE questionnaire?
- Have you ever felt the need to Cut down on drinking?
- Have you ever felt Annoyed by criticism of your drinking?
- Have you ever felt Guilty about drinking? Have you ever taken a drink first thing in the morning (Eye – Opener) to steady your nerves or get rid of a hangover?
What are some sensitive topics that call for specific approaches?
- Sexual History
- Mental Health History
- Alcohol and Illicit Drug Use
- Family Violence
- Death and Dying Patient
What is the sigle most important rule when broaching a sensitive topic?
The single most important rule is to be nonjudgmental.
What are some guidelines for broaching sensitive topics?
- The single most important rule is to be nonjudgmental.
- Explain why you need to know certain information
- Find opening questions for sensitive topics and learn the specific kinds of information needed for your assessments
- Consciously acknowledge whatever discomfort you are feeling. Denying your discomfort may lead you to avoid the topic altogether.
What are some clues of possible physical abuse?
- If injuries are unexplained, seem inconsistent with the patient’s story, are concealed by the patient, or cause embarrassment.
- If the patient has delayed in obtaining treatment for trauma.
- If there is a past history of repeated injuries or “accidents.”
- If the patient or person close to the patient has a history of alcohol or drug abuse.
- If the partner tries to dominate the interview, will not leave the room, or seems unusually anxious or solicitous.
Name the steps of the Kubler-Ross Model of Death and Dying
- 1.Denial and isolation
- 4.Depression or sadness
Things to look for during a general survey of a patient:
- Apparent state of health –Acute or chronically ill, frail
- Level of consciousness –Awake, alert, responsive or lethargic, obtunded, comatose
- Signs of distress –Cardiac or respiratory; pain; anxiety/depression
- Skin color and obvious lesions
- Dress, grooming, and personal hygiene –Appropriate to weather and temperature –Clean, properly buttoned/zipped
- Facial expression –Eye contact, appropriate changes in facial expression
- Odors of body and breath
- Posture, gait, and motor activity
Formula for calculating the BMI:
Weight in lbs/ (Height in inches)2 x 703
Vital Signs (5):
- 1.Blood pressure
- 2.Heart rate and rhythm
- 3.Respiratory rate and rhythm
A silent interval that may be present between the systolic and diastolic blood pressures; i.e., the sound disappears for a while, then reappears
Orthostatic blood pressure:
- Measure blood pressure and heart rate with the patient supine; wait 3 minutes, then have the patient stand up; now repeat the measurements
- Normal: systolic BP drops slightly or remains unchanged; diastolic BP rises slightly
- Orthostasis: systolic BP drops >20 mm Hg or diastolic BP drops >10 mm Hg
What are some methods used to intensify sounds when reading blood pressure?
- Raise the patient’s arm before and while you inflate the cuff. Then lower the arm to determine blood pressure.
- Inflate the cuff. Ask the patient to make a fist several times, and then determine the blood pressure.
Never take blood pressure in an arm with:
- An IV line or heplock in place
- A dialysis or other fistula or shunt
- On the same side as a mastectomy.
- Average oral temperature: 37°C or 98.6°F
Things to look for when indentifying pain:
Assess location, severity, associated features, attempted treatments/medications, related illnesses, impact on daily activities
Types of Pain:
- Nociceptive or somatic – related to tissue damage
- Neuropathic – resulting from direct trauma to the peripheral or central nervous system
- Psychogenic – relates to factors that influence the patient’s report of pain: Psychiatric conditions, Personality and coping style, Cultural norms, Social support systems
- Idiopathic – no identifiable etiology
The prevalence of mental disorders in the U.S population is ____% , yet only approximately____% of affected patients receive treatment.
Adherence to treatment guidelines in primary care offices is less than ___%.
What are some of the contributing factors to the lack of affected patients with mental disorders receiving treatment, and lack of adherence to treatment of those who are receiving treatment?
- Stigma surrounding the receipt of mental health treatment
- Inexperienced clinicians
- Cost issues
- Lack of access to care
- Lack Insurance
What are some steps used in identifying a patients symptoms?
- Physical vs. Psychological
- Medically unexplained (Somatoform disorders)
- Functional syndromes i.e. IBS, fibromyalgia, chronic fatigue, TMJ
Failure to recognize physical and functional syndromes with common mental health disorders adds to loss of the patient’s “______________” and impaired treatment outcomes.
quality of life
Meets DSM-IV-TR IV:
identifies recent psychosocial stressors such as a death of a loved one, divorce, losing a job, etc. Psychosocial and Environmental Problems
Patient Identifier for Mental Health Screening:
- Unexplained conditions lasting beyond 6wks
- Multiple physical or somatic symptoms
- Recent stress
- Substance abuse
- Chronic pain
- Frequent Flyers
- Distrust, suspicious
- Detachment from social relationships, with a restricsted range of emotional expression
Eccentric in behavior
Disregard for others
Grandiose, no empathy
Rigid detailed-oriented behavior
Common signs and symptoms of Anxiety:
- Excessive tension and worry
- Feeling restless or jumpy
- Irritability or feeling “on edge”
- Racing heart or shortness of breath
- Nausea, trembling, or dizziness
- Muscle tension, headaches
- Trouble concentrating
Common signs and symptoms of Depression:
- Feelings of helplessness and hopelessness
- Loss of interest in daily activities
- Inability to experience pleasure
- Appetite or weight changes
- Sleep changes
- Loss of energy
- Strong feelings of worthlessness or guilt
- Concentration problems
Terminology: The Mental Status Examination
Level of consciousness:
- Level of consciousness- how aware the person is of his environment
- Attention-the ability to focus or concentrate
- Alert- awake and aware
- Lethargic- must speak to pt. in loud forceful manner to get response
- Obtunded-you must shake a person to get response
- Stuporous-patient is unarousable except for painful stimuli (sternal rub)
- Coma-the patient is completely unarousable
- the process of recording and retrieving information
- memory covers events or memories that occurred minutes to days before
- memory covers events or memories that occurred months to years before
aware of person (who they are), place (where they are), and time (when is it); this requires memory and attention
awareness of the objects in the environment to the five senses and their interrelationships
the logic, coherence, and relevance of a patient’s thoughts as they lead to thoughts and goals; HOW people think
awareness that thought, symptoms, or behaviors are normal or abnormal; e.g., distinguishing that a daydream or hallucination is not real
process of comparing and evaluating different possible courses of action
the observable mood of a person expressed through facial expression, body movements, and voice
- the sustained emotion of the patient
- Euthymic: normal
- Dysthymic: depressed
- Manic: elated
the complex symbolic system for expressing written and verbal thoughts, emotion, attention, and memory
Higher cognitive functions:
level of intelligence assessed by vocabulary, knowledge base, calculations, and abstract thinking
What are the components of a Mental Status Exam?
- Appearance and behavior
- Speech and language
- Thoughts and perceptions
- Cognitive function: memory, attention, information and vocabulary, calculations, abstract thinking, and constructional ability
Asssessing the Apperance 3 factors:
- 1. Posture and motor behavior - Does the patient lie in bed or prefer to walk around? - Is the patient sitting or lying comfortably? - Is the patient agitated with repetitive movements?
- 2. Assess the patient’s dress, grooming, and personal hygiene - Generally, grooming and hygiene deteriorate in depression or schizophrenia
- 3. Assess the patient’s facial expressions A flat affect (lack of facial movement) can be seen due to a physical reason such as Parkinson’s disease or a psychological reason such as profound depression
Assessing Speech and Language:
- Fluency: involves the rate, flow, and melody of speech
- Hesitancies in speech (as seen in patients with aphasia from strokes)
- Monotone inflections (schizophrenia or severe depression)
- Circumlocutions: words or phrases are substituted for the word a person cannot remember; e.g., “the thing you block out your writing with” for an eraser
- Paraphasias: words are malformed (“I write with a den”), wrong (“I write with a branch”), or invented (“I write with a dar”)
- Use open-ended questions
- “How do you feel about that?”
- “How are you feeling?”
- How long has the patient’s mood been this way
- How good or bad has the patient felt
- Sometimes you have to ask friends or family of the patient to help you assess the patient’s mood
- Do not be afraid to ask the patient about thoughts of self-harm or suicide
Assessing the Thought and Perception process:
- Assess thought processes: logic, relevance, organization, and coherence
- Abnormalities in the thought process
- Circumstantiality: speech characterized by indirection and delay due to the patient’s excessive use of detailsthat have no connection to the point
- Derailment: speech in which a person shifts topics with no apparent relation between the topics
- Flight of ideas: accelerated change of topics in a very fast but generally coherent manner
- Neologisms: invented or distorted words
- Incoherence: speech that is incomprehensible because it is illogical
- Blocking: sudden interruption of speech, before the completion of an idea, occurs in normal people
- Confabulation: fabrication of facts to hide memory impairment
- Perseveration: persistent repetition of words or ideas
- Echolalia: repetition of the words or phrases of others
- Clanging: choosing a word on the basis of sound rather than meaning
Assessing Abnormalities of Thought Content:
- Assess thought content during the interview by following appropriate leads as they occur
- Abnormalities of thought content
- Compulsions: repetitive behaviors that a person feels driven to perform to prevent or produce some future state of affairs
- Obsessions: recurrent, uncontrollable thoughts, images, or impulses that a patient considers unacceptable
- Phobias: persistent fear of a stimuli the patient feels is irrational (spiders, snakes, the dark)
- Anxiety: apprehension or fear that may be focused (phobia) or free floating (general sense of dread)
- false, fixed beliefs that are not shared by other members of the person’s culture
- Delusion of persecution, grandeur, or jealousy
- Delusion of reference: a person believes an outside event or object has an unusual personal reference to them; i.e., a comet passing earth means the patient should buy a car
- Delusion of being controlled by outside forces
- Somatic delusion: believing one has a disease or defect that he does not
- Systematized delusion: a single elusion with many elaborations around a single theme all systematized into a complex network; i.e., the KGB is after the patient
Inquire about false perceptions:
- Do you hear voices other people don’t hear?
- Do you see things other people don’t see?
- Do you know things other people don’t know?
Abnormalities of perceptions:
- Illusions: misinterpretations of real stimuli; e.g., the postman leaves mail, therefore there is a plot to poison the patient
- Hallucinations: a subjective external stimuli the patient hears or sees that others do not hear or see and that the patient may not recognize as false; these can be auditory, visual, olfactory, gustatory, or tactile
- Abe Lincoln speaks to the patient from the back of a penny
- Do not include false perceptions associated with dreaming/falling asleep