Term
| Why do a history and physical |
|
Definition
screen for disease
assess risk for future problems
encourage healthy lifestyle
provide patient education
update vaccinations
establish and maintain relationship with patient in event of illness of injury |
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|
Term
| types of histoy and physicals |
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Definition
focused/brief/problem focused
screening
comprehensive
consultative
surgical
specility specific
age specific
propose specific (occupation, sports, tracel etc) |
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|
Term
| usual parts of a history and physical |
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Definition
patient interview
history
exam
differential diagnosis and assessment
plan
liegible and proper documentation |
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Term
| professionalism and conduct in a patient interview |
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Definition
approporate attire
hygenic
knock, ask to come in, be friendly, welcoming
identify patient
wash hands
shake hands
maintain eye contact
adjust enivornment
ensure privacy
dont interrupt |
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Term
| tips for questioning in a patient interview |
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Definition
use open and closed ended questions
restate and reflect
clarify
sequencing
probing
summerize
pay attention to non verbal cues |
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Term
| what to avoid in a patient internview |
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Definition
personal advice
leading
assuming anything
being a victim to prejudices |
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Term
| what are the points to ask about a chief complaint |
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Definition
onset
palliative: what makes it better or worse?
quality/quantity
radiation
severity: scale of 0-10 today? three days ago?
timing
associated findings: other signs and symptoms |
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Term
| past medical history questions |
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Definition
chronological order of medical conditions/injuries/hospitilizations with age for each
communicable diseases: exposures, treated, risk factors
transfusions (esp 1978-1985)
psychiatric
OB GYN |
|
|
Term
| past surgical history questions |
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Definition
chronological order
anestesia (local or general)
drug reactions
what was done, where, by whom, outcome |
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Term
| medication history questions |
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Definition
current: what, dose, frequency, why, side effects, how long
perscription, otc, herbal, home remedies |
|
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Term
| allergy history questions |
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Definition
medications Rx or OTC
food
animals, plants, enivornmental
what happens? |
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|
Term
| what family members to ask history of |
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Definition
| parents, grandparents, siblings, aunts, uncles by blood |
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Term
| questions to ask about social history |
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Definition
living/work/school
alcohol, tobacco, caffiene, recreational drugs
hobbies
skeep, diet, exercise
safety issues: seatbelt helmut, sun block, etc
sexual, HIV risk |
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Term
| what to do if your patient has a hearing deficit |
|
Definition
face the patient
check for a hearing aid and direct voice to it
avoid shouting or speaking too soft
use non verbal cues |
|
|
Term
| what to do if your patient has a visual deficit |
|
Definition
look at the patient
avoid speaking loudly
do not touch without permission
knock upon entry to the room every time |
|
|
Term
| what to do if your patient has a speech deficit |
|
Definition
use yes and no questions if possible
give patient a chance to speak
direct questions to the patient |
|
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Term
| what to do if your patient isnt talkative enough |
|
Definition
periodically check to make sure their ok
frequently recap or summerize
try to find a common ground |
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|
Term
| what to do if your patient is too talkative |
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Definition
let them go for 5-10 min or a brief time
say things like lets focus on your 1-2 biggest concerns |
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|
Term
| what to do if your patient does not speak english |
|
Definition
avoid their family
use an interperter if possible
get the cultural information from the interperter
avoid slang
clear short simple sentences
look for non verbal cues
verify understanding with questions |
|
|
Term
| what to do if your patient is anxious or angry |
|
Definition
acknowledge the anxiety or anger
avoid anger
avoid close contact
look for non verbal cues
get an attendant
stay between the patient and the door
ask if another time would be better |
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|
Term
| what to do if your patient is under the influence |
|
Definition
anger or hostility is common
are they are reliable historian
ask for labs, test, and exaimine they carefully
get an attendant
it takes more time |
|
|
Term
| what to do if your patient is sexually inappropirate |
|
Definition
have a third party present at all times
set limits |
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|
Term
| how to adress a young patient |
|
Definition
get data from an adult
once school age it info from both
once their an adolescent get the info from them alone and discuss sharing it |
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|
Term
| how to adress an older patient |
|
Definition
it takes more time
different cultures may also affect
use family to get necessary or preferably a trained interperter to gather data as appropirate
do not assume or impose your cultural standards |
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|
Term
| pedatric history and physical timing |
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Definition
newborn, 2 weeks, 1, 2, 4, 6, 9, 12, 15, 18, 24 mnths
3, 4, 5, 6, 8, 10 years
annualy from 11-21 years |
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Term
| young adult history and physical timing |
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Definition
18-21 annually
20s every two years (cholesterol check at first 20s exam)
30s every two years
screen for chlamydia if sexually ative
height yearly
weight every visit
total skin exam every 2 years
yearly dental exam
cancer detection every 2-3 years
vaccinations |
|
|
Term
| female specific history and physical timing |
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Definition
pap and pelvic every 1-2 years, if clear three times in a row every 2-3 years
screen for cervical cancer every 3 years after intercourse or by age 21
monthly self breast exams |
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|
Term
| male specific history and physical timing |
|
Definition
genital/testicular exam at every complete exam
monthly self testicular exams |
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|
Term
| adult history and physical timing |
|
Definition
exam every 5 years
eye exam every 2-4 years
height and weight each visit
DRE for cancer annually
after 50: yearly stool for occult blood
colonoscopy every 10 years at 50
pneumococcal and influenze vaccing at 65 and ever 10 years after |
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|
Term
| female specific adult history and physical timing |
|
Definition
annual breast exam
bone density and osteoperosis screening within a year of menopause |
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|
Term
|
Definition
| general survey, skin, hair, nails, vitals, neck, chest, lungs, breast, heart, peripheral vascular, abdomen, GU/rectal, muscoskeletal, lymphatic, neurlogical, psychological, labs |
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|
Term
| parts of the physical exam specific to older adults |
|
Definition
annual eye exam, glaucoma check, DRE, SOFB, skin, pneumococcal and flu vaccine, visual and hearing, height, weight, pap/pelvic, prostate
bone densiry every 2-3 years |
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|
Term
| counseling and exducation examples |
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Definition
| seat belt use, fire escape, smoke detector, firearms, helmut, diet, hydration, nutrition, calcium, alcohol, tobacco, abuse, depression, suicide, STDs |
|
|
Term
| adolescent specific counseling and education examples |
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Definition
| STDs, pregnacy, eating disorders, ADHD, abuse, stress management, UV light damage, depression, anxiety |
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|
Term
| how to deal with sensitive topics |
|
Definition
dont be judgmental
explain reason to ask and know
confidentiality |
|
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Term
| types of sensitive topics |
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Definition
| sexual history, mental health, alcohol, illegal drugs, femily violence, terminal illness, legal issues |
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|
Term
| proper documentation of the history and physical |
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Definition
| complete asap, organize, neat, avoid redundencies, avoid value laden comments, make sure you have the correct chart, date, time, sign, quote patient often, cross out initial and date errors, if not documented it isnt done, if not done dont document |
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|
Term
|
Definition
| subjective, objective, assessment, plan |
|
|
Term
|
Definition
ID/profile: date age, gender, race, source of history, who accompanied the patient
CC, Hx of CC/HPI. PMH, PSH, SH, FH ....?wtf
allergies, medications, ROS |
|
|
Term
|
Definition
general survey
height, weight, vitals
examination data
labs
other pertinent diagnostic tests |
|
|
Term
|
Definition
| apparent state of health, level of consciousness, signs of distress, build, dress, grooming, hygiene, eye contact |
|
|
Term
|
Definition
differential diagnosis
final diagnosis |
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|
Term
|
Definition
| treatment, medications, follow up, recommendations, patient understanding, patient compliance, consults, other |
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|
Term
| the two parts of a patient interview |
|
Definition
patient centered
physician centered |
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|
Term
| patient centered interview process (this is a long flash card) |
|
Definition
begins with patient centered approach
1. set the stage: polite, door knock, privacy, etc
2. set the agenda: date and time, identy, questioning, history, exam, discuss treatment, adress issues, clarify
3. elict the patients story: take history CC, open ended questions, sit down, eye contact, show interest
4. make the transition: summerize the interview, verbalise the transition to a physician centered interview |
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Term
| physician centered interview process |
|
Definition
1. ask what where when about CC
2. build on this info and clarify, be specific and accurate
3. adress the location radiation quality.. etc
4. secondary history: expands primary history, supportive info
5. tertiary history: elements that direct bearing on patient condition
6. do a review of systems: ask a series of questions from different systems |
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|
Term
| what does hipaa stand for |
|
Definition
| health insurance portability and accountability act |
|
|
Term
|
Definition
| protect confidentiality of health care information |
|
|
Term
| what does hipaa require of providers |
|
Definition
| have to notify patients of their legal rights with respect to privacy and make a good faith effort to obtain from patients a signed notice that they have been notified |
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|
Term
| hippa rights in regards to employer |
|
Definition
| cannot be disclosed to employer without concent |
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|
Term
| hippa rights in regards to medical staff |
|
Definition
| info on a need to know basis |
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|
Term
| hippa rights in regards to minors |
|
Definition
| parents can access all info |
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|
Term
| hippa rights in regards to research |
|
Definition
| all identification information must be removed |
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|
Term
| hippa rights in regards to marketing |
|
Definition
| records protected from use for marketing (drug companies) |
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|
Term
| hippa rights in regards to medical business associates |
|
Definition
| associates connected with care must sign contract agreeing to keep info confidential |
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|
Term
| hippa rights in regards to records |
|
Definition
| must be secured and errors must be corrected |
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|
Term
| covered entities under hippa |
|
Definition
| provider that conducts transactions in electronic form, health care clearinghouse, health plan |
|
|
Term
| what is protected health information (PHI) |
|
Definition
| any info, oral or recorded, in any form that is made or recieved by a provider, health plan, public health authority, employer, life insurance company, school, or clearing house past present and future physical and mental health, condition, payment |
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|
Term
| what are exceptions to hipaa |
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Definition
| required by law, public health activities, abuse, neglect, violence, social services, health oversight activities, judicial, law enforcement, decendents (coroner, funeral director, organ donation) |
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|
Term
| who reviews and enforces hipaa |
|
Definition
| office of civil rights, state attorney general (complaint only not private law suit) |
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|
Term
| what are the core ethical companticies |
|
Definition
| medical knowledge, patient care, practice based learning and improvement, systems based practive, professionalism, communication skills, use of informatics |
|
|
Term
| greatest gaps in core compenticies |
|
Definition
| communication skills, working as a health care team, conflict management, customer service, patient experiences, end of life care |
|
|
Term
| each facility has different compliances rules regarding hippa, what do you need to do to make sure you are in the know |
|
Definition
| get credientialed, meet with medical records or HR and get informed before you ever see a patient |
|
|
Term
|
Definition
| the process by which a fully informed patient can participate in choices about their health care. |
|
|
Term
| where does informed concent originate |
|
Definition
| from the legal and ethical right the patient has to direct what happens to their body and from the ethical duty of the physician to involve the patient in their health care |
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|
Term
| what is the resonable physician standard |
|
Definition
| inconsistant with the rules of concent, allows physician to determine what the patient needs to know, focus on physician |
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|
Term
| what is the reasonable patient standard |
|
Definition
| what the average patient needs to know to make an informed decision, focuses on only the need to know to have an understanding |
|
|
Term
| what is the subjective standard |
|
Definition
| what a patient needs to know and the presentation of the information taliored to their needs of great understanding. |
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|
Term
| what informed concent standard is the best |
|
Definition
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|
Term
| what populations are considered vulnerable |
|
Definition
| children, persons with disabilities, prisoners, poor, people of color, terminally ill, fetuses, homeless |
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|
Term
|
Definition
| relieves suffering and restores people to health, does not cure the disease |
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|
Term
|
Definition
| aquires an understanding of the physiological and biochemical processes, seeks to improve theraperies and illimate disease |
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|
Term
| what are some ways to tell if research is not leditimate |
|
Definition
| no peer review, no statistics, trying to sell something |
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|
Term
| what are signs of legitimate research |
|
Definition
| appears in competitive peer review journals, statistics, no sales |
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|
Term
| how can you tell if something is a basic science article rather than research |
|
Definition
| tells how something works, aimed at mechanism of action, causation |
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|
Term
| how can you tell if an article is a clinical research article |
|
Definition
| answers "what is the statistical connection", aimed at liklihood of events being associated, not usually able to answer causation |
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|
Term
| what are the shortcomings of clinical research |
|
Definition
| lack of enivormental control (exposure, behavioral, other substances, compliance), genetic predisposition, other causes |
|
|
Term
| what are the shortcomings of basic science research |
|
Definition
| lack of genetic variance, lack of perdictive value (done before clinical), relative contribution to cause |
|
|
Term
| which is better basic science or clinical research |
|
Definition
| neither, both must be used together |
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