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118 Cards in this Set
- Front
- Back
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Health History Primary reason
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collect subjective data
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Anticipatory Guidance ‐ is
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Opportunity to teach
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The Art of Asking Questions
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Techniques:
– broad opening statements – echoing / restating – clarification – silence / listen actively – confront contradictions – empathize – open body language – timing |
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Communication Don’ts
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• Offer advice
• Abruptly change subjects • Act defensively • Minimize feelings • Offer false assurances • Jump to conclusions |
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Chief Complaint‐
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the reason the patient is seeking
assistance, written in quotes |
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HPI:
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History of present illness: a detailed
description of the primary problem using symptom analysis |
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ROS:
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Review of systems
– opportunity to go through each system head to toe – makes examiner aware of other trouble spots – do systematically – devise own workable approach (page 9‐11 in Bates, Handout) – Documentation • This is the patient’s opportunity to tell you any problems they have • This is not the physical component • It must be pertinent negatives (or a positive) – Denies chest pain, shortness of breath… – It is never written as “no problems” |
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Symptom Analysis • P:
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Provocative (precipitating)
/Palliative – What causes the symptom? – What makes it better or worse? – What do you do for it ? Med./rest? – Looking for triggers, relievers, aggravators |
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Symptom Analysis Q:
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Quantity or Quality:
– How does “it” feel, look, sound, smell ? – How much are you experiencing now? – Does it interfere with ADLs – Is it worse better or different than last time? |
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Symptom Analysis R:
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Region / Radiation:
– Where is “it” located? – Does “it” travel any where else in your body? |
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Symptom Analysis S:
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Severity
– On a scale of 1 ‐ 10 how bad is “it”? – At it’s worse do you have to sit, lie down, or slow down – Is it getting better, worse, or the same? |
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Symptom Analysis T
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Timing
– When did “it” begin? date/time – Type of onset ‐ How did it start? suddenly or gradually – Frequency ‐ how often does it occur? When does it occur? What time of day? Does it wake you up? Does it happen after/before food? Seasonal? – Duration‐ how long does it last |
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Symptom Analysis
Most Important Question? |
Have you ever had this before???
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• Seven Attributes of a Symptom:
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Location
– Quality – Quantity or severity – Timing – Setting in which it occurs – Remitting or exacerbating factors – Associated manifestations |
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Subjective Data:
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Information told to you by
the patient about the situation |
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Objective Data:
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Information you have
determined through your observation, assessment, lab values, testing |
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Obesity in adults*
Overweight bmi |
body mass index value between 25 and
29.9 |
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Obesity: BMI
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body mass index value greater than or equal
to 30. |
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Risk factors for obesity in children
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– Maternal overweight directly affects fetus
– Maternal smoking linked to higher BMIs – Overweight fathers – Prolonged bottle feeding – Physical activity |
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Adolescent Assessment
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H: How are things at home?
• E: How is school? Grades? Subjects? education • A: What kind of activities do you do? what is affect, ambition, anger? • D: Do you use drugs, etoh, does any one in your family? • S: Are you engaging in sex ? Sexuality issues |
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CAGE questionnaire
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ETOH/ Drugs
useful • Have you ever been concerned about your drinking/ Feel the need to cut down? • Have you ever felt annoyed by criticism of your drinking? • Have you ever felt guilty about your drinking or what you did while drinking? • Have you ever felt the need for a morning eye‐opener |
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Violence
Every person should be asked 2 questions: |
Have you been hit by your partner?
– Have you been forced to have sex by your partner? |
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Mini ‐ Mental State Test: MMSE
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Standardized screening tool of mental status
– max score is 30 – depressed clients w/o dementia score 24 ‐ 30 – score of 20 or less is found with dementia, delirium, schizophrenia, or an affective disorder |
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MOCA: Montreal Cognitive Assessment
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A brief (10 minutes) screening tool for mild
cognitive impairment (MCI) – Can detect people who score in the normal range of MMSE – More sensitive for the early or mild impairment – MCI is a risk factor for dementia – Normal score of 26‐30 – Lower score requires more in‐depth assessment |
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Beck Depression Inventory
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• Assess severity of depression in adults & adolescents (13 & up)
w/a diagnosis of a psychiatric illness • Not a sole diagnostic measure • Highly reliable >35 years, regardless of population • 0‐13 minimal range • 14‐19 mild • 20‐28 moderate • 29‐63 severe |
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Mental Status
• 2 question Screen: A quick way of assessing if a patient may be depressed |
In the last month have you been bothered by:
– Little interest or pleasure doing things – Yes No – Feeling down, depressed, or hopeless? – Yes No • If the patient’s response to both questions is no it is negative • If the patient responded yes to either question it requires further assessment |
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Primary prevention:
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Can prevent or arrest disease process by
promoting healthier lifestyle or immunizations |
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Secondary prevention:
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Detecting and treating asymptomatic risk factors
– Detecting and treating early asymptomatic disease |
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U.S. Preventative Task Force(USPSTF)
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Established in 1984 ‐ 1st report 1989
– Works w/Agency for Healthcare Research & Quality – Mission to enhance quality, appropriateness and effectiveness of health services – Assuring decision makers have access to evidence for most efficient screening/diagnostic & therapeutic choices – Translates evidence into recommendations and clinical guidelines |
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Guidelines ensure
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effective preventive
services that hold providers and systems accountable |
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CPT
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Current Procedural Terminology)
– describes the procedures, services or supplies you provide to your patients |
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ICD‐9: is
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(the International Classification of Diseases)
– identifies the patient's disease or physical state • Supported in MRD (Medical Record documentation) • Used by Medicare as a classification system for billing • Pertains to the H & P • More than 7000 codes identified • Under constant update & revision |
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New & Established Patient
New: |
has not received any professional service from
provider or another provider (same specialty) in same practice w/in last 3 years |
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Established:
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has received services from provider or
another in group w/in last 3 years • No distinction is made for patients in ER |
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Consultation
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evaluation/management of a specific problem is requested by
another provider • Consultant may initiate diagnostic &/or therapeutic services • If consultant takes over care own codes are now used |
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Four categories of consultation
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– Office
– Initial patient – Follow‐up inpatient – Confirmatory |
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Concurrent Care
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• Provision of similar services (hosp visits) to the same
patient by more than 1 provider on the same day |
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– Chief Complaint
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Concise statement describing the symptom, problem,
condition, diagnosis or other factor that is the reason for the encounter‐patient’s own words |
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HPI
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Chronological description of the development of illness
from 1st sign to present: includes description of – Location – Quality – Severity – Timing – Context – Modifying & associated S & S |
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Review of systems
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Inventory obtained thru series of questions seeking to id: S/S &
baseline data on other systems that might need intervention |
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Past History
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Past experience w/illness, injury, treatments
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Family History
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Review of medical events in patient’s family
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Social History
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Age appropriate review of past & current activities that could
impact health |
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Levels of E/M
Problem: |
focused; CC, brief HPI
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Expanded problem focused:
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CC, brief HPI, problem pertinent
system review |
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Primary prevention:
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Can prevent or arrest disease process by
promoting healthier lifestyle or immunizations |
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Secondary prevention:
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Detecting and treating asymptomatic risk factors
– Detecting and treating early asymptomatic disease |
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U.S. Preventative Task Force(USPSTF)
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Established in 1984 ‐ 1st report 1989
– Works w/Agency for Healthcare Research & Quality – Mission to enhance quality, appropriateness and effectiveness of health services – Assuring decision makers have access to evidence for most efficient screening/diagnostic & therapeutic choices – Translates evidence into recommendations and clinical guidelines |
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Promotion Guidelines
Guidelines ensure |
effective preventive
services that hold providers and systems accountable |
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CPT
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describes the procedures, services or supplies you provide to
your patients |
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ICD‐9
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identifies the patient's disease or physical state
Used by Medicare as a classification system for billing |
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New & Established Patient
New: |
has not received any professional service from
provider or another provider (same specialty) in same practice w/in last 3 years |
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Established:
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has received services from provider or
another in group w/in last 3 years |
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– Consultation
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Service provided by a physician whose opinion or advice re:
evaluation/management of a specific problem is requested by another provider |
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Four categories of consultation
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Office
Initial patient Follow‐up inpatient Confirmatory |
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– Concurrent Care
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Provision of similar services (hosp visits) to the same
patient by more than 1 provider on the same day |
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Chief Complaint
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Concise statement describing the symptom, problem,
condition, diagnosis or other factor that is the reason for the encounter‐patient’s own words |
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• Time considered key only if care composed
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>than 50%
of encounter |
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Brief HPI =
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3 elements of present illness
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Extended HPI =
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4 elements or the status of 3
chronic or inactive conditions |
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Lung Borders Apex ‐
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highest point 3‐4cm above inner third of the clavicles
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Lung Borders Base ‐
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lower border rests on diaphragm at the
6th rib MCL T10 corresponds to the base – Deep inspiration drops to T12 |
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Lung Borders Posteriorly
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C7 is the apex
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Lobes of the lung
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– Right is shorter b/c of liver
– Right has 3 lobes – Left is narrower b/c of heart – Left has 2 lobes – Stacked in diagonal sloping separated by fissures |
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negative intrapleural pressure prevents
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lungs from
collapsing |
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lungs
Obesity results: |
in hypoinflation
(Pickwickian syndrome) places an excessive load on the pulmonary system.. Symptoms: excessive daytime sleepiness, shortness of breath due to elevated blood carbon dioxide pressure, disturbed sleep at night and flushed face skin can also have a bluish tint, high blood pressure enlarged liver, abnormally high red blood cell count. |
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Barrel Chest‐
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Ribs are horizontal
• normal aging, chromic asthma & emphysema |
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Pectus Excavatum:
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sunken sternum,
• funnel chest ‐ congenital non symptomatic |
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Pectus Carinatum:
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protrusion of sternum
• pigeon breast, congenital non symptomatic |
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Scoliosis
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lateral S curve thoracic & lumbar spine >45
may decrease lung volume |
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Kyphosis:
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exaggerated posterior curve of thoracic
spine(humpback) may impair C‐V |
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Biot’s:
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irregular pattern normal 3‐4 breaths followed by
apnea • cycle lasts 10 sec to 1 minute • seen in head trauma, brain abscess,heat stroke |
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Cheyne‐Stokes:
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resp wax and wane in a regular pattern
• breaths 20 ‐ 30 secs w/20 secs of apnea alternating • severe CHF, renal failure,meningitis, drug OD • normal in aging & infants w/sleep |
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Hyperventilation:
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Increase in depth and rate
• extreme fear, exertion, DKA, ASA OD, hepatic coma, midbrain lesion, increased CO2 |
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To rule out a middle lobe pneumonia, you would
make sure to auscultate: |
Beneath the right
breast 2. Beneath the left breast 3. Under the left axilla 4. Under the right axilla |
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Symmetric Expansion
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place hands on chest wall
• thumbs at T9 or T10 level • Slide fingers to pinch small amount of skin • As patient takes deep breath ‐ thumbs should move apart symmetrically • abn= atelectasis, pneumonia, thoracic trauma, accompanied with pain is pleuritis |
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Tactile (vocal) Fremitus
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palpable vibration from chest wall
– using ulna sides of the hand – pt repeats “99” – symmetrically side to side • same sequence – should feel the same throughout – Infant • Place hand or fingertips over chest wall palpating for symmetry of the transmitted vibrations |
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• ABN: Increased fremitus
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compression or consolidation of lung tissue
• lobar pneumonia • sound is conducted better through solid |
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ABN:Decreased fremitus
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with obstruction
– effusion, pneumothorax, emphysema |
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Physical Exam Percussion
Purpose: |
To set the chest wall an underlying tissue into
motion – Produces audible sounds – To determine if underlying tissue is air‐filled, fluid filled, or solid |
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Physical Exam Percussion
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Place distal joint of middle finger over intercostal
space – Strike sharply with tip of other hand – Start at apices – Side to side comparisons at 5cm intervals – Avoid damping effect of scapula and ribs |
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Dullness‐
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medium intensity, medium ‐ high pitch
thudlike: heard over organs or a sign of a pneumonia, atelectasis, or tumor |
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Flatness‐
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soft intensity, high pitch,dull‐like heard
over scapula – large pleural effusion |
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Resonance‐
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loud intensity, low pitch, hollow like,
heard over all areas of the lung |
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Hyperresonance‐
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very loud intensity, lower
pitch, booming, classic sound of over inflation found with emphysema, or asthma |
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Tympany
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loud intensity, high pitch, drumlike,
found over gastric air bubble or air filled bowel |
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Diaphragmatic Excursion: Purpose
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percuss the boundary between resonant lung and
the level of the diaphragm – done in both inspiration and expiration – measures the distance the diaphragm travels during inspiration and expiration |
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Diaphragmatic Excursion: Method
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have pt exhale and hold breath while you percuss
down the scapula line on each side to the point where resonance turns to dullness mark the spot – have pt take a deep breath and hold it and percuss again – measure the difference |
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Diaphragmatic Excursion:Findings
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normal : 3 ‐ 5 cm or 7‐8 in well conditioned
– high level of dullness ‐ effusion/atelectasis – absence of excursion ‐ effusion/atelectasis – failure of diaphragm to contract • paralysis • muscle flattening as in COPD |
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Expected Sounds Tracheal
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over trachea ,loud, high pitch, I/E = tubular
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Expected Sounds Bronchial
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over manubrium, loud, high pitch, E>I
• Abnormal when heard over vesicular areas as with consolidation (alveolar collapse, fluid‐filled, fibrosis) |
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Expected Sounds Bronchovesicular‐
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transitional, main bronchus area,
moderate, moderate pitch, I = E |
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Expected Sounds Vesicular
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lung field, soft, low pitch, I > E, rustling
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Fine:
Discontinuous (Crackles): |
intermittent, nonmusical, brief
like dots in time, air passing through moisture, not clear w/cough |
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Discontinuous (Crackles):
Coarse: |
louder, lower in pitch and longer 20‐30 secs
– during inspiration, lung base, dependent portion – pulmonary edema, pneumonia, fibrosis |
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• Adventitious Sounds:
– Infant |
Same as adult except more difficult to distinguish
• Often occur together • Wheezes more common b/c of smaller size of the tracheobronchial tree • Crackles can be heard w/pneumonia & bronchiolitis |
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Continuous (Wheeze):
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Air being forced through narrowed
passage |
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High‐Pitched: (sibilant)
(Wheeze) |
musical – musical, squeaking, predominate in E, but continuous
– acute asthma, chronic emphysema |
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Low‐ Pitched: ( rhonchi ‐ sonorous)
(Wheeze) |
low‐pitched, musical snoring, >E, but continuous
– larger airway may clear with cough – bronchitis, obstruction from airway tumo |
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Absence of sound: =
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Effusion
– Atelectasis – Consolidation • Pneumonia • Tumor |
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Bronchophany‐
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Pt says “99” upon auscultation
• Normal is a muffled/indistinct sound • Abnormal is the clear voice sound seen in lung consolidation |
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Egophany:
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Pt says “E” upon auscultation
– Normal‐ muffled sound – Abnormal ‐ “E” sounds like “A” nasal quality indicates lung consolidation E A |
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Whispered Pectoriloquy
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Pt whispers “1 2 3” upon auscultation
– Normal‐ faint/indistinct/not al all – Abnormal‐ loud and clear = lung consolidation as in pneumonia, tumor, fibrosis |
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Lobar Pneumonia
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crackles fine to medium
– + bronchophony, egophony, whispered pectoriloquy – dull percussion over lobe – increased rate with guarding and lag on affected side – chest expansion decreased on affected side |
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Bronchitis:
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hacking rasping cough, thick mucoid sputum
– seen with smokers – + tactile fremitus – resonant percussion – voice sounds normal – crackles over deflated areas, may have wheeze |
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Emphysema;
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Increased AP diameter, barrel chest
– Increased use of accessory muscles, DOE – 80 ‐ 90 % caused by smoking – decreased tactile fremitus and chest expansion – Hyperresonant, decreased diaphragmatic excursion – decreased BS,prolonged expiration,may hear wheeze |
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Asthma
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increased airway resistance
– increased rate, SOB,accessory muscle use – anxiety, apprehension,cyanosis – decreased tactile fremitus – resonant or Hyperresonant – decreased BS with prolonged expiration – voice sounds decreased – wheeze on expiration |
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Tail of Spence
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superior lateral corner in the axilla
projects up into axilla |
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Breast
Glandular tissue |
15 ‐ 20 lobes: radiating from nipple
• composed of lobules w/in are alveoli producing milk • converge to sinus behind nipple for storage |
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Suspensory ligaments (Cooper’s):
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fibrous bands extend vertically from surface to attach to chest
wall • support the breast tissue • become contracted in cancer causing the dimpling & pits seen in overlaying skin |
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Breast
Internal Anatomy: – Adipose Tissue |
lobes are imbedded in this
• layers of subcutaneous and retromammary fat provide bulk of tissue • proportion depends on age, cycle, pregnancy, lactation, & nutritional state |
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Breast
Lymphatic |
extensive lymphatic drainage
– >75% drains into the ipsilateral axillary nodes – central axillary: high up in axilla – pectoral(anterior): lateral edge of pectoralis muscle inside axillary fold – subscapular(posterior); lateral edge of scapula deep in posterior fold – lateral: along humerus, inside upper arm |
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Breast
Inspection: Infant |
Often enlarged from maternal estrogen effect
– May be engorged w/white liquid may last 1‐2 weeks |
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Benign Breast Disease (Fibrocystic )
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• 6 diagnostic categories
• 50% all women have a form • nodularity occurs bilaterally • regular firm, mobile, rubbery • pain may be dull and cyclic or not • cysts are discrete, fluid filled sacs – must be investigated |
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Breast Cancer:
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solitary unilateral mass
• solid, hard, dense,fixed to underlying tissue • borders are poorly delineated • grows, often painless • most common in upper outer quadrant • found in women 30 ‐ 80 • increased risk 40 ‐ 44, & >50 • as advances‐ axillary nodes, dimpling, nipple retraction, elevation, discharge |
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Risk Factors Breast Cancer:
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Age: ¾ of cases woman >50, ½ >65
Higher education and income double risk(r/t parity) Higher rates in Caucasian ~ AA, Latinos, Asian +FH 1* relative Early menarche Delayed menopause 1st live birth after 35 bx =atypical hyperplasia |
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Fibroadenoma
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• solitary nontender mass
• category of benign breast disease • solid, firm, rubbery, elastic • round, oval or lobulated, 1 ‐ 5 cm • freely moving, slippery, slides through tissue • most common 15 ‐ 30 but can occur up to 55 • grows quickly and constantly • diagnosed by biopsy |
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Paget’s Disease
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Malignant lesion of the areola &/or nipple
• Appears as a scaly dermatitis of the nipple • Itching, crusting, & eventually erosion • May occur w/out underlying mass • Any redness & thickness of the nipple should be considered suspicious • 1% of breast cancers higher in male breast cancer |
