Bates' Advanced Health Assessment Chapters 1-4, & 7 (Health History, HEENT)

Mr. Curtiss has a history of obesity, diabetes, osteoarthritis of the knees, HTN, and obstructive sleep apnea. His BMI is 43 and he has been discouraged by his difficulty in losing weight. He is also discouraged that his goal weight is 158 pounds away. What would you tell him?

"Even a weight loss of 10% can make a noticeable improvement in the problems you mention."

You have just asked a patient how he feels about his emphysema. He becomes silent, folds his arms across his chest and leans back in his chair, and then replies, "It is what it is." How should you respond?

"You seem bothered by this question."

A 30-year-old sales clerk comes to your office wanting to lose weight; her BMI is 30.0 kg/m2. What is the most appropriate amount for a weekly weight reduction goal?

.5 to 1 pound per week

seven attributes of a symptom

1. Location 2. Quality 3. Quantity or severity 4. Timing (including onset, duration, and frequency) 5. The setting in which it occurs 6. factors that have aggravated or relieved the symptom 7. associated manifestations

A 12-year-old presents to the clinic with his father for evaluation of a painful lump in the left eye. It started this morning. He denies any trauma or injury. There is no visual disturbance. Upon physical examination, there is a red raised area at the margin of the eyelid that is tender to palpation; no tearing occurs with palpation of the lesion. Based on this description, what is the most likely diagnosis?

A hordeolum, or sty, is a painful, tender, erythematous infection in a gland at the margin of the eyelid.

For which of the following patients would a comprehensive health history be appropriate?

A new patient with the chief complaint of "I am here to establish care"

A 37-year-old nurse comes for evaluation of colicky right upper quadrant abdominal pain. The pain is associated with nausea and vomiting and occurs 1 to 2 hours after eating greasy foods. Which one of the following physical examination descriptions would be most consistent with the diagnosis of cholecystitis?

Abdomen is soft and tender to palpation in the right upper quadrant with inspiration, to the point of stopping inspiration, and there is no rebound or guarding. In cholecystitis, the pain, which originates from the gallbladder, is located in the right upper quadrant. Severity of pain with inspiration that is sufficient to stop further inhalation is also known as Murphy's sign, which, if present, is further indicative of inflammation of the gallbladder.

The following information is best placed in which category? "The patient had a stent placed in the left anterior descending artery (LAD) in 1999." Adult illness Surgeries Obstetric/gynecology psychiatric

Adult illness

The following information is best placed in which category? "The patient was treated for an asthma exacerbation in the hospital last year; the patient has never been intubated." Adult illness Surgeries Obstetric/gynecology psychiatric

Adult illness

Which of the following is a "red flag" regarding patients presenting with headache? Unilateral headache Pain over the sinuses Age over 50 Phonophobia and photophobia

Age over 50 Other red flags include: acute onset, the worst headache of my life; very high blood pressure; rash or signs of infection; known presence of cancer, HIV, or pregnancy; vomiting; recent head trauma; and persistent neurologic problems.

You are performing a young woman's first pelvic examination. You make sure to tell her verbally what is coming next and what to expect. Then you carry out each maneuver of the examination. You let her know at the outset that if she needs a break or wants to stop, this is possible. You ask several times during the examination, "How are you doing, Brittney?" What are you accomplishing with these techniques? Increasing the patient's sense of control Increasing the patient's trust in you as a caregiver Decreasing her sense of vulnerability All of the above

All of the above

A 15-year-old high school sophomore comes to the clinic for evaluation of a 3-week history of sneezing; itchy, watery eyes; clear nasal discharge; ear pain; and nonproductive cough. Which is the most likely pathologic process?

Allergic

Diplopia, which is present with one eye covered, can be caused by which of the following problems?

An irregularity in the cornea or lens

A 23-year-old graduate student comes to your clinic for evaluation of a urethral discharge. As the provider, you need to get a sexual history. Which one of the following questions is inappropriate for eliciting the information?

Are you sexually active?

When you enter your patient's examination room, his wife is waiting there with him. Which of the following is most appropriate?

Ask if it's okay to carry out the visit with both people in the room.

On a very busy day in the office, Mrs. Donelan, who is 81 years old, comes for her usual visit for her blood pressure. She is on a low-dose diuretic chronically and denies any side effects. Her blood pressure is 118/78 today, which is well-controlled. As you are writing her script, she mentions that it is hard not having her husband Bill around anymore. What would you do next?

Ask why Bill is not there.

Alexandra is a 28-year-old editor who presents to the clinic with abdominal pain. The pain is a dull ache, located in the right upper quadrant, that she rates as a 3 at the least and an 8 at the worst. The pain started a few weeks ago, it lasts for 2 to 3 hours at a time, it comes and goes, and it seems to be worse a couple of hours after eating. She has noticed that it starts after eating greasy foods, so she has cut down on these as much as she can. Initially it occurred once a week, but now it is occurring every other day. Nothing makes it better. From this description, which of the seven attributes of a symptom has been omitted?

Associated manifestations

Mrs. Lenzo weighs herself every day with a very accurate balance-type scale. She has noticed that over the past 2 days she has gained 4 pounds. How would you best explain this?

Attribute this to body fluid.

Very sensitive methods for detecting hearing loss include which of the following?

Audiometric testing

Mrs. H. comes to your clinic, wanting antibiotics for a sinus infection. When you enter the room, she appears to be very angry. She has a raised tone of voice and states that she has been waiting for the past hour and has to get back to work. She states that she is unimpressed by the reception staff, the nurse, and the clinic in general and wants to know why the office wouldn't call in an antibiotic for her. Which of the following techniques is not useful in helping to calm this patient? Avoiding admission that you had a part in provoking her anger because you were late Accepting angry feelings from the patient and trying not to get angry in return Staying calm Keeping your posture relaxed

Avoiding admission that you had a part in provoking her anger because you were late

A 49-year-old administrative assistant comes to your office for evaluation of dizziness. You elicit the information that the dizziness is a spinning sensation of sudden onset, worse with head position changes. The episodes last a few seconds and then go away, and they are accompanied by intense nausea. She has vomited one time. She denies tinnitus. You perform a physical examination of the head and neck and note that the patient's hearing is intact to Weber and Rinne and that there is nystagmus. Her gait is normal. Based on this description, what is the most likely diagnosis?

Benign positional vertigo

You are beginning the examination of a patient. All of the following areas are important to observe as part of the General Survey except:

Blood pressure

A 55-year-old bookkeeper comes to your office for a routine visit. You note that on a previous visit for treatment of contact dermatitis, her blood pressure was elevated. She does not have prior elevated readings and her family history is negative for hypertension. You measure her blood pressure in your office today. Which of the following factors can result in a false high reading?

Blood pressure cuff is tightly fitted.

Mrs. T. comes for her regular visit to the clinic. She is on your schedule because her regular provider is on vacation and she wanted to be seen. You have heard about her many times from your colleague and are aware that she is a very talkative person. Which of the following is a helpful technique to improve the quality of the interview for both the provider and the patient?

Briefly summarize what you heard from the patient in the first 5 minutes and then try to have her focus on one aspect of what she told you.

You are running late after your quarterly quality improvement meeting at the hospital and have just gotten paged from the nurses' station because a family member of one of your patients wants to talk with you about that patient's care. You have clinic this afternoon and are double-booked for the first appointment time; three other patients also have arrived and are sitting in the waiting room. Which of the following demeanors is a behavior consistent with skilled interviewing when you walk into the examination room to speak with your first clinic patient?

Calm

A patient comes to the emergency room for evaluation of shortness of breath. To which anatomic region would you assign the symptom? Reproductive Urinary Cardiac Hematologic

Cardiac disorders such as congestive heart failure are the most likely on this list to result in shortness of breath. There are cases within the other categories which may also result in shortness of breath, such as anemia in the hematologic category, pregnancy in the reproductive category, or sepsis with UTI in the urinary category. This demonstrates the tension in clinical reasoning between making sure all possibilities are covered, while still being able to pick the most likely cause.

A patient presents for evaluation of a sharp, aching chest pain which increases with breathing. Which anatomic area would you localize the symptom to? Musculoskeletal Reproductive Urinary Endocrine

Chest pain may be due to a musculoskeletal condition, such as costochondritis or intercostal muscle cramp. This would be worsened by motion of the chest wall. Pleuritic chest pain is also a sharp chest pain which increases with a deep breath. This type of pain can occur with inflammation of the pleura from pneumonia or other conditions and pulmonary embolus.

You are seeing an elderly man with multiple complaints. He has chronic arthritis, pain from an old war injury, and headaches. Today he complains of these pains, as well as dull chest pain under his sternum. What would the order of priority be for your problem list?

Chest pain, headaches, arthritis, war injury pain

You are observing a patient with heart failure and notice that there are pauses in his breathing. On closer examination, you notice that after the pauses the patient takes progressively deeper breaths and then progressively shallower breaths, which are followed by another apneic spell. The patient is not in any distress. You make the diagnosis of:

Cheyne-Stokes respiration Cheyne-Stokes respiration can be seen in patients with heart failure and is usually not a sign of an immediate problem. Ataxic breathing is very irregular in rhythm and depth and is seen with brain injury. Kussmaul's respiration is seen in patients with a metabolic acidosis, as they are trying to rid their bodies of carbon dioxide to compensate. Respirations in COPD are usually regular and are not usually associated with apneic episodes.

You have recently returned from a medical missions trip to sub-Saharan Africa, where you learned a great deal about malaria. You decide to use some of the same questions and maneuvers in your "routine" when examining patients in the midwestern United States. You are disappointed to find that despite getting some positive answers and findings, on further workup, none of your patients has malaria except one, who recently emigrated from Ghana. How should you next approach these questions and maneuvers?

Continue asking these questions in a more selective way.

You are growing fatigued of performing a maneuver on examination because you have never found a positive and are usually pressed for time. How should you next approach this maneuver?

Continue performing it on all future examinations. This is an example of a specific test that lacks sensitivity. With this scenario, when you finally find a positive, you might be very certain that a given condition is present. We generally develop our examinations to fit our clinical experiences. Sensitive tests are performed routinely on the screening examination, while specific tests are usually saved for the detailed or branched examinations. Branched examinations are further maneuvers we can perform to investigate positive findings on our screening examinations. Save this type of maneuver to confirm your hypothesis. All of this information also applies to history questions.

You are excited about a positive test finding you have just noticed on physical examination of your patient. You go on to do more examination, laboratory work, and diagnostic tests, only to find that there is no sign of the disease you thought would correlate with the finding. This same experience happens several times. What should you conclude?

Continue using the test, perhaps doing less laboratory work and diagnostics. This is an example of a sensitive physical finding that lacks specificity. This does not make this a useless test, because the purpose of a screening physical is to find disease. This finding made you consider the associated condition as one of your hypotheses, and this in itself has value. Other possibilities are that you may be doing the maneuver incorrectly or using it on the wrong population. It is important to ask for hands-on help from your instructor when you have a question about a maneuver. Make sure that your information about the maneuver comes from a reliable source as well. All of this information also applies to history questions.

Likelihood Ratio

Conveys the odds that a finding occurs in a patient with the condition compared to a patient without the condition. When the LR>1.0, the probability of the condition goes up; when the LR is <1.0, the probability of the condition goes down. The LR of subarachnoid hemorrhage is 10 if neck stiffness is present, and 0.4 if neck stiffness is absent.

Common or concerning symptoms to inquire about in the General Survey and vital signs include all of the following except:

Cough

A patient complains of knee pain on your arrival in the room. What should your first sentence be after greeting the patient?

Could you please describe what happened?

Reliability

Indicates how dependably repeated measurements of the same relatively stable phenomenon will give the same result, also known as precision. May be measured for one observer or for more than one observer

Mr. Larson is a 42-year-old widowed father of two children, ages 4 and 11. He works in a sales office to support his family. Recently he has injured his back and you are thinking he would benefit from physical therapy, three times a week, for an hour per session. What would be your next step?

Discuss the plan with Mr. Larson

Predictive Value

Indicates how well a given symptom, sign, or test result, either positive or negative, predicts the presence or absence of a disease

A 29-year-old physical therapist presents for evaluation of an eyelid problem. On observation, the right eyeball appears to be protruding forward. Based on this description, what is the most likely diagnosis?

Exophthalmos

Mr. W. is a 51-year-old auto mechanic who comes to the emergency room wanting to be checked out for the symptom of chest pain. As you listen to him describe his symptom in more detail, you say "Go on," and later, "Mm-hmmm." This is an example of which of the following skilled interviewing techniques?

Facilitation This is an example of facilitation. Facilitation can be posture, actions, or words that encourage the patient to say more.

A 25-year-old radio announcer comes to the clinic for an annual examination. His BMI is 26.0 kg/m2. He is concerned about his weight. Based on this information, what is appropriate counsel for the patient during the visit?

Give the patient information about reduction of fat, cholesterol, and calories because he is overweight.

Suzanne, a 25 year old, comes to your clinic to establish care. You are the student preparing to go into the examination room to interview her. Which of the following is the most logical sequence for the patient-provider interview?

Greet the patient, establish rapport, invite the patient's story, establish the agenda, expand and clarify the patient's story, and negotiate a plan.

A 67-year-old retired janitor comes to the clinic with his wife. She brought him in because she is concerned about his weight loss. He has a history of smoking 3 packs of cigarettes a day for 30 years, for a total of 90 pack-years. He has noticed a daily cough for the past several years, which he states is productive of sputum. He came into the clinic approximately 1 year ago, and at that time his weight was 140 pounds. Today, his weight is 110 pounds. Which one of the following questions would be the most important to ask if you suspect that he has lung cancer?

Have you tried to lose weight?

A 19-year old-college student presents to the emergency room with fever, headache, and neck pain/stiffness. She is concerned about the possibility of meningococcal meningitis. Several of her dorm mates have been vaccinated, but she hasn't been. Which of the following physical examination descriptions is most consistent with meningitis?

Head is normocephalic and atraumatic, fundi with blurred disc margins, neck tender to palpation, unable to perform range of motion Blurred disc margins are consistent with papilledema, and neck tenderness and lack of range of motion are consistent with neck stiffness, which in this scenario is likely to be caused by meningeal inflammation. Later, you will learn about Kernig's and Brudzinski's signs, which are helpful in testing for meningeal irritation on examination.

A patient complains of epistaxis. Which other cause should be considered?

Hematemesis

Specificity

Identifies the proportion of people who test negative in a group of people known to be without a given disease or condition, or the proportion of people who are "true negatives" compared with the total number of people without the disease. When the observation or test is positive in people without the disease, the result is called a false positive. Beneficial observations and tests have a specificity of more than 90% and help RULE IN disease because THE TEST IS RARELY POSITIVE WHEN DISEASE IS ABSENT, and there are FEW FALSE POSITIVES. SpPin

Sensitivity

Identifies the proportion of people who test positive in a group of people known to have the disease or condition, or the proportion of people who are true positives compared with the total number of people who actually have the disease. When the observation or test is negative in people with the disease, the result is a false negative. Good observations or tests have a sensitivity of more than 90% and, WHEN NEGATIVE, help to RULE OUT disease because there are FEW FALSE NEGATIVES. Such observations or tests are especially useful for screening. Example: Homan's sign has 50% sensitivity for DVT. So if Homan's is absent, it is not helpful because 50% of patients with DVTs have negative Homan's sign. SnNout

Sudden, painful unilateral loss of vision may be caused by which of the following conditions?

In multiple sclerosis, sudden painful loss of vision may accompany optic neuritis

Glaucoma is the leading cause of blindness in African-Americans and the second leading cause of blindness overall. What features would be noted on funduscopic examination?

Increased cup-to-disc ratio

Validity

Indicates how closely a given observation agrees with the "true state of affairs," or the best possible measure of reality.

You are seeing an older patient who has not had medical care for many years. Her vital signs taken by your office staff are: T 37.2, HR 78, BP 118/92, and RR 14, and she denies pain. You notice that she has some hypertensive changes in her retinas and you find mild proteinuria on a urine test in your office. You expected the BP to be higher. She is not on any medications. What do you think is causing this BP reading, which doesn't correlate with the other findings?

It is caused by an "auscultatory gap."

An 18-year-old college freshman presents to the clinic for evaluation of gastroenteritis. You measure the patient's temperature and it is 104 degrees Fahrenheit. What type of pulse would you expect to feel during his initial examination?

Large amplitude, forceful

A 50-year-old body builder is upset by a letter of denial from his life insurance company. He is very lean but has gained 2 pounds over the past 6 months. You personally performed his health assessment and found no problems whatsoever. He says he is classified as "high risk" because of obesity. What should you do next?

Measure his waist.

Kappa measurement of interobserver agreement

Measures the degree of observer agreement, or precision, of a clinical finding compared to agreement by chance alone. Slight 0-.2 Fair .2-.4 Moderate .4-.8 Substantial .8-1

A 55-year-old data entry operator comes to the clinic to establish care. She has the following symptoms: headache, neck pain, sinus congestion, sore throat, ringing in ears, sharp brief chest pains at rest, burning abdominal pain with spicy foods, constipation, urinary frequency that is worse with coughing and sneezing, and swelling in legs. This cluster of symptoms is explained by: one or more than one disease process?

More than one disease process

A 55-year-old bank teller comes to your office for persistent episodes of dizziness. The first episode started suddenly and lasted 3 to 4 hours. He experienced a lot of nausea with vomiting; the episode resolved spontaneously. He has had five episodes in the past weeks. He does note some tinnitus that comes and goes. Upon physical examination, you note that he has a normal gait. The Weber localizes to the right side and the air conduction is equal to the bone conduction in the right ear. Nystagmus is present. Based on this description, what is the most likely diagnosis?

Ménière's disease

Mr. Garcia comes to your office for a rash on his chest associated with a burning pain. Even a light touch causes this burning sensation to worsen. On examination, you note a rash with small blisters (vesicles) on a background of reddened skin. The rash overlies an entire rib on his right side. What type of pain is this?

Neuropathic pain

When using an interpreter to facilitate an interview, where should the interpreter be positioned?

Next to the patient, so the examiner can maintain eye contact and observe the nonverbal cues of the patient

Is the following information subjective or objective? Mr. M. has a respiratory rate of 32 and a pulse rate of 120

Objective

A 62-year-old teacher presents to the clinic for evaluation of the following symptoms: fever, headache, sinus congestion, sore throat, green nasal discharge, and cough. This cluster of symptoms is best explained by: one or more than one disease process?

One disease process.

Ms. Washington is a 67-year-old who had a heart attack last month. Now she complains of shortness of breath and not being able to sleep in a flat position (orthopnea). On examination you note increased jugular venous pressure, an S3 gallop, crackles low in the lung fields, and swollen ankles (edema). This is an example of a: Pathophysiologic problem Psychopathologic problem

Pathophysiologic problem

On the way to see your next patient, you glance at the calendar and make a mental note to buy a Mother's Day card. Your patient is Ms. Hernandez, a 76-year-old widow who lost her husband in May, two years ago. She comes in today with a headaches, abdominal pain, and general malaise. This happened once before, about a year ago, according to your detailed office notes. You have done a thorough evaluation but are unable to arrive at a consistent picture to tie these symptoms together. This is an example of a: Pathophysiologic problem Psychopathologic problem

Psychopathologic problem

A 67-year-old lawyer comes to your clinic for an annual examination. He denies any history of eye trauma. He denies any visual changes. You inspect his eyes and find a triangular thickening of the bulbar conjunctiva across the outer surface of the cornea. He has a normal pupillary reaction to light and accommodation. Based on this description, what is the most likely diagnosis?

Pterygium

A patient is describing a very personal part of her history very quickly and in great detail. How should you react to this?

Push away from the keyboard or put down your pen and listen.

You arrive at the bedside of an elderly woman who has had a stroke, affecting her entire right side. She cannot speak (aphasia). You are supposed to examine her. You notice that the last examiner left her socks at the bottom of the bed, and although sensitive areas are covered by a sheet, the blanket is heaped by her feet at the bottom of the bed. What would you do next?

Put her socks back on and cover her completely before beginning the evaluation.

A 25-year-old type 1 diabetic clerk presents to the emergency room with shortness of breath and states that his blood sugar was 605 at home. You diagnose the patient with diabetic ketoacidosis. What is the expected pattern of breathing?

Rapid and deep This is the expected rate and depth in diabetic ketoacidosis. The body is trying to rid itself of carbon dioxide to compensate for the acidosis. This is known as Kussmaul's breathing and is seen in other causes of acidosis as well.

A 15-year-old high school sophomore and her mother come to your clinic because the mother is concerned about her daughter's weight. You measure her daughter's height and weight and obtain a BMI of 19.5 kg/m2. Based on this information, which of the following is appropriate?

Reassure the mother that this is a normal body weight.

You are interviewing an elderly woman in the ambulatory setting and trying to get more information about her urinary symptoms. Which of the following techniques is not a component of adaptive questioning? Directed questioning: starting with the general and proceeding to the specific in a manner that does not make the patient give a yes/no answer Reassuring the patient that the urinary symptoms are benign and that she doesn't need to worry about it being a sign of cancer Offering the patient multiple choices in order to clarify the character of the urinary symptoms that she is experiencing Asking her to tell you exactly what she means when she states that she has a urinary tract infection

Reassuring the patient that the urinary symptoms are benign and that she doesn't need to worry about it being a sign of cancer

Ms. Wright comes to your office, complaining of palpitations. While checking her pulse you notice an irregular rhythm. When you listen to her heart, every fourth beat sounds different. It sounds like a triplet rather than the usual "lub dup." How would you document your examination?

Regularly irregular rhythm

A sudden, painless unilateral vision loss may be caused by which of the following?

Retinal detachment is generally painless, as is chronic glaucoma.

Name the components of the health history.

Review of systems, present illness, personal and social items. Also: identifying data and source of the history; reliability, chief complaints, present illness, past history, family history, personal and social history, review of systems.

Which of the following is a symptom involving the eye? Scotomas Tinnitus Dysphagia Rhinorrhea

Scotomas

Jason is a 41-year-old electrician who presents to the clinic for evaluation of shortness of breath. The shortness of breath occurs with exertion and improves with rest. It has been going on for several months and initially occurred only a couple of times a day with strenuous exertion; however, it has started to occur with minimal exertion and is happening more than a dozen times per day. The shortness of breath lasts for less than 5 minutes at a time. He has no cough, chest pressure, chest pain, swelling in his feet, palpitations, orthopnea, or paroxysmal nocturnal dyspnea. Which of the following symptom attributes was not addressed in this description?

Severity

Jenny is one of your favorite patients who usually shares a joke with you and is nattily dressed. Today she is dressed in old jeans, lacks makeup, and avoids eye contact. To what do you attribute these changes?

She is depressed.

Mrs. R. is a 92-year-old retired teacher who comes to your clinic accompanied by her daughter. You ask Mrs. R. why she came to your clinic today. She looks at her daughter and doesn't say anything in response to your question. This is an example of which type of challenging patient?

Silent patient

A 49-year-old truck driver comes to the emergency room for shortness of breath and swelling in his ankles. He is diagnosed with congestive heart failure and admitted to the hospital. You are the student assigned to do the patient's complete history and physical examination. When you palpate the pulse, what do you expect to feel?

Small amplitude, weak

A 15-year-old high school sophomore presents to the emergency room with his mother for evaluation of an area of blood in the left eye. He denies trauma or injury but has been coughing forcefully with a recent cold. He denies visual disturbances, eye pain, or discharge from the eye. On physical examination, the pupils are equal, round, and reactive to light, with a visual acuity of 20/20 in each eye and 20/20 bilaterally. There is a homogeneous, sharply demarcated area at the lateral aspect of the base of the left eye. The cornea is clear. Based on this description, what is the most likely diagnosis?

Subconjunctival hemorrhage

Is the following information subjective or objective? Mr. M. has shortness of breath that has persisted for the past 10 days; it is worse with activity and relieved by rest

Subjective

The following information is best placed in which category? "The patient has had three cesarean sections." Adult illness Surgeries Obstetric/gynecology psychiatric

Surgeries

A patient presents for evaluation of a cough. Which of the following anatomic regions can be responsible for a cough? Ophthalmologic Auditory Cardiac Endocrine

The cardiac system can cause a cough if the patient has congestive heart failure. This results in fluid buildup in the lungs, which in turn can cause a cough that produces pink, frothy sputum. A foreign body in the ear may also cause a cough by stimulating Arnold's branch of the vagus nerve, but this is less likely to be seen clinically than heart failure.

A 22-year-old advertising copywriter presents for evaluation of joint pain. The pain is new, located in the wrists and fingers bilaterally, with some subjective fever. The patient denies a rash; she also denies recent travel or camping activities. She has a family history significant for rheumatoid arthritis. Based on this information, which of the following pathologic processes would be the most correct? Infectious Inflammatory Hematologic Traumatic

The description is most consistent with an inflammatory process, although all the other etiologies should be considered. Lyme disease is an infection which commonly causes arthritis, hemophilia is a hematologic condition which can cause bleeding in the joints, and trauma can obviously cause joint pain. Your clinical reasoning skills are important for sorting through all of the data to arrive at the most likely conclusion.

A 47-year-old contractor presents for evaluation of neck pain, which has been intermittent for several years. He normally takes over-the-counter medications to ease the pain, but this time they haven't worked as well and he still has discomfort. He recently wallpapered the entire second floor in his house, which caused him great discomfort. The pain resolved with rest. He denies fever, chills, rash, upper respiratory symptoms, trauma, or injury to the neck. Based on this description, what is the most likely pathologic process? Infectious Neoplastic Degenerative Traumatic

The description is most consistent with degenerative arthritis in the neck. The patient has had intermittent symptoms and the questions asked to elicit pertinent negative and positive findings are negative for infectious, traumatic, or neoplastic disease.

A patient tells you about her experience with prolonged therapy for her breast cancer. You comment, "That must have been a very trying time for you." What is this an example of?

Validation

Mr. Q. is a 45-year-old salesman who comes to your office for evaluation of fatigue. He has come to the office many times in the past with a variety of injuries, and you suspect that he has a problem with alcohol. Which one of the following questions will be most helpful in diagnosing this problem?

When was your last drink?

Despite having high BP readings in the office, Mr. Kelly tells you that his readings at home are much lower. He checks them twice a day at the same time of day and has kept a log. How do you respond?

You question the accuracy of his measurements.

comprehensive assessment

all the elements of the health history and the complete physical examination

The following information is recorded in the health history: "I feel really tired." Which category does it belong to? Present illness chief complaint personal and social history review of systems

chief complaint

inspection

close observation of the details of the patient's appearance, behavior, and movement such as facial expression, mood, body habitus and conditioning, skin conditions such as petechiae or ecchymoses, eye movements, pharyngeal color, symmetry of the thorax, height of jugular venous pulsations, abdominal contour, lower extremity edema, and gait.

Steve has just seen a 5-year-old girl who wheezes when exposed to cats. The patient's family history is positive for asthma. You think the child most likely has asthma. What have you just accomplished?

created a hypothesis

focused or problem-oriented assessment

for patients that you know well that are returning for routine office care or for patients with specific "urgent care" concerns

The following information is recorded in the health history: "The patient completed 8th grade. He currently lives with his wife and two children. He works on old cars on the weekend. He works in a glass factory during the week." Which category does it belong to? Present illness chief complaint personal and social history review of systems

personal and social history

The following information is recorded in the health history: "The patient has had abdominal pain for 1 week. The pain lasts for 30 minutes at a time; it comes and goes. The severity is 7 to 9 on a scale of 1 to 10. It is accompanied by nausea and vomiting. It is located in the mid-epigastric area." Which of these categories does it belong to? Present illness chief complaint personal and social history review of systems

present illness

The following information is recorded in the health history: "Patient denies chest pain, palpitations, orthopnea, and paroxysmal nocturnal dyspnea." Which category does it belong to? Present illness chief complaint personal and social history review of systems

review of systems

palpation

tactile pressure from the palmar fingers or fingerpads to assess areas of skin elevation, depression, warmth, or tenderness, lymph nodes, pulses, contours and sizes of organs and masses, and crepitus in the joints.

Positive predictive value

the probability of disease in a patient with a positive (abnormal) test, or the proportion of "true positives" out of the total population with the disease The proportion of women that actually have breast cancer with palpable breast nodules .

Negative predictive value

the probability of not having the condition or disease when the test is negative, or normal, or the proportion of "true negatives" out of the total population without the disease The proportion of women without confirmed breast cancer without palpable breast nodules.

auscultation

use of the diaphragm and bell of the stethoscope to detect the characteristics of heart, lung, and bowel sounds, including location, timing, duration, pitch, and intensity. For the heart, this involves sounds from closing of the four valves and flow into the ventricles as well as murmurs. Auscultation also permits detection of bruits or turbulence over arterial vessels.

Percussion

use of the striking or plexor finger, usually the third, to deliver a rapid tap or blow against the distal pleximeter finger, usually the distal third finger of the left hand laid against the surface of the chest or abdomen, to evoke a sound wave such as resonance or dullness from the underlying tissue or organs. This sound wave also generates a tactile vibration against the pleximeter finger.

subjective data

what the patient tells you

objective data

what you detect during the examination. All physical examination findings.