Health Assessment Intro to class, History & Physical lecture

general ROS

Usual weight, recent weight change, clothing that fits more tightly or loosely than before; weakness, fatigue, or fever. •

communitarianism

which emphasizes the interests of communities and societies over individuals and social responsibilities bearing on the need to maintain the institutions of civil society

Mixed Episode

which must last at least 1 week, meets the criteria for both major and manic depressive episodes.

ROS: Head (CNS)

headache, head injury, syncope, seizures, vertigo, paralysis/paresis, tremor, ataxia, fainting, lightheadedness, dysesthesias

Cardiovascular ROS

"Heart trouble," high blood pressure, rheumatic fever, heart murmurs, chest pain or discomfort, palpitations, dyspnea, orthopnea, paroxysmal nocturnal dyspnea, edema, results of past electrocardiograms or other cardiovascular tests

chief complaint

-The one or more symptoms or concerns causing the patient to seek care -Make every attempt to quote the patient's own words. -summerize pts verbal complaint and include a duration. Should be limited to one complaint

Domestic Violence

. "Are you in a relationship where you have been hit or threatened?" with a pause to encourage the patient to respond. If the patient says no, continue with "Has anyone ever treated you badly or made you do things you don't want to?" or "Is there anyone you are afraid of?" or "Have you ever been hit, kicked, punched, or hurt by someone you know?" Following disclosure, empathic validating and nonjudgmental responses are critical but currently occur less than half the time.

Musculoskeletal Exam

If indicated, with the patient still sitting, examine the hands, arms, shoulders, neck, and temporomandibular joints. Inspect and palpate the joints and check their range of motion

Phys Exam: Extremities/Muscloskeletal

No clubbing, cyanosis, edema noted. Full ROM, Joints nontender, Peripheral pulses intact and equal throughout. (dorsalis pedis, posterior tibialis, radial, brachial) Muscle strength equal throughout.

Phys Exam: Back

Normal curvature, nontender, no CVA tenderness. -fist percussion or palpation of vertebrae - pain, tenderness, para spinal area -fist percussion of CVA (kidney for punch tenderness) - around 12th rib -Performs fist percussion of or palpates vertebrae - any pain or tenderness? Performs fist percussion of CVA (kidneys for punch tenderness) at the level of 12 rib - percuss using tap tap move tap tap move with tip of finger striking - tympany in hallow organ like abdomen, resonance in lung, dull over organs

Facial expression

Note expressions of anxiety, depression, apathy, anger, elation, or facial immobility in parkinsonism.

Odd or Eccentric Disorders

Paranoid - Distrust and suspiciousness Schizoid - Detachment from social relations with a restricted emotional range Schizotypal - Eccentricities in behavior and cognitive distortions; acute discomfort in close relationships

cheyne-stokes breathing

Periods of deep breathing alternate with periods of apnea (no breathing). Children and aging people normally may show this pattern in sleep. Other causes include heart failure, uremia, drug-induced respiratory depression, and brain damage (typically on both sides of the cerebral hemispheres or diencephalon).

Perseveration

Persistent repetition of words or ideas

Phobias

Persistent, irrational fears, accompanied by a compelling desire to avoid the stimulus

Phys Exam: Skin

Pink, Warm and dry with instant recoil (or with good turgor). No masses, lesions, scars. Hair normal in distribution and consistency. No clubbing, cyanosis, deformities of nails.

Body Dismorphic Disorder

Preoccupation with an imagined or exaggerated defect in physical appearance

tachypnea

Rapid shallow breathing has a number of causes, including restrictive lung disease, pleuritic chest pain, and an elevated diaphragm.

Conversion Disorder

Syndrome of symptoms of deficits mimicking neurologic or medical illness in which psychological factors are judged to be of etiologic importance

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.

Angry Patient

You can validate their feelings without agreeing with their reasons. "I understand that you felt very frustrated by answering the same questions over and over. Our complex health care system can seem very unsupportive when you are not feeling well."

skin

changes in skin color, scars, plaques, or nevi Pallor, cyanosis, jaundice, rashes, bruises

Dysarthria

defective articulation

Accomodation

look into distance over shoulder ask pt to look at finger first, then to object or background.

casuistry

the analysis of paradigmatic prior cases as relevant

Substance-Induced Psychotic Disorder

Prominent hallucinations or delusions may be induced by intoxication or withdrawal from a substance such as alcohol, cocaine, or opioids. For this diagnosis, these symptoms should not occur exclusively during the course of delirium. The substance should be judged to be causally related to the symptoms.

reliabilty

Varies according to the patient's memory, trust, and mood

DNR

What experiences have you had with the death of a close friend or relative?" "What do you know about cardiopulmonary resuscitation (CPR)?" Educate patients about the likely success of CPR, especially if they are chronically ill or advanced in age.

ROS: Breasts

: skin changes, pain, nipple changes, lumps (masses), fibrocystic disease, breast cancer hx., knowledge of self exam, frequency of self exam, date of last mammogram

Neurologic ROS

Changes in mood, attention, or speech; changes in orientation, memory, insight, or judgment; headache, dizziness, vertigo, fainting, blackouts; weakness, paralysis, numbness or loss of sensation, tingling or "pins and needles," tremors or other involuntary movements, seizures

Hypochondriasis

Chronic preoccupation with the idea of having a serious disease. The preoccupation is usually poorly amenable to reassurance

Dissociative Disorders

Disruptions of consciousness, memory, identity, or perception judged to be due to psychological factors

Active Listening

Emphatic responses. Guided questioning. Nonverbal communication. Validation. Reassurance. Partnering. Summarization. Transitions. Empowering the patient.

Confabulation

Fabrication of facts or events in response to questions, to fill in the gaps in an impaired memory

Phys Exam: Eyes

Inspects eyes (retracts lid), EOM, convergence, pupillary response to light (direct and consensual), near reflex (accomodation), visual field by confrontation - 4 quadrants each eye, visual accuity, opthalmoscopic exam -using pen light or ophthalmoscope shine check pupillary response (direction and consensual reaction - one pupil constricts so does the other) --Ask pt to look up as you depress both lower lids with you thumbs, exposing the sclera and conjunctiva. Note color, vascular pattern, look for nodules or swelling. Ask pt to look to each side and down.

Nonverbal CX

Just as mirroring your position can signify the patient's increasing sense of connectedness, matching your position to the patient's can signal increased rapport. You can also mirror the patient's paralanguage, or qualities of speech, such as pacing, tone, and volume, to increase rapport.

Breasts ROS

Lumps, pain, or discomfort, nipple discharge, self-examination practices.

Psychiatric ROS

Nervousness, tension, mood, including depression, memory change, suicide attempts, if relevant

Cyclothymic Episode

Numerous periods of hypomanic and depressive symptoms that last for at least 2 years (1 year in children and adolescents). Freedom from symptoms lasts no more than 2 months at a time.

H&P

Omit most of your negative findings unless they relate directly to the patient's complaints or to specific exclusions in your diagnostic assessment. Do not list abnormalities that you did not observe. Instead, concentrate on a few major ones, such as "no heart murmurs," and try to describe structures in a concise, positive way.

ROS: Cardiovascular

chest pain, typical angina pectoris, palpitations, exertional dyspnea, orthopnea, paroxysmal nocturnal dyspnea, murmur, rheumatic fever, heartdisease, past EKG or other heart tests.

ROS: Neck

lymphadenopathy, goiter, pain in neck, lumps

Idiopathic pain

pain without an identifiable etiology.

feminist ethics

which invoke problems of marginalization of social groups

Glass Thermometer

insert it under the tongue, instruct the patient to close both lips, and wait 3 to 5 minutes. Then read the thermometer, reinsert it for a minute, and read it again. If the temperature is still rising, repeat this procedure until the reading remains stable. Note that hot or cold liquids, and even smoking, can alter the temperature reading. In these situations, it is best to delay measuring the temperature for 10 to 15 minutes.

Common or concerning symptoms

-Fatigue and weakness -Fever, chills, night sweats -Weight changes -Pain

Feelings of Unreality

A sense that things in the environment are strange, unreal, or remote

Hematologic ROS

Anemia, easy bruising or bleeding, omit transfusions (already in the history) past transfusions, transfusion reactions.

four A's

-Analgesia -Activities of daily living -Adverse effects •-Aberrant drug-related behaviors to monitor patient outcomes from opioids

Developing Hypotheses about Patients

1) Select the most specific and critical findings to support your hypothesis 2) Using your inferences about the structures and processes involved, match your findings against all the conditions you know that can produce them 3) eliminate the diagnostic possibilities that fail to explain the findings 4) Weigh the competing possibilities and select the most likely diagnosis from among the conditions that might be responsible for the patient's findings. statistical probability Thetiming of the patient's illness 5. , give special attention to potentially life-threatening and treatable conditions . Here you make every effort to minimize the risk for missing conditions that may occur less frequently or be less probable but that, if present, would be particularly ominous. One rule of thumb is always to include "the worst case scenario" in your list of differential diagnoses and make sure you have ruled out that possibility based on your findings and patient assessment.

Assessment

: (include rationale & reference) 1. Diagnosis ICD 10 code Diagnosis - history findings, physical exam findings, diagnostic reasoning Also write the ICD 10 code Also write the rationale, why do you think it's that? Include your reference If doing, wellness exam there is a code. Include pre-existing conditions Write None for diagnosis Strep Pharyngitis, Code, According to the CDC, the diagnosis of Strep Pharyngitis may be made based on the following criteria.... How that criteria measures to your patient and that is why you feel your patient has that diagnosis List any other diagnosis that your patient brings to the visit with them. Past medical history of Hypertension, Diabetes bc coming in with diagnosis no need to write rational for that. Write ICD10 code.

Urinary ROS

: Frequency of urination, polyuria, nocturia, urgency, burning or pain during urination, hematuria, urinary infections, kidney or flank pain, kidney stones, ureteral colic, suprapubic pain, incontinence; in males, reduced caliber or force of the urinary stream, hesitancy, dribbling.

ROS: Male Genito-Reproductive

: penile discharge or lesions, history of VD and its treatment, serology, hernias, testicular pain, swelling,or masses, infertility, impotence, libido, sexual problems. Is there a history of sexual abuse/rape?

ROS Endocrine

: thyroid disease, goiter, heat or cold intolerance, change in voice, excessive sweating, diabetes, polyuria, polyphagia, polydipsia, gynecomastia, hirsutism.

Affect

An observable, usually episodic, feeling or tone expressed through voice, facial expression, and demeanor -external expression of the inner emotional state.

Anxious or Fearful Disorders

Avoidant - Social inhibition, feelings of inadequacy and hypersensitivity to negative evaluation Dependent - Submissive and clinging behavior; psychological dependence on others Obsessive-compulsive - Rigid, detail-oriented behavior, often associated with compulsions to perform tasks repetitively and unnecessarily and rigid conformity to rules

Orientation

Awareness of personal identity, place, and time; requires both memory and attention

Tolerance

A state of adaptation in which exposure to a drug induces changes that result in a diminution of one or more of the drug's effects over time.

Physical Dependence:

A state of adaptation that is manifested by a drug class-specific withdrawal syndrome that can be produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug, and/or administration of an antagonist.

Insight

Awareness that symptoms or disturbed behaviors are normal or abnormal; for example, distinguishing between daydreams and hallucinations that seem real What brings you to the hospital?" "What seems to be the trouble?" "What do you think is wrong?" More specifically, note whether the patient is aware that a particular mood, thought, or perception is abnormal or part of an illness. Patients with psychotic disorders often lack insight into their illness. Denial of impairment may accompany some neurologic disorders

ROS: Integument (Skin)

rashes, sweating, dryness, color change, change in hair or nails,itching, lumps, bleeding tendency/bruising, piercings or tattoo, sunscreen use, tanning beds

Mitral Stenosis

Ask the patient to roll partly onto the left side while you listen at the apex for an S3

Pathophysiologic Process

reflecting derangements of biologic functions, such as congestive heart failure or migraine headache

sighing respirations

Breathing punctuated by frequent sighs should alert you to the possibility of hyperventilation syndrome—a common cause of dyspnea and dizziness. Occasional sighs are normal.

Low Literacy Patient

To detect low literacy, ask about years completed in school. Or try practical approaches like asking "How comfortable are you about filling out health forms?" or checking how well the patient can read written instructions. Another rapid screen is to hand the patient a written text upside down—most patients will turn the page around immediately.

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 is >1.0, the probability of the condition goes up; when the LR is <1.0, the probability of the condition goes down.

Respiratory ROS

Cough, sputum (color, quantity), hemoptysis, dyspnea, wheezing, pleurisy, last chest x-ray. You may wish to include asthma, bronchitis, emphysema, pneumonia, and tuberculosis

Nonmaleficence or primum non nocere

commonly stated as, "First, do no harm." In the context of an interview, giving information that is incorrect or not really related to the patient's problem can do harm. Avoiding relevant topics or creating barriers to open communication can also do harm.

ROS: Mouth and Throat

condition of teeth and gums (caries, extractions, dentures, caps,bleeding gums, pyorrhea), difficulty chewing, date of last dental exam, brushing, flossingsore tongue, taste changes.

ROS: Respiratory

cough, sputum color and quantity, hemoptysis, wheezing, dyspnea, pain on respiration, frequent respiratory infections, asthma, bronchitis, emphysema,pneumonia, tuberculosis, exposure to tuberculosis, tuberculin test (date and result).

Delusional Disorder

characterized by nonbizarre delusions that involve situations in real life, such as having a disease or being deceived by a lover. The delusion has persisted for at least a month, but the person's functioning is not markedly impaired, and behavior is not obviously odd or bizarre. The symptoms of schizophrenia, except for tactile and olfactory hallucinations related to the delusion, have not been present.

malnutrition

weakness, easy fatigability, cold intolerance, flaky dermatitis, and ankle swelling. . Ask general questions about intake at different times throughout the day, such as "Tell me what you typically eat for lunch." "What do you eat for a snack?" "When?"

Phys Exam: Female Genitalia

deferred for HNG 515 students. Date of last exam Hair dist. normal, no lesions, inflammation or ulceration noted. Bartholin's, Skene's glands without discharge. Cervix pink, mobile, nontender and in (anteverted, retroverted, or midline) position. No adnexal masses. Ovaries nontender (or not palpated) and cm's.

Phys Exam: Male Genitalia

deferred for HNG 515 students. Date of last exam Hair dist. normal, no lesions, ulcers, masses noted of penis, scrotum, or perineum. Urethra without discharge. Spermatic cord, Epididymis, without masses or tenderness. No lymphadenopathy. Prostate normal size, nontender.

Weakness

demonstrable loss of muscle power -especially if localized in a neuroanatomical pattern, suggests possible neuropathy or myopathy.

Hypothermia

exposure to cold. Other predisposing causes include reduced movement as in paralysis, interference with vasoconstriction from sepsis or excess alcohol, starvation, hypothyroidism, and hypoglycemia. Older adults are especially susceptible to hypothermia and also less likely to develop fever

Tangential Lighting

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

SLIDTA

severity, location, influencing factors, duration, type & associated symptoms

ROS: General

weight change (intentional or unintentional), weakness, fatigue, fever, chills, night sweats, hours sleep/night do you feel rested

Values

the standards we use to measure our own and others' beliefs and behaviors

Major Depressive Episode

At least five of the symptoms listed below (including one of the first two) must be present during the same 2-week period. They must also represent a change from the person's previous state. Depressed mood (may be an irritable mood in children and adolescents) most of the day, nearly every day Markedly diminished interest or pleasure in almost all activities most of the day, nearly every day Significant weight gain or loss (not dieting) or increased or decreased appetite nearly every day Insomnia or hypersomnia nearly every day Psychomotor agitation or retardation nearly every day Fatigue or loss of energy nearly every day Feelings of worthlessness or inappropriate guilt nearly every day Inability to think or concentrate or indecisiveness nearly every day Recurrent thoughts of death or suicide, or a specific plan for or attempt at suicide The symptoms cause significant distress or impair social, occupational, or other important functions. In severe cases, hallucinations and delusions may occur.

ataxic breathing/biots breathing

Ataxic breathing is characterized by unpredictable irregularity. Breaths may be shallow or deep, and stop for short periods. Causes include respiratory depression and brain damage, typically at the medullary level.

Attention

The ability to focus or concentrate over time on one task or activity—an inattentive or distractible person with impaired consciousness has difficulty giving a history or responding to questions.

five segments of neurologic exam

mental status, cranial nerves (including funduscopic examination), motor system, sensory system, and reflexes.

Tympanic Membrane Temp

method measures core body temperature, which is higher than the normal oral temperature by approximately 0.8°C (1.4°F). Tympanic measurements are more variable than oral or rectal measurements, including right and left comparisons in the same person.[49]

ROS: Nose and Sinuses

nasal congestion, frequent colds, sinus trouble, epistaxis, olfactorychanges, deviated septum, hay fever, loss of smell.

ROS: Psychiatric/Emotional Status

nervousness, hyperventilation, tension, mood,depression, insomnia, nightmares, memory loss, phobias.

chronic pain

pain not associated with cancer or other medical conditions that persists for more than 3 to 6 months; pain lasting more than 1 month beyond the course of an acute illness or injury; or pain recurring at intervals of months or years.[2] Chronic noncancer pain affects 5% to 33% of patients in primary care settings. More than 40% of patients report that their pain is poorly controlled -describe the pain and how it started. Is it related to a site of injury, movement, or time of day? What is the quality of the pain—sharp, dull, burning? Ask if the pain radiates or follows a particular pattern. What makes the pain better or worse? -treatments that the patient has tried, including medications, physical therapy, and alternative medicines. -comorbid conditions such as arthritis, diabetes, HIV/AIDS, substance abuse, sickle cell disease, or psychiatric disorders. -the leading cause of disability and impaired performance at work. Inquire about the effects of pain on the patient's daily activities, mood, sleep, work, and sexual activity. -may be a spectrum disorder in patients with anxiety, depression, or somatic symptoms

ROS: Ears

pain, hearing loss, deafness, infection, discharge, tinnitus, rupturedtympanic membrane, vertigo, occupational exposure to loud noise, headphone use

Fever

patient felt feverish or unusually hot, noted excessive sweating, or felt chilly and cold -take temp at home -distinguish between subjective chilliness, and a shaking chill with shivering throughout the body and chattering of teeth. -Recurrent shaking chills suggest more extreme swings in temperature and systemic bacteremia. -Feeling cold, goosebumps, and shivering accompany a rising temperature, while feeling hot and sweating accompany a falling temperature -night sweats occur. Malaise, headache, and pain in the muscles and joints -Feeling hot and sweating also accompany menopause. Night sweats occur intuberculosis and malignancy -the timing of the illness and its associated symptoms -travel, contact with sick people, or other unusual exposures -medications can cause -aspirin, acetaminophen, corticosteroids, and nonsteroidal anti-inflammatory drugs may mask fever

Obtunded

patients open their eyes and look at you, but respond slowly and are somewhat confused.

Limited Intelligence Patient

pay special attention to the patient's schooling and ability to function independently. How far have such patients gone in school? If they didn't finish, why not? What kinds of courses have they taken? How did they do? Have they had any testing done? Are they living alone? Do they need assistance with activities such as transportation or shopping? The sexual history is equally important and often overlooked. Find out if the patient is sexually active and provide information that may be needed about pregnancy or sexually transmitted infections. If you are unsure about the patient's level of intelligence, make a smooth transition to the mental status examination and assess simple calculations, vocabulary, memory, and abstract thinking. -severe mental retardation, turn to family or caregivers to elicit the history, but always show interest in the patient first. Establish rapport, make eye contact, and engage in simple conversation.

Autonomy

reminds us that patients have the right to determine what is in their own best interest. This principle has become increasingly important over time and is consistent with collaborative rather than paternalistic clinician-patient relationships.

Fatigue

sense of weariness or loss of energy that patients describe in various ways. "I don't feel like getting up in the morning"... "I don't have any energy"... "I just feel blah"... "I'm all done in"... "I can hardly get through the day"... "By the time I get to the office, I feel as if I've done a day's work." Because fatigue is a normal response to hard work, sustained stress, or grief, elicit the life circumstances in which it occurs -common symptom of depression and anxiety, but also considerinfections (such as hepatitis, infectious mononucleosis, and tuberculosis);endocrine disorders (hypothyroidism, adrenal insufficiency, diabetes mellitus, panhypopituitarism); heart failure; chronic disease of the lungs, kidneys, or liver; electrolyte imbalance; moderate to severe anemia; malignancies; nutritional deficits; and medications.

Plan

should make reference to diagnosis, therapy, and patient education. -it is important to share your assessment and clinical thinking with the patient and seek out his or her opinions, concerns, and willingness to proceed with any further testing or evaluation (Include rationale & reference) in this order always Medications - you are ordering and meds the pt already on Labs Diagnostics Referrals Patient education Follow up meds - dosage, route, frequency, duration, rationale, where you got info from Continue any other medications that the patient was taking in addition to the new. Continue lisinopril, dosage, route, frequency etc Labs - CBC, BMP, etc can be for screening purposes if not ordering labs write "none" Diagnostic - CT, MRI, Colonosocpy, Mammography, why??? Referrals - who are you referring the patient to and why? If colonoscopy, you need to write a referral to Gastroenterologist, mammography no need to write referral - they are going to go any radiology, if specific test that requires physician present to do the test write referral, nutrition, psychotherapist -Patient education - bullet format, key aspects of pt education that are important based on diagnosis -Follow up - when you want to see this patient again

the big four lifestyle habits

smoking, excessive drinking, lack of exercise, and unhealthy diet

Episodic/Periodic History

taken upon a subsequent visit after the initial data base(comprehensive) has been completed. The data elicited from the history will depend upon the purpose of the visit, and the amount of time which has elapsed since the last visit. The health record is updated to include changes in health/illnesses/medications. -If patient came in with headache and you order CT scan. Come back in two weeks following cat scan. When patient comes back ask about headache, change, review results of cat scan. That is episodic periodic visit. Amount of time which elapsed from last visit. If they don't come back 2-3 years, need another comprehensive visit. If 2 weeks later, 3 months later - episodic

Hypertension

the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure recommended using the mean of two or more properly measured seated blood pressure readings, taken on two or more office visits, for diagnosis of hypertension.[41] Blood pressure measurement should be verified in the contralateral arm. NCVII Blood Pressure Classification for Adults Category Systolic (mm Hg) Diastolic (mm Hg) Normal <120 <80 Prehypertension 120-139 80-89 Stage 1 Hypertension 140-159 90-99 Stage 2 Hypertension ≥160 ≥100 If Diabetes or Renal Disease <130 <80 -Assessment of hypertension also includes its effects on target "end organs"—the eyes, heart, brain, and kidneys. Look for hypertensive retinopathy, left ventricular hypertrophy, and neurologic deficits suggesting stroke. Renal assessment requires urinalysis and blood tests of renal function. -In isolated systolic this, systolic blood pressure is ≥140 mm Hg, and diastolic blood pressure is <90 mm Hg.

Beneficence

the dictum that the clinician needs to "do good" for the patient. As clinicians, your actions need to be motivated by what is in the patient's best interest.

Culture

the system of shared ideas, rules, and meanings that influences how we view the world, experience it emotionally, and behave in relation to other people -the "lens" through which we perceive and make sense out of the world we inhabit. -broader than the term "ethnicity

central sensitization pain

there is alteration of central nervous system processing of sensation, leading to amplification of pain signals. -There is a lower pain threshold to nonpainful stimuli, and the response to pain may be more severe than expected. -Mechanisms are the subject of ongoing research. -An example is fibromyalgia, which has a strong overlap with depression, anxiety, and somatization disorders and responds best to medications that modify neurotransmitters like serotonin and dopamine.56

Drug Use

"In your lifetime have you ever used: marijuana; cocaine; prescription stimulants; methamphetamines; sedatives or sleeping pills; hallucinogens like LSD, ecstasy, mushrooms ... ; street opioids like heroin or opium; prescription opioids like fentanyl, oxycodone, hydrocodone ... ; or other substances." For those answering yes, a series of further questions is recommended.[80] Another approach is to adapt the CAGE questions to screening for substance abuse by adding "or drugs" to each question. Once you identify substance abuse, continue further with questions like "Are you always able to control your use of drugs?" "Have you had any bad reactions?" "What happened ... Any drug-related accidents, injuries, or arrests? Job or family problems?" ... "Have you ever tried to quit? Tell me about it."

Alcohol

"Tell me about your use of alcohol" is an opening query that avoids the easy yes-no response. Remember that some patients do not consider wine or beer as "alcohol." Positive answers to two additional questions are highly suspicious for problem-drinking: "Have you ever had a drinking problem?"; and "When was your last drink?" especially if the night before.[76] The most widely used screening questions are theCAGE questions about Cutting down, Annoyance when criticized, Guilty feelings, and Eye-openers. -Two or more affirmative answers to the CAGE Questionnaire suggest alcohol misuse and have a sensitivity that ranges from 43% to 94% and specificity that ranges from 70% to 96%. -If you detect misuse, you need to ask about blackouts (loss of memory about events during drinking), seizures, accidents or injuries while drinking, job problems, conflict in personal relationships. -People with alcoholism may have other serious and potentially correctable problems such as hypoglycemia, subdural hematoma, or postictal state.

Endocrine ROS

"Thyroid trouble," heat or cold intolerance, excessive sweating, excessive thirst or hunger, polyuria, change in glove or shoe size.

Phys Exam: HEENT

(Head Ears Eyes Nose and Throat. Include face, mouth, sinuses, and pharynx in this section). Head normocephalic, atraumatic, with no masses or lesions. Hair normal (male, female) distribution. Face symmetrical, light touch intact. Lashes and brows intact, no stare, ptosis, or lidlag noted. Vision 20/20 both eyes Color vision (red and green) intact. EOM's intact, no nystagmus, PERRLA (pupils, equal round reactive to light and accommodation). Conjunctiva clear, sclera white, no defects of cornea or iris. Normal globe tension, Corneal light reflex equal, corneal reflex intact, Cover test negative (no strabismus). Red reflex present bilat. Disc margins sharp, AV ratio=2:3 (or arterioles and venules normal) no AV nicking. No hemorrhages or exudates. Ears: no masses or lesions of auricles, no discharge, external canal normal in appearance, no mastoid tenderness, TM's pearly grey bilat. with good light reflex. No bulge or retraction noted. Watch tick and whisper heard bilat. Weber - no lateralization, Rinne - AC>BC bilat. Nose patent bilat. no discharge, no septal deviation or perforation. No frontal or maxillary sinus tenderness on palpation. No lesions or masses of lips, oral mucosa, gingiva, pink, moist. Teeth in good repair. Tongue midline, no tremor, lesions, or masses noted. Pharynx pink, no tonsillar enlargement or exudate, gag reflex present, uvula rises in midline on phonation.

Safety Issues

(age appropriate)-seatbelt use, protective sports equipment, smoke detectors, carbon monoxide detectors, guns (locked up), safety bars, grab bars, loose rugs text and drive, hands free devices, do you eat and drive or makeup and drive? cell phone while driving etc. **Remember that this section is still subjective and must be documented subjectively: denies.... or reports......

Greeting

, greet the patient by name and introduce yourself, giving your own name. If possible, shake hands with the patient. If this is the first contact, explain your role, including your status as a student and how you will be involved in the patient's care. -When visitors are in the room, be sure to acknowledge and greet each one in turn, inquiring about each person's name and relationship to the patient.

ROS Value Beliefs

- Impact of religious belief and practice on health care practices-Advanced directives- Health practices- Complementary health practices

Motivational Interviewing

- helps patients "to say why and how they might change, and is based on the use of a guiding style" of interviewing rather than direct advice. -It engages patients to express the pros and cons of a given behavior. -makes the assumption that many patients already know what is best for them and helps them confront their ambivalence to change.[32] -Using three core skills empowers the patient to provide ideas, solutions, and a timetable for change, -"Ask" open-ended questions-invite the patient to consider how and why they might change -"Listen" to understand your patient's experience-"capture" their account with brief summaries or reflective listening statements such as "quitting smoking feels beyond you at the moment"; these express empathy, encourage the patient to elaborate, and are often the best way to respond to resistance -"Inform"-by asking permission to provide information, and then asking what the implications might be for the patient.

Weight changes

-"How often do you check your weight?" "How is it compared to a year ago?" If there are changes, ask, "Why do you think it has changed?" "What would you like to weigh?" If weight gain or loss appears to be a problem, ask about the amount of change, its timing, the setting in which it occurred, and any associated symptoms. -Rapid changes in weight, over a few days, suggest changes in body fluids, not tissues -Edema from extravascular fluid retention is visible in conditions like heart failure, nephrotic syndrome, and liver failure.

Cultural Humility

-"process that requires humility as individuals continually engage in self-reflection and self-critique as lifelong learners and reflective practitioners."[44] -It is a process that includes "the difficult work of examining cultural beliefs and cultural systems of both patients and providers to locate the points of cultural dissonance or synergy that contribute to patients' health outcomes."[45] -It calls for clinicians to "bring into check the power imbalances that exist in the dynamics of (clinician)-patient communication" and maintain mutually respectful and dynamic partnerships with patients and communities. -To attain these attributes, seek out the more effective training models that continue to emerge.[46]-[51] -Self-awareness. Learn about your own biases; we all have them. -Respectful communication. Work to eliminate assumptions about what is "normal." Learn directly from your patients; they are the experts on their culture and illness. -Collaborative partnerships. Build your patient relationships on respect and mutually acceptable plans. -"What did you hope to get from this visit?"

Principles of Sharing Power

-Evoke the patient's perspective. -Convey interest in the person, not just the problem. -Follow the patient's leads. -Elicit and validate emotional content. -Share information with the patient, especially at transition points during the visit. -Make your clinical reasoning transparent to the patient. -Reveal the limits of your knowledge.

Tips for Ensuring Quality Patient Data

-Ask open-ended questions and listen carefully and patiently to the patient's story. -Craft a thorough and systematic sequence to history taking and physical examination. -Keep an open mind toward both the patient and the data. -Always include "the worst-case scenario" in your list of possible explanations of the patient's problem, and make sure it can be safely eliminated. -Analyze any mistakes in data collection or interpretation. -Confer with colleagues and review the pertinent medical literature to clarify uncertainties. -Apply principles of data analysis to patient information and testing.

Extraocular Muscle Function

-6 directions -make an H -pause on extreme lateral --move finger in space in the shape on "H" - ask pt to follow your finger in space without moving his/her head 1) extreme right 2) to the right and upward 3) down on the right 4) without pausing in the middle to the extreme left 5) to the left and upward 6) down on the left

Equipment for Physical Exam

-An ophthalmoscope and an otoscope. If you are examining children, the otoscope should allow for pneumatic otoscopy. -A flashlight or penlight -Tongue depressors -A ruler and flexible tape measure, preferably marked in centimeters -Often a thermometer -A watch with a second hand -A sphygmomanometer -A stethoscope with the following characteristics: Gloves and lubricant for oral, vaginal, and rectal examinations -Vaginal specula and equipment for cytologic and perhaps bacteriologic study -A reflex hammer -Tuning forks, ideally one of 128 Hz and one of 512 Hz -Q-tips, safety pins, or other disposable objects for testing sensation and two-point discrimination -Cotton for testing the sense of light touch -Two test tubes (optional) for testing temperature sensation -Paper and pen or pencil, or desktop or laptop computer

Mental Health History

-Changes in attention, mood, or speech -Changes in insight, orientation, or memory -Anxiety, panic, ritualistic behavior, and phobias -Delirium or dementia -As you listen to the patient's story, you will quickly observe the patient's level of alertness and orientation, and mood, attention, and memory.While the history unfolds, you will learn about the patient's insight andjudgment, as well as any recurring or unusual thoughts or perceptions -assess level of consciousness; general appearance; mood, including depression or mania; and ability to pay attention, remember, understand, and speak -patient's responses to illness and life circumstances often tell you about insight and judgment. If you suspect a problem in orientation and memory, you can ask, "Let's see, your last clinic appointment was when ... ?" "And the date today?"

Personal and Social History

-Describes educational level, family of origin, current household, personal interests, and lifestyle -personality and interests, sources of support, coping style, strengths, and fears. -occupation and the last year of schooling; home situation and significant others; sources of stress, both recent and long-term; important life experiences, such as military service, job history, financial situation, and retirement; leisure activities; religious affiliation and spiritual beliefs; and activities of daily living (ADLs). -Baseline level of function -History includes lifestyle habits that promote health or create risk, such as exercise and diet, including frequency of exercise, usual daily food intake, dietary supplements or restrictions, and use of coffee, tea, and other caffeinated beverages, and safety measures, including use of seat belts, bicycle helmets, sunblock, smoke detectors, and other devices related to specific hazards. Include any alternative health care practices. Alcohol (quantified) - don't just write social, how many ounces quantified, 6 pack beer how much alcohol and how often, (8oz wine 3X/week) Smoking(include smokeless tobacco), pack years, year quit (if applicable) Number of packs smoked per day X years smoked = pack years If an ex-smoker, year they quit and then pack years calculated Recreational drugs Exercise (type & frequency) - what to they do, how often, duration Education - highest level Occupation: if retired, ask occupation prior to retirement - FDNY post 911 Significant Other Lives with: Marital Status:

Review of Systems

-Documents presence or absence of common symptoms related to each major body system -asking a series of questions going from "head to toe." -Start with a fairly general question -Reports intentional 10 lb weight loss over the past 6 months. Denies all the other sx (list out). Sleeps more than 8 hours a night and feels rested. -Reports sinus issues and give a little bit more information about it -Denies fever, night sweats etc -Is done at the very end of the health history. -It is a HISTORICAL review organized by body system. -It DOES NOT include any observations, that data belongs only in the physical examination section of the document. -Use the review of systems information to generate data for your history of present illness. Any information used in the history of present illness is NOT repeated in the Review of Systems section. Rather, just indicate "see hpi" to refer the reader back to where you have placed the data within the history of present illness. -MEMORIZE this list so that the questions simply "roll" off your tongue during the history portion of your assessment. -PURPOSES: To elicit any additional health problems. To review the patient's ability to self-manage health. To review patient's preventive health practices. To review patient's health practices. To elicit patient's/family's responses to illness

Genital and Rectal Exam in Women

-Examine the external genitalia, vagina, and cervix. Obtain a Pap smear. Palpate the uterus and adnexa bimanually. -The patient is supine in the lithotomy position. You should be seated during examination with the speculum, then standing during bimanual examination of the uterus, adnexa (and rectum as indicated).

appearance

-Excess clothing may reflect the cold intolerance of hypothyroidism, hide skin rash or needle marks, mask anorexia, or signal personal lifestyle preferences. Glance at the patient's shoes. Are there cut-outs or holes? Are the shoes run-down? -Cut-out holes or slippers may indicate gout, bunions, edema, or other painful foot conditions. Run-down shoes can contribute to foot and back pain, calluses, falls, and infection. Is the patient wearing unusual jewelry? Are there body piercings? -Copper bracelets are sometimes worn for arthritis. Piercing may appear on any part of the body. Note the patient's hair, fingernails, and use of cosmetics. They may be clues to the patient's personality, mood, lifestyle, and self-regard. "Grown-out" hair and nail polish can help you estimate the length of an illness. Fingernails chewed to the quick may reflect stress. -Do personal hygiene and grooming seem appropriate to the patient's age, lifestyle, occupation, and stage of life? -Unkempt appearance may be seen in depression and dementia, but this appearance must be compared with the patient's probable norm.

comprehensive assessment

-For patients you are seeing for the first time in the office or hospital, you will usually choose to conduct this. -includes all the elements of the health history and the complete physical examination • Is appropriate for new patients in the office or hospital -Provides fundamental and personalized knowledge about the patient -Strengthens the clinician-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 -source of fundamental and personalized knowledge about the patient that strengthens the clinician-patient relationship -provides a more complete basis for assessing these concerns and answering patient questions.

Talkative Patient

-Give the patient free rein for the first 5 or 10 minutes, listening closely to the conversation. -Perhaps the patient simply needs a good listener and is expressing pent-up concerns, or the patient's style is to tell stories. -Does the patient seem obsessively detailed? Is the patient unduly anxious or apprehensive? Is there flight of ideas or a disorganized thought process that suggests a thought disorder? -Focus on what seems most important to the patient. -Show your interest by asking questions in those areas. Interrupt only if necessary, but be courteous. - Learn to set limits when needed. -A brief summary may help you change the subject yet validate any concerns -If time runs out, explain the need for a second meeting. Setting a time limit for the next appointment may be helpful.

present illness

-HPI - history of present illness Amplifies the Chief Complaint; describes how each symptom developed -Includes patient's thoughts and feelings about the illness -Pulls in relevant portions of the Review of Systems, called "pertinent positives and negatives" (see p. 10) -May include medications, allergies, and habits of smoking and alcohol, which are frequently pertinent to the present illness -a complete, clear, and chronologic account of the problems prompting the patient to seek care. -onset of the problem, the setting in which it has developed, its manifestations, and any treatments -include "pertinent positives" and "pertinent negatives" from sections of the Review of Systems related to the Chief Complaint -The Present Illness should reveal the patient's responses to his or her symptoms and what effect the illness has had on the patient's life -Each symptommerits its own paragraph and a full description. -Meds, Allergies, tobacco use (pack years), alcohol and drug use -in chronologic order, starting with the current episode, then filling in relevant background information -Include SLIDTA (severity, location, influencing factors, duration, type & associated symptoms) Start with..This is a(age, race, sex) who presents today complaining of.................

Screening Mental Health Disorders

-Hypochondriacal: Whiteley Index -Alcohol and Substance Abuse: CAGE -Multidimensional: PRIME-MD (Primary Care Evaluation of Mental Disorders) for the five most common disorders in primary care: depression, anxiety, alcohol, somatoform, and eating disorders; 26-item patient questionnaire followed by clinician evaluation; takes approximately 10 minutes33 -PRIME-MD Patient Health Questionnaire, available as patient health questionnaire for self-rating; takes approximately 3 minutes23

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.

seven components of the Comprehensive Adult Health History

-Identifying Data and Source of the History; Reliability -Chief Complaint(s) -Present Illness -Past History -Family History -Personal and Social History -Review of Systems

Identifying Data

-Identifying data—such as age, gender, occupation, marital status -Source of the history—usually the patient, but can be a family member or friend, letter of referral, or the medical record -If appropriate, establish source of referral, because a written report may be needed.

Steps to Ensure Accurate Blood Pressure Measurement

-In ideal situations, instruct the patient to avoid smoking or drinking caffeinated beverages for 30 minutes before the blood pressure is measured. -Check to make sure the examining room is quiet and comfortably warm. -Ask the patient to sit quietly for at least 5 minutes in a chair with feet on the floor, rather than on the examining table. -Make sure the arm selected is free of clothing. There should be no arteriovenous fistulas for dialysis, scarring from prior brachial artery cutdowns, or signs of lymphedema (seen after axillary node dissection or radiation therapy). -Palpate the brachial artery to confirm that it has a viable pulse. -Position the arm so that the brachial artery, at the antecubital crease, is at heart level—roughly level with the 4th interspace at its junction with the sternum. -If the patient is seated, rest the arm on a table a little above the patient's waist; if standing, try to support the patient's arm at the midchest level. -If the brachial artery is 7 to 8 cm below heart level, the blood pressure will read approximately 6 cm higher; if the brachial artery is 6 to 7 cm higher, the blood pressure will read 5 cm lower.38,39.

Taking Blood Pressure

-Inflate the cuff rapidly again to the level just determined, and then deflate it slowly at a rate of about 2 to 3 mm Hg per second. Note the level at which you hear the sounds of at least two consecutive beats. This is thesystolic pressure. -Continue to lower the pressure slowly until the sounds become muffled and then disappear. To confirm the disappearance of sounds, listen as the pressure falls another 10 to 20 mm Hg. Then deflate the cuff rapidly to zero. The disappearance point, which is usually only a few mm Hg below the muffling point, provides the best estimate of true diastolic pressure in adults. -In some people, the muffling point and the disappearance point are farther apart. Occasionally, as in aortic regurgitation, the sounds never disappear. If the difference is 10 mm Hg or greater, record both figures (e.g., 154/80/68). -Read both the systolic and the diastolic levels to the nearest 2 mm Hg. Wait 2 or more minutes and repeat. Average your readings. If the first two readings differ by more than 5 mm Hg, take additional readings. -By making the sounds less audible, venous congestion may produce artificially low systolic and high diastolic pressures. -When using an aneroid instrument, hold the dial so that it faces you directly. Avoid slow or repetitive inflations of the cuff, because the resulting venous congestion can cause false readings. -Blood pressure should be taken in both arms at least once. Normally, there may be a difference in pressure of 5 mm Hg and sometimes up to 10 mm Hg. Subsequent readings should be made on the arm with the higher pressure. -Pressure difference of more than 10-15 mm Hg occurs in subclavian steal syndrome, aortic dissection

Clues to Sexual and Physical Abuse

-Injuries that are unexplained, seem inconsistent with the patient's story, are concealed by the patient, or cause embarrassment -Delay in getting treatment for trauma -History of repeated injuries or "accidents" -Presence of alcohol or drug abuse in patient or partner -Partner tries to dominate the visit, will not leave the room, or seems unusually anxious or solicitous -Pregnancy at a young age; multiple partners -Repeated vaginal infections and STIs -Difficulty walking or sitting due to genital/anal pain -Vaginal lacerations or bruises -Fear of the pelvic examination or physical contact -Fear of leaving the examination room -When you suspect abuse, it is important to spend part of the encounter alone with the patient. You can use the transition to the physical examination as a reason to ask others to leave the room. -To begin screening for child abuse, ask parents about their approach to discipline. Ask how they cope with a baby who will not stop crying or a child who misbehaves: "Most parents get very upset when their baby cries (or their child has been naughty). How do you feel when your baby cries?" "What do you do when your baby won't stop crying?" "Do you have any fears that you might hurt your child?"

Closing the Interview

-Let the patient know that the end of the interview is approaching to allow time for any final questions. -"We need to stop now. Do you have any questions about what we've covered?" -As you close, reviewing future evaluation, treatments, and follow-up is helpful. -ask the patient to relate the plan back to you.[33],[34] -The patient should have a chance to ask any final questions; however, these few minutes are not the time to bring up new topics. - If this happens and the concern is not life threatening, simply assure the patient of your interest and make plans to address the problem at a future time. "That knee pain sounds concerning. Why don't you make an appointment for next week so we can discuss it?" -Reaffirming your on-going commitment to the patient's health is always appreciated and transmits caring and esteem.

Past Health History

-Lists childhood illnesses -Lists adult illnesses with dates for at least four categories: medical, surgical, obstetric/gynecologic, and psychiatric -Includes health maintenance practices such as immunizations, screening tests, lifestyle issues, and home safety -; number and gender of sexual partners; and risky sexual practices

Four Steps to Promote Optimal Weight and Nutrition

-Measure BMI and waist circumference; identify risk of overweight and obesity and establish additional risk factors for heart disease and obesity-related diseases. 1. Assess dietary intake. 2. Assess the patient's motivation to change. 3. Provide counseling about nutrition and exercise. Experts note that patients often have a "dream weight" as much as 30% below initial body weight.[1] However, a 5% to 10% weight loss is more realistic and still proven to reduce risk of diabetes and other obesity-associated health problems. -hitting a plateau due to feedback physiologic systems that maintain body homeostasis; poor adherence to diet due to increasing hunger over time as weight declines; and inhibition of leptin, a protein cytokine secreted and stored in fat cells that modulates hunger -A safe goal for weight loss is ½ to 2 pounds per week.

identifiers for mental health screening

-Medically unexplained physical symptoms—more than half indicate a depressive or anxiety disorder -Multiple physical or somatic symptoms or "high symptom count" -High severity of the presenting somatic symptom -Chronic pain -Symptoms for more than 6 weeks -Physician rating as a "difficult encounter" -Recent stress -Low self-rating of overall health -High use of health care services -Substance abuse

National Institute of Alcohol Abuse and Alcoholism Safe Drinking Levels for Adults

-Men: ≤14 drinks/week and ≤4 drinks on 1 occasion -Women: ≤7 drinks/week and ≤3 drinks on 1 occasion -NIAAA recommends ≤1 drink/day for people ≥65 years old -1 drink is defined as 12 ounces of beer, 5 ounces of wine, or 1.5 ounces of spirits

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 ("Which of the following words best describes your pain: aching, sharp, pressing, burning, shooting, or something else?" ) -Clarifying what the patient means -Encouraging with continuers - Pausing with a nod of the head or remaining silent, yet attentive and relaxed, is a cue for the patient to continue. Leaning forward, making eye contact, and using phrases like "Mm-hmm," or "Go on," or "I'm listening -Using echoing - simple repetition of the patient's last words -proceed from general to specific

Seven Key Attributes to a Symptom

-OLD CARTS, or Onset, Location, Duration, Character,Aggravating/Alleviating Factors, Radiation, and Timing, and -OPQRST, or Onset, Palliating/Provoking Factors, Quality, Radiation,Site, and Timing -1. Location. Where is it? Does it radiate? -2. Quality. What is it like? -3. Quantity or severity. How bad is it? (For pain, ask for a rating on a scale of 1 to 10.) -4. Timing. When did (does) it start? How long does it last? How often does it come? -5. Setting in which it occurs. Include environmental factors, personal activities, emotional reactions, or other circumstances that may have contributed to the illness. -6. Remitting or exacerbating factors. Is there anything that makes it better or worse? -7. Associated manifestations. Have you noticed anything else that accompanies it? -establish the sequence and time course

General Survey

-Observe the patient's general state of health, height, build, and sexual development. Obtain the patient's weight. Note posture, motor activity, and gait; dress, grooming, and personal hygiene; and any odors of the body or breath. -Watch the patient's facial expressions and note manner, affect, and reactions to people and things in the environment. Listen to the patient's manner of speaking and note the state of awareness or level of consciousness. -height and weight, blood pressure, posture, mood and alertness, facial coloration, dentition and condition of the tongue and gingiva, color of the nail beds, and muscle bulk -height, weight, BMI, and risk for obesity -Does the patient hear you when greeted in the waiting room or examination room? Rise with ease? Walk easily or stiffly? If hospitalized when you first meet, what is the patient doing—sitting up and enjoying television?... or lying in bed?... What do you see on the bedside table—a magazine?... a flock of "get well" cards?... a Bible or a rosary?... an emesis basin?... or nothing at all? -Vital signs, b/p in each arm, HR, Temp. Ht/Wt/BMI : This is a well developed, well nourished, (race, sex) who appears stated age. Recent and remote memory intact. (No MMSE, you'll know by now based on responses) Speech clear, dressed appropriately for the season. Answers congruent with questions. In no acute distress. -If they appear older or younger than their stated age, write that. -North face parka, ugg boots, gloves in middle of June - problem -Answers congruent with questions -In no acute distress BP (seated, rt arm, lt arm) P R T WT HT BMI Include other specifics that might be necessary (i.e orthostatic BP, pulse ox This is a well developed, well nourished, (race, sex) who appears stated age. Recent and remote memory intact. Speech clear, dressed appropriately for the season. Answers congruent with questions. In no acute distress.(emaciated, cachexia, malnourished, disoriented, in acute respiratory, cardiac, etc. distress)

Family History

-Outlines or diagrams age and health, or age and -cause of death, of siblings, parents, and grandparents -Documents presence or absence of specific illnesses in family, such as hypertension or coronary artery disease -outline or diagram the age and health, or age and cause of death, of each immediate relative, including parents, grandparents, siblings, children, and grandchildren. Review each of the following conditions and record whether they are present or absent in the family:hypertension, coronary artery disease, elevated cholesterol levels, stroke, diabetes, thyroid or renal disease, arthritis, tuberculosis, asthma or lung disease, headache, seizure disorder, mental illness, suicide, substance abuse, and allergies, as well as symptoms reported by the patient. Ask about any history of breast, ovarian, colon, or prostate cancer. Ask about any genetically transmitted diseases. -should be modified according to age of patient Example Mother: 55 alive, DMT2, HTN Father: deceased age 50 MI Siblings Maternal grandmother Maternal grandfather Paternal grandmother Paternal grandfather Include children in family history -Family history should be modified according to age of patient. For example, in a geriatric patient asking for for the health of their grandparents is non-productive.

Depression

-Over the past 2 weeks, have you felt down, depressed, or hopeless? -Over the past 2 weeks, have you felt little interest or pleasure in doing things (anhedonia)? low self-esteem, loss of pleasure in daily activities (anhedonia), sleep disorders, and difficulty concentrating or making decisions. Watch carefully for depression symptoms in vulnerable patients, especially those who are young, female, single, divorced or separated, seriously or chronically ill, bereaved, or have other psychiatric disorders, including substance abuse. Prior history or family history of depression also place patients at risk. Depression is twice as common in women and is a frequent companion of chronic medical illness. -suicide rates among patients with major depression are eight times higher than in the general population. • Do you get pretty discouraged (or depressed or blue)? • How low do you feel? • What do you see for yourself in the future? • Do you ever feel that life isn't worth living? Or that you would just as soon be dead? • Have you ever thought of doing away with yourself? • How did (do) you think you would do it? • What do you think would happen after you were dead?

Crying Patient

-Pausing, gentle probing, or responding with empathy gives the patient permission to cry. -Offer a tissue and wait for the patient to recover

Anorexia Nervosa

-Refusal to maintain minimally normal body weight (or BMI above 17.5 kg/m2) -Afraid of appearing fat -Frequently starving but in denial; lacking insight -Often brought in by family members -May present as failure to make expected weight gains in childhood or adolescence, amenorrhea in women, loss of libido or potency in men -Associated with depressive symptoms such as depressed mood, irritability, social withdrawal, insomnia, decreased libido -Additional features supporting diagnosis: self-induced vomiting or purging, excessive exercise, use of appetite suppressants and/or diuretics -Biologic complications -Neuroendocrine changes: amenorrhea, increased corticotropin-releasing factor, cortisol, growth hormone, serotonin; decreased diurnal cortisol fluctuation, luteinizing hormone, follicle-stimulating hormone, thyroid-stimulating hormone -Cardiovascular disorders: bradycardia, hypotension, arrhythmias, cardiomyopathy -Metabolic disorders: hypokalemia, hypochloremic metabolic alkalosis, increased BUN, edema -Other: dry skin, dental caries, delayed gastric emptying, constipation, anemia, osteoporosis

Bulimia Nervosa

-Repeated binge eating followed by self-induced vomiting, misuse of laxatives, diuretics or other medications, fasting, or excessive exercise -Often with normal weight -Overeating at least twice a week during 3-month period; large amounts of food consumed in short period (∼2 hrs) -Preoccupation with eating; craving and compulsion to eat; lack of control over eating; alternating with periods of starvation -Dread of fatness but may be obese -Subtypes of -Purging: bulimic episodes accompanied by self-induced vomiting or use of laxatives, diuretics, or enemas -Nonpurging: bulimic episodes accompanied by compensatory behavior such as fasting, exercise, but without purging -Biologic complications See changes listed for anorexia nervosa, especially weakness, fatigue, mild cognitive disorder; also erosion of dental enamel, parotitis, pancreatic inflammation with elevated amylase, mild neuropathies, seizures, hypokalemia, hypochloremic metabolic acidosis, hypomagnesemia

Sodium

-Sodium loading suppresses the renin-angiotensin-aldosterone system by inhibiting renin release and "increases oxidative stress and endothelial dysfunction and promotes ... fibrosis in the heart, kidneys, and arteries ... resulting in cardiac and vascular remodeling."

Strategies for Weight Loss

-The most effective diets combine realistic weight loss goals with exercise and behavioral reinforcements. -Encourage patients to walk 30 to 60 minutes 5 or more days a week, or a total of at least 150 minutes a week. Pedometers help patients match distance in steps with calories burned. -The total calorie goal, usually 800 to 1,200 calories a day, is more important than type of diet. Since many types of diets have been studied and appear to confer similar results, support the patient's preferences as long as they are reasonable.11,12 Consider low-fat diets for those with dyslipidemias. -Encourage behavioral habits that have been shown to assist weight loss such as portion-controlled meals, meal planning, food diaries, and activity records. -Follow professional guidelines for pharmacologic therapies in patients at high weights and morbidities who do not respond to conventional treatment.13

Exploring the Patients Perspective (FIFE)

-The patient's Feelings, including fears or concerns, about the problem -The patient's Ideas about the nature and the cause of the problem -The effect of the problem on the patient's life and Function -The patient's Expectations of the disease, of the clinician, or of health care, often based on prior personal or family experiences Clues: Direct statement(s) by the patient of explanations, emotions, expectations, and effects of the illness17 -Expression of feelings about the illness without naming the illness -Attempts to explain or understand symptoms -Speech clues (e.g., repetition, prolonged reflective pauses) -Sharing a personal story -Behavioral clues indicative of unidentified concerns, dissatisfaction, or unmet needs such as reluctance to accept recommendations, seeking a second opinion, or early return appointment -A mnemonic for responding to emotional cues is NURes: Naming—"That sounds like a scary experience";Understanding or legitimization—"It's understandable that you feel that way"; and Respecting—"You've done better than most people would with this."

Sensitive Topics

-The single most important rule is to be nonjudgmental. The clinician's role is to learn about the patient and help the patient achieve better health. Disapproval of behaviors or elements in the health history will only interfere with this goal. -Explain why you need to know certain information. This makes patients less apprehensive. For example, say to patients, "Because sexual practices put people at risk for certain diseases, I ask all of my patients the following questions." -Find opening questions for sensitive topics and learn the specific kinds of information needed for your assessments. -Finally, consciously acknowledge whatever discomfort you are feeling. Denying your discomfort may lead you to avoid the topic altogether.

Posture/Activity

-There is a preference for sitting upright in left-sided heart failure and for leaning forward with arms braced in chronic obstructive pulmonary disease -Anxious patients appear agitated and restless. Patients in pain often avoid movement. -Look for tremors, other involuntary movements, or paralysis

coarctation of the aorta

-To detect this, make two further blood pressure measurements at least once in every hypertensive patient: -results from narrowing of the thoracic aorta, usually proximal but sometimes distal to the left subclavian artery. •Compare blood pressures in the arms and legs. In normal patients, the systolic blood pressure should be 5 to 10 mm higher in the arms. -this and occlusive aortic disease are distinguished by hypertension in the upper extremities and low blood pressure in the legs, and by diminished or delayed femoral pulses.[47] -Compare the volume and timing of the radial or brachial and femoral pulses. Normally, volume is equal and the pulses occur simultaneously. -To determine blood pressure in the leg, use a wide, long thigh cuff that has a bladder size of 18 × 42 cm, and apply it to the midthigh. -Center the bladder over the posterior surface, wrap it securely, and listen over the popliteal artery. -If possible, the patient should be prone. -Alternatively, ask the supine patient to flex one leg slightly, with the heel resting on the bed.

common chronic disorders

-Unexplained conditions lasting beyond 6 weeks - should prompt screening for depression, anxiety, or both -two-tier approach: brief screening questions with high sensitivity and specificity for patients at risk, followed by more detailed investigation when indicated.

Finding auscultatory gap

-With the arm at heart level, center the inflatable bladder over the brachial artery. The lower border of the cuff should be about 2.5 cm above the antecubital crease. Secure the cuff snugly. Position the patient's arm so that it is slightly flexed at the elbow. -A loose cuff or a bladder that balloons outside the cuff leads to falsely high readings. -To determine how high to raise the cuff pressure, first estimate the systolic pressure by palpation. As you feel the radial artery with the fingers of one hand, rapidly inflate the cuff until the radial pulse disappears. Read this pressure on the manometer and add 30 mm Hg to it. Use of this sum as the target for subsequent inflations prevents discomfort from unnecessarily high cuff pressures. It also avoids the occasional error caused by an auscultatory gap—a silent interval that may be present between the systolic and the diastolic pressures. -An unrecognized one may lead to serious underestimation of systolic pressure (150/98 in the example below) or overestimation of diastolic pressure. •Deflate the cuff promptly and completely and wait 15 to 30 seconds. •Now place the bell of a stethoscope lightly over the brachial artery, taking care to make an air seal with its full rim. Because the sounds to be heard, the Korotkoff sounds, are relatively low in pitch, they are generally better heard with the bell. -If you find this, record your findings completely (e.g., 200/98 with an auscultatory gap from 170-150). -associated with arterial stiffness and atherosclerotic disease.[40]

Ethics

-a set of principles crafted through reflection and discussion to define right and wrong. -guide our professional behavior, are neither static nor simple, but several principles have guided clinicians throughout the ages. -body of ethics has been termed "principalism."

Personality Disorder

-an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual's culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment -dysfunctional interpersonal coping styles that disrupt and destabilize their relationships -co-occur at high frequencies with alcohol and substance abuse and with the Axis I disorders of depression, anxiety disorders, bipolar disorder, ADHD, autism spectrum disorders, anorexia nervosa, bulimia nervosa, and schizophrenia. -co-existing mood, anxiety, and substance abuse disorders. Presenting symptoms overlap with depression, anxiety, substance abuse, and eating disorders, which complicate diagnosis impulsive—more than 50% attempt suicide and cut or injure themselves. -Recurrent suicidal threats or acts, combined with fear of abandonment, strongly suggest the diagnosis.[41] -More than half lose their jobs because of interpersonal problems, and roughly one-third experience sexual abuse. Patients often report feeling depressed and empty, with mood swings that spiral out of control leading to feelings of rage, sadness, and anxiety. - To clinicians, these patients may appear demanding, disruptive, or manipulative

Reflexes

-biceps - hit your thumb over tendon -> flexion of elbow -triceps - hitting elbow -brachioradialis - above wrist -patellar reflex - below knee, feet off ground -achilles reflex - passively dorsiflex foot, strick achilles, planter flex in hand relax them, talk to them while doing (tests bilaterally and elicit using maneuvers if necessary) Biceps - arm relaxed bent and laying on top of leg, press finger by joint and hit the upper part of arm (inside) - arm partially flexed at elbow with palm down, place your thumb or finger firmly on the biceps tendon and strike with hammer so blow is aimed through your digit toward bicepts tendon. (p. 726) Triceps - arm bent with elbow to the side, arm hanging down tap top of elbow. "Extend your arm like an L". - Flex the pts arm at the elbow, with palm toward the body, pull it slightly across the chest, strike the tricept tendon above the elbow with a blow from directly behind it. Brachioradialis - tap over vein that lines radial artery about 3 inches up from the hand. strike the radius with the flat edge about 1-2 inches above the wrist Patellar reflex - tap on front of knee, just below the patella (p.728) Achilles reflex - tap on back of ankle, strike with flat part of hammer DON&#39;T DO BABISKINI FOR OSCE PRACTICE OR FINAL

source of history or referral

-can be the patient, a family member or friend, an officer, a consultant, or the medical record. -Designating the source of referral helps you to assess the type of information provided and any possible biases.

Phys Exam: Ears

-examine ears BIL with otoscope - properly maniuplate ear, turn head opposite side, pull ear up and back and out -otoscope must go in ear -tests for acuity (whisper, finger rub, watch tick) in both ears -occlude ear not being tested, stand 2 feet away and whisper 2 syllable word -Examines ears bilaterally with otoscope- properly manipulating ear: (make sure you put a cover on it) ask pt to tilt head to opposite side tilt ear up (grab tip of ear) and out and look into tympanic membrane -Tests for auditory acuity (whisper, finger rub, watch tick, etc. in both ears) (ask pt to occlude one ear and ask them if they can hear your fingers rubbing) - whispered voice test = stand 2 ft behind the pt. Occlude the nontest ear with finger and gently rub the tragus in circular motion to prevent transfer of sound to nontest ear. Exhale a full breath before whispering - whisper a combination of three numbers and letters - ex. 3 U 1 and use a different combination in the other ear.

Convergence

-get close to nose, pupils constrict, eyes come together -bring your finger close to the pt's nose and then pull away and observe for this and accommodation

Anxiety

-include generalized anxiety disorder, social phobia, panic disorder, posttraumatic stress disorder, and acute stress disorder. -Over the past 2 weeks, have you been feeling nervous, anxious, or on edge? -Over the past 2 weeks, have you been unable to stop or control worrying? -Over the past 4 weeks, have you had an anxiety attack—suddenly feeling fear or panic?

Mood Disorders

-may be either depressive or bipolar. -A bipolar disorder can include manic, hypomanic, or depressive features. -Four types of episodes are combined in different ways in diagnosis of mood disorders. -A major depressive disorder includes only one or more major depressive episodes. -A bipolar I disorder includes one or more manic or mixed episodes, usually accompanied by major depressive episodes. -A bipolar II disorder includes one or more major depressive episodes accompanied by at least one hypomanic episode. -Dysthymic and cyclothymic disorders are chronic and less severe conditions that do not meet the criteria of the other disorders. -Mood disorders due to general medical conditions or substance abuse are classified separately. include major depression, dysthymic disorder, and bipolar disorder

Phys Exam: Arms

-inspect and palpate both arms including joints -inspect and palpate both hands, fingers, and fingernails -tests shoulder strength - flexion and extension against resistance -tests flexion/extension of elbows against resistance -tests flexion/extension of wrists against resistance -tests hand muscles (grip strength, interosseious muscles - finger spread (outside), break ring (try to break it) of thumb and index finger) (palapte radial pulses and axillary nodes) http://www.learnerstv.com/video/Free-video- Lecture-1638- Medical.htm http://www.learnerstv.com/video/Free-video- Lecture-1090- Medical.htm http://www.learnerstv.com/video/Free-video- Lecture-1091- Medical.htm Palpates both arms including joints - bend arm to about 70 degrees and palpate process for tenderness or effusion (p. 627). Inspects and palpates both hands, fingers, and fingernails - palpate joints in fingers and wrist p. 630 Tests shoulder strength- flexion and extension against resistance - Flexion= "Raise your arms in front of you and overhead" Extension = "Raise your arms behind you" flexion is pt raising straight arm all the way up with palm down, extension is brining the straight arm all the way down towards his back/ behind his body. p.620 Tests flexion/extension of elbows against resistance - Flexion = "Bend your elbow" Extension = "Straighten your elbow" Supination = "Turn your palms up as if carrying a bowl of soup" Pronation = "Turn your palms down" Tests flexion/extension of wrists against resistance : flexion is asking person to bend both wrists downward, extension is lifting both wrist upwards Tests hand muscles (grip strength, interosseous muscles- finger spread, break ring of thumb and index finger), have person spread all 5 fingers wide as you push them inward using your index fingers. Hand grip tested using index and middle finger asking pt to hold on

Phys Exam: Mouth

-inspects lips, gums, tongue, and teeth (opens mouth, makes an effort to move mucosa out of the way) -inspects floor of mouth and base of tongue (lift tongue to roof of mouth) -inspect posterior pharynx (looks to back of mouth and throat) -observes elevation of palate (roof of mouth) by having patient say ahh - uvula and soft palate should rise -tongue blide and light - teeth sides of mouth, gums, lift tongue, buckle mucosa, tongue sides, say ahh -Inspects lips, gums, tongue, and teeth (opens mouth, makes an effort to move mucosa out of the way, etc.) using tongue depressor and light. Look at dorsal and under surface of tongue. Tap on a few teeth for looseness or use your gloved thumb and index finger to check for looseness. -Inspects floor of mouth and base of tongue (student or patient lifts tongue to roof of mouth) -Inspects posterior pharynx (looks to back of mouth and throat) : ask pt to put out his or her tongue. inspect for symmetry (CN XII - hypoglossal nerve) . Put tongue blade far enough to visualize pharynx but not so far to cause gagging. Ask pt to say "AH" and note rise of soft palate - CN X (vagal nerve) (saying "ah" replaces gag) -Observes elevation of palate (roof of mouth) by having the patient say "aah" (CN X) don't gag them

Somatoform Disorder

-lacks an adequate medical or physical explanation -meets DSM-IV-TR diagnostic criteria -anxiety and depression, the most common mental health disorders in the general population, -Two-thirds of patients with depression, for example, present with physical complaints, and half report multiple unexplained or somatic symptoms -functional syndromes have been shown to "frequently co-occur and share key symptoms and selected objective abnormalities -a generalized warning sign of underlying psychological distress, of which depression is an advanced manifestation."

Biases

-the attitudes or feelings that we attach to perceived differences.

Phys Exam: Legs

-palpate both legs including joints -palpate lower extremity pulses (dorsalis pedis - top of foot, posterior tibial - medial malleolus) -tests flexion/extension of thighs against resistance - push up and down -test flexion/extention of knee against resistance - up and back -test flexion/extension of ankle against resistance - dorsi and plantar flexion -check for leg edema (press finger of pretibila area) -Palpates both legs including joints - pt laying down, palpate femur bone, have patient bend knee and palpate trochanter head, down the leg/medial thigh and the bones of the knee. Using thumbs, palpate anterior aspect of each ankle joint, feel along Achilles tendon, palpate heel. (p. 660) Palpates lower extremity pulses (dorsalis pedis and posterior tibial) - on top of foot and behind each ankle Tests flexion/extension of thighs against resistance - person sitting up with knees bent, ask pt to push thigh up from seat as you push down on leg . Or pt laying down, ask pt to light thigh up from table while you push leg down above the knee (p. 713) Tests flexion/extension of knee against resistance : extension is have pt sitting on table, extend leg outward and press down on leg (tibia) 3 times while asking pt to resist against your push. Flexion is asking pt to bend knee in and place foot on table. Then have pt push up on your hand as you press down on tibia, and then push back as you hold the back of leg Tests flexion/extension of ankle against resistance : have pt flex/bend their knee, have pt bend foot upward and then downward. Checks for leg edema (presses finger on pretibial area)

focused or problem-oriented assessment

-particularly for patients you know well who are returning for routine office care or for patients with specific "urgent care" concerns like sore throat or knee pain -Is appropriate for established patients, especially during routine or urgent care visits -Addresses focused concerns or symptoms -Assesses symptoms restricted to a specific body system -Applies examination methods relevant to assessing the concern or problem as precisely and carefully as possible

Opthalmoscopic Exam

-set 0 diapters, adjust dial according, 0 is normal -use small round white beam of light and get close -ask patient to look directly at light, open door a little and shut lights off -red reflex, not a dilated exam, looking to see vessels, optic nerve and macula -dim lights before exam -hold properly and use index fingers to switch lenses -examine patients right eye with your right eye and right hand, LLL -inspect -Dim lights before opthalmoscopic examination : switch on the opthalmoscope light and turn the lens disc until you see the large round beam of white light. Dim the lights in the room* Shine the light on the back of your hand to check the type of light. -Turn the lens disc to the 0 diopter. Keep your finger on the edge of the lens disc so you can turn the disc to focus the lens when you examine the fundus -Holds ophthalmoscope properly and uses index finger to switch lens -Examine patient's right eye with right eye and left eye with left eye: hold ophthalmoscope in your right hand and use your right eye to examine the patient's right eye; hold the scope in your left hand and use to examine the pt's left eye. - Inspect with opthalmoscope - Ask patient to look directly at light (observe macula) (p.232)

pulseless or unable to get BP

-shock -In rare cases, patients are pulseless due to occlusive disease in the arteries of all the limbs from Takayasu arteritis, giant cell arteritis, or atherosclerosis. -you may be able to estimate the systolic pressure by palpation. Alternative methods such as Doppler techniques or direct arterial pressure tracings may be necessary. -To intensify Korotkoff sounds, one of the following methods may be helpful: -Raise the patient's arm before and while you inflate the cuff. Then lower the arm and determine the blood pressure. -Inflate the cuff. Ask the patient to make a fist several times, and then determine the blood pressure.

Brief Action Planning

-structured around three core questions: ____ Elicit person's preferences/desires for behavior change. - "Is there anything you would like to do for your health in the next week or two?" ___ What? ___ Where? ___ When? ___ How often? ___ Elicit commitment statement - "Just to make sure we understand each other, would you please tell me back what you've decided to do?" ____ Evaluate confidence. - "I wonder how confident you feel about carrying out your plan. Considering a scale of 0 to 10, where '0' means you are not at all confident and '10' means you are very confident, about how confident do you feel?" - (If the confidence level is less than 7, problem solve overcoming barriers or adjusting plan. "5 is great. A lot higher than zero. I wonder if there is any way we might modify the plan to get you to a level of '7' or more? -Maybe we could make the goal a little easier, or you could ask for help from a friend or family member, or even think of something else that might help you feel more confident?" ____ Arrange a follow-up (or accountability). "Sounds like a plan that's going to work for you. When would you like to check in with me to review how you're doing with your plan?"

Phys Exam: Nose

-tests for nasal patency both sides (pinches off one side a time) occlude 1 nostril and blow down -inspects nasal vaults with nasal speculum on otoscope - get a new cover! -palpates/percusses frontal and maxillary sinus for tenderness - above eyebrow and cheek/nose area Tests for nasal patency both sides (pinches off one side at a time) - ask pt to occlude one nostril and ask them to blow down or breath in -Inspects nasal vaults with nasal speculum on otoscope : don't forget to change cap on Otoscope from checking ears! *(do a miss piggy and check each nostril) change caps between ears or nostril -Palpates/percusses frontal and maxillary sinus for tenderness - ask if any pain or tenderness when I pressed. : Press up on the frontal sinuses from under the bony brows, avoiding pressure on the eyes. Then press up on the maxillary sinuses.

Decision Making Capacity

-the ability to understand information related to health, to make medical choices based on reason and a consistent set of values, and to declare preferences about treatments -Mini-Mental State Examination and the MacArthur Competence Assessment Tool for Treatment -psychiatric consultation is usually helpful -Consider dividing the interview into two segments-one with the patient and the other with both the patient and a second informant. -you will often need to find a surrogate informant or decision maker to assist with the history and decision making. -Check whether the patient has a durable power of attorney for health careor a health care proxy. -If not, a spouse or family member, who can represent the patient's wishes, can fill this role in many cases.

somatic symptoms

30% of symptoms are medically unexplained. -Some of them involve single complaints that appear to persist longer than others, for example, back pain, headache, or musculoskeletal complaints. -Others occur in clusters presenting as functional syndromes, such as irritable bowel syndrome, fibromyalgia, chronic fatigue, temporomandibular joint disorder, and multiple chemical sensitivity. -When patients exhibit physical symptoms that are not fully explained by a medical condition, the effects of substance abuse, or other mental health disorders, consider the diagnosis of somatoform disorder, -pain from headache, backache, or musculoskeletal conditions; gastrointestinal symptoms; sexual or reproductive symptoms; and neurologic symptoms such as dizziness or loss of balance

Echolalia

Repetition of the words and phrases of others

Language

A complex symbolic system for expressing, receiving, and comprehending words; as with consciousness, attention, and memory, language is essential for assessing other mental functions

Dysthymic Disorder

A depressed mood and symptoms for most of the day, for more days than not, over at least 2 years (1 year in children and adolescents). Freedom from symptoms lasts no more than 2 months at a time.

Manic Episode

A distinct period of abnormally and persistently elevated, expansive, or irritable mood must be present for at least a week (any duration if hospitalization is necessary). During this time, at least three of the symptoms listed below have been persistent and significant. (Four of these symptoms are required if the mood is only irritable.) Inflated self-esteem or grandiosity Decreased need for sleep (feels rested after sleeping 3 hours) More talkative than usual or pressure to keep talking Flight of ideas or racing thoughts Distractibility Increased goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation Excessive involvement in pleasurable high-risk activities (buying sprees, foolish business ventures, sexual indiscretions) The disturbance is severe enough to impair social or occupational functions or relationships. It may necessitate hospitalization for the protection of self or others. In severe cases, hallucinations and delusions may occur.

Mood

A more sustained emotion that may color a person's view of the world (affect is to mood as weather is to climate) How did you feel about that?", for example, or, more generally, "How is your overall mood?" The reports of relatives and friends may be of great value. Moods include sadness and deep melancholy; contentment, joy, euphoria, and elation; anger and rage; anxiety and worry; and detachment and indifference. What has the patient's mood been like? How intense has it been? Has it been labile or unchanging? How long has it lasted? Is it appropriate to the patient's circumstances? In case of depression, have there also been episodes of an elevated mood, suggesting a bipolar disorder?

Panic Disorder

A panic disorder is defined by recurrent, unexpected panic attacks, at least one of which has been followed by a month or more of persistent concern about further attacks, worry over their implications or consequences, or a significant change in behavior in relation to the attacks. A panic attack is a discrete period of intense fear or discomfort that develops abruptly and peaks within 10 minutes. It involves at least four of the following symptoms: (1) palpitations, pounding heart, or accelerated heart rate; (2) sweating; (3) trembling or shaking; (4) shortness of breath or a sense of smothering; (5) a feeling of choking; (6) chest pain or discomfort; (7) nausea or abdominal distress; (8) feeling dizzy, unsteady, lightheaded, or faint; (9) feelings of unreality or depersonalization; (10) fear of losing control or going crazy; (11) fear of dying; (12) paresthesias (numbness or tingling); (13) chills or hot flushes. Panic disorder may occur with or without agoraphobia.

Addiction

A primary, chronic, neurobiologic disease, with genetic, psychosocial, and environmental factors influencing its development and manifestations. It is characterized by behaviors that include one or more of the following: impaired control over drug use, compulsive use, continued use despite harm, and craving.

Feelings of Depersonalization

A sense that one's self is different, changed, or unreal, or has lost identity or become detached from one's mind or body

Compulsions

Repetitive behaviors or mental acts that a person feels driven to perform in order to produce or prevent some future state of affairs, although such expectations are unrealistic

Female Genitalia ROS

Age at menarche, regularity, frequency, and duration of periods, amount of bleeding; bleeding between periods or after intercourse, last menstrual period, dysmenorrhea, premenstrual tension. Age at menopause, menopausal symptoms, postmenopausal bleeding. If the patient was born before 1971, exposure to diethylstilbestrol (DES) from maternal use during pregnancy (linked to cervical carcinoma). Vaginal discharge, itching, sores, lumps, sexually transmitted infections and treatments. Number of pregnancies, number and type of deliveries, number of abortions (spontaneous and induced), complications of pregnancy, birth-control methods. Sexual preference, interest, function, satisfaction, any problems, including dyspareunia. Concerns about HIV infection.

Phys Exam: Neuro

Alert and Oriented x3 Memory (recent and remote) intact Appropriate behavior and speech Cranial Nerves 1-12 grossly intact 1-identifies alcohol 2-vision 20/20 both eyes color intact, visual fields by gross confront. intact. 3,4,6,- EOM intact, no ptosis, nystagmus, PERRLA 5-sensation intact, jaw closure normal (palpate clenched masseter muscles and test facial sensation BIL - upper middle and lower - using qtip close eyes do you feel?) 7-face symmetrical, no weakness - tests upper (raise eyebrows or wrinkles forehead) and lower (smile or puff checks) 8-hearing intact, whisper heard bilaterally. Weber - no lateralization, Rinne- AC>BC 9,10-swallow and gag reflex intact, uvula rises in midline on phonation. - (ask about gag, say ahh) 11-head movement and shoulder shrug normal - (head rotation against resistance and shoulder shrug against resistance) 12-tongue protrudes in midline, no tremor (observe midline protrustion of tongue) Coordination intact, Romberg negative, gait normal Motor function intact (no weakness tremors, atrophy) Sensory function intact - Light touch, pinprick, vibratory sense (128 or 256 cps) Reflexes 2+/4+ intact throughout Plantars downgoing bliaterally Cerebellar - tests rapid alternating movement - hands, slap lap, back and front of hand -tests finger to nose BIL - stretch arms out close eyes and touch nose OR touch your nose touch my finger and move it around to diff areas -tests heel to shin (knee to ankle) - take foot and run it down opposite leg -observes gait - ataxic, staggering -observe tandem gate (heel to toe) -Tests rapid alternating movements- hands flipping back and forth on tights looking for balance. - show pt how to strike one hand on the thigh, raise the hand, turn it over, and then strike the back of the hand down on the same place. urge pt to repeat these alternating movements as rapidly as possible Tests finger-to- nose bilaterally - touch their nose touch my finger in different directions Tests heel-to- shin (knee to ankle) - ask pt to place one heel on the opposite knee, and then run it down the shin to the big toe. Repeat on other side. Performs Romberg test - close their eyes when standing - pt should be able stand for 20 secs, legs and feet together, arms straight down on each side Observes gait - please walk across the room Observes tandem gait (heel to toe) - DWI test, "please walk heel-to- toe in a straight line" Sensory: -tests light touch and light pain (sharp vs dull) in both hands or feet - close eyes, distal to proximal, keep going up arm, feel sensation -tests position sense or vibration sense in both feet or hands - close eyes lift your finger up and down or toes or set tuning fork in motion, hold from stem on bony area of finger, tell me when you feel, tell me when it stops -Tests light touch and light pain (sharp vs. dull) in both feet or both hands (using cotton tip - work up from fingers to up arm - sharp or dull?) Tests position sense (finger) or vibration sense in both feet or both hands - 128 tuning fork - set it in motion - place tunning fork on finger or foot - do you feel it vibrate - tell me when it stops (you stop it by holding). Check at least twice in each hand and foot - if abnormal move up the arm - Also move finger up and down - "is your finger up or down?" with eyes closed (proprioception) p. 721

Flight of Ideas

An almost continuous flow of accelerated speech in which a person changes abruptly from topic to topic. Changes are usually based on understandable associations, plays on words, or distracting stimuli, but the ideas do not progress to sensible conversation.

sexual history

An orienting sentence or two is often helpful. "To assess your risk for various diseases, I need to ask you some questions about your sexual health and practices" or "I routinely ask all patients about their sexual function." For more specific complaints you might state, "To figure out why you have this discharge and what we should do about it, I need to ask some questions about your sexual activity." Try to be matter-of-fact in your style; the patient will be likely to follow your lead. -ask about specific sexual behaviors as well as satisfaction with sexual function. -"When was the last time you had intimate physical contact with someone?" Did that contact include sexual intercourse?" Using the term "sexually active" can be ambiguous. Patients have been known to reply, "No, I just lie there." -"Do you have sex with men, women, or both?" Individuals may have sex with persons of the same gender, yet not consider themselves gay, lesbian, or bisexual. Some gay and lesbian patients have had sex with the opposite gender. Your questions should always be about the behaviors. -"How many sexual partners have you had in the last 6 months? In the last 5 years? In your lifetime?" Again, these questions give the patient an easy opportunity to acknowledge multiple partners. Ask also about routine use of condoms. "Do you always use condoms?" -It is important to ask all patients, "Do you have any concerns about HIV infection or AIDS?", since infection occurs even in the absence of risk factors.

Dramatic, Emotional or Erratic Disorders

Antisocial - Disregard for the law and the rights of others; a defect in the experience of compunction or remorse for harming others Borderline - Instability in interpersonal relationships, self-image and affective regulation; impulsivity Histrionic - Emotional overreactivity, theatrical behavior, and seductiveness; attention-seeking behavior Narcissistic - Persisting grandiosity, need for admiration and lack of empathy for others

Anxieties

Apprehensions, fears, tensions, or uneasiness that may be focused (phobia) or free-floating (a general sense of ill-defined dread or impending doom)

mental illness

Ask open-ended questions initially. "Have you ever had any problem with emotional or mental illnesses?" Then move to more specific questions such as "Have you ever visited a counselor or psychotherapist?" "Have you ever been prescribed medication for emotional issues?" "Have you or has anyone in your family ever been hospitalized for an emotional or mental health problem?" -Be sensitive to reports of mood changes or symptoms such as fatigue, unusual tearfulness, appetite or weight changes, insomnia, and vague somatic complaints. Two opening screening questions for depression are: "Over the past 2 weeks, have you felt down, depressed, or hopeless?" and "Over the past 2 weeks, have you felt little interest or pleasure in doing things?" -If the patient seems depressed, always ask about suicide: "Have you ever thought about hurting yourself or ending your life?" As with chest pain, you must evaluate severity—both depression and angina are potentially lethal.

Similarities

Ask the patient to tell you how the following things are alike: An orange and an apple A church and a theater A cat and a mouse A piano and a violin A child and a dwarf Wood and coal

Overweight or obese

Ask when the weight gain began. Was the patient overweight as a child? Are the parents overweight? Ask about weight at life milestones like birth, kindergarten, high school or college graduation, military discharge, pregnancy, menopause, and retirement. Has a recent disability or surgery affected weight? Establish the patient's level of physical activity and the outcomes of any prior attempts at weight loss. Assess eating patterns and dietary preferences. -tricyclic antidepressants; insulin and sulfonylurea; contraceptives, glucocorticoids, and progestational steroids; mirtazapine and paroxetine; gabapentin and valproate; and propranolol. -increase risk of heart disease, numerous types of cancers, type 2 diabetes, stroke, arthritis, sleep apnea, infertility, and depression. Obesity may increase risk of death.8,9 -Reducing weight by even 5% to 10% can improve blood pressure, lipid levels, and glucose tolerance, and reduce the risk of diabetes or hypertension.

Higher cognitive functions

Assessed by vocabulary, fund of information, abstract thinking, calculations, construction of objects that have two or three dimensions

Height and Weight

Be aware of very short stature in Turner's syndrome, childhood renal failure, and achondroplastic and hypopituitary dwarfism; long limbs in proportion to the trunk in hypogonadism and Marfan's syndrome; height loss in osteoporosisand vertebral compression fractures. There is generalized fat in simple obesity; truncal fat with relatively thin limbs in Cushing's syndrome and metabolic syndrome.

Grooming and dress

How does it compare with clothing and grooming worn by people of comparable age and social group?---Grooming and personal hygiene may deteriorate in depression, schizophrenia, and dementia. Excessive fastidiousness may be seen with obsessive-compulsive disorder. One-sided neglect may result from a lesion in the opposite parietal cortex, usually the nondominant side.

Common Functional Symptoms

Co-occurrence rates for irritable bowel syndrome, fibromyalgia, chronic fatigue, temporomandibular joint disorder, and multiple chemical sensitivity reach 30% to 90%, depending on the disorders compared. -prevalence of symptom overlap is high namely, complaints of fatigue, sleep disturbance, musculoskeletal pain, headache, and gastrointestinal problems -overlap in rates of functional impairment, psychiatric comorbidity, and response to cognitive and antidepressant therapy.

Obesity related health factors

Cardiovascular Hypertension Coronary artery disease Atrial fibrillation Heart failure Cor pulmonale Varicose veins Endocrine Metabolic syndrome Type 2 diabetes Dyslipidemia Polycystic ovarian syndrome/androgenicity Amenorrhea/infertility/menstrual disorders Gastrointestinal Gastroesophageal reflux disease (GERD) Nonalcoholic fatty liver disease (NAFLD) Cholelithiasis Hernias Cancer: colon, pancreas, esophagus, liver Genitourinary Urinary stress incontinence Obesity-related glomerulopathy Hypogonadism (male) Cancer: breast, cervical, ovarian, uterine Pregnancy complications Nephrolithiasis, chronic renal disease Integument Striae distensae (stretch marks) Status pigmentation of legs Lymphedema Cellulitis Intertrigo, carbuncles Acanthosis nigricans/skin tags Muscoloskeletal Hyperuricemia and gout Immobility Osteoarthritis (knees, hips) Low back pain Neurologic Stroke Idiopathic intracranial hypertension Meralgia paresthetica Psychological Depression/low self-esteem Body image disturbance Social stigmatization Respiratory Dyspnea Obstructive sleep apnea Hypoventilation syndrome/Pickwickian syndrome Pulmonary embolism Asthma

Eye Exam

Check visual acuity and screen the visual fields. Note the position and alignment of the eyes. Observe the eyelids and inspect the sclera and conjunctiva of each eye. With oblique lighting, inspect each cornea, iris, and lens. Compare the pupils, and test their reactions to light. Assess the extraocular movements. With an ophthalmoscope, inspect the ocular fundi. -The room should be darkened for the ophthalmoscopic examination. This promotes pupillary dilation and visibility of the fundi.

Somatization disorder

Chronic multisystem disorder characterized by complaints of pain, gastrointestinal and sexual dysfunction, and pseudoneurologic symptoms. Onset is usually early in life, and psychosocial and vocational achievements are limited.

Pain Disorder

Clinical syndrome characterized predominantly by pain in which psychological factors are judged to be of etiologic importance

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 thorax, height of jugular venous pulsations, abdominal contour, lower extremity edema, and gait.

Comprehensive History

Comprehensive History - asks everything taken on the initial visit to a clinic, office, or health care facility. More time to see patient. It includes: a) demographic information b) chief complaint c) history of present illness d) past medical and surgical histories e))family history g) social history h) review of systems

Abstract thinking

Concrete responses are often given by people with mental retardation,delirium, or dementia but may also be a function of limited education. Patients with schizophrenia may respond concretely or with personal, bizarre interpretations.

Posture and movement

Does the patient lie in bed or prefer to walk around? Note body posture and the patient's ability to relax. Observe the pace, range, and character of movements. Do they seem to be under voluntary control? Are certain parts immobile? Do posture and motor activity change with topics under discussion or with activities or people around the patient? Look for tense posture, restlessness, and anxiety fidgeting; the crying, pacing, and hand-wringing of agitated depression; the hopeless, slumped posture and slowed movements of depression; the agitated and expansive movements of amanic episode.

Manners and relationships

Does the patient seem to hear or see things that you do not or seem to be conversing with someone who is not there? -Watch for the anger, hostility, suspiciousness, or evasiveness of patients withparanoia; the elation and euphoria of mania; the flat affect and remoteness ofschizophrenia; the apathy (dulled affect with detachment and indifference) ofdementia; and anxiety or depression.

Delusions

False, fixed, personal beliefs that are not shared by other members of the person's culture. Examples include: Delusions of persecution Delusions of grandeur Delusional jealousy Delusions of reference, in which a person believes that external events, objects, or people have a particular and unusual personal significance (e.g., that the radio or television might be giving instructions to the person) Delusions of being controlled by an outside force Somatic delusions of having a disease, disorder, or physical defect Systematized delusions, a single delusion with many elaborations or a cluster of related delusions around a single theme, all systematized into a complex network

Nose Exam

Examine the external nose; using a light and a nasal speculum, inspect the nasal mucosa, septum, and turbinates. Palpate for tenderness of the frontal and maxillary sinuses.

FACES

Explain to the person that each face is for a person who feels happy because he has no pain (hurt) or sad because he has some or a lot of pain. Face 0 is very happy because he doesn't hurt at all. Face 2 hurts just a little bit. Face 4 hurts a little more. Face 6 hurts even more. Face 8 hurts a whole lot. Face 10 hurts as much as you can imagine, although you don't have to be crying to feel this bad. Ask the person to choose the face that best describes how he is feeling.

routine clinical check-up, or periodic physical examination

Findings have validated the importance of physical examination techniques: blood pressure measurement, assessment of central venous pressure from the jugular venous pulse, listening to the heart for evidence of valvular disease, detection of hepatic and splenic enlargement, and the pelvic examination with Papanicolaou smears.

Special Assessments

Folstein mini mental, Get up & Go, etc. Fulsetin, MMSM, tenety get up and go - write results, and interpret the results, not just 2/3 - do they have the thing or not? PHQ9 - depression scale - goes in special assessment Don't just write the number, write what the results indicate When recording results of special assessment , make sure to include the maximum score: Folstein mini mental: 27/30

New learning ability

Give the patient three or four words such as "83 Water Street and blue," or "table, flower, green, and hamburger." Ask the patient to repeat them so that you know that the information has been heard and registered. This step, like digit span, tests registration and immediate recall. Then proceed to other parts of the examination. After 3 to 5 minutes, ask the patient to repeat the words. Note the accuracy of the response, awareness of whether it is correct, and any tendency to confabulate. Normally, a person should be able to remember the words.

Rapid Screen for Dietary Intake

Grains, cereals, bread group _____ 6-11 Fruit group _____ 2-4 Vegetable group _____ 3-5 Meat/meat substitute group _____ 2-3 Dairy group _____ 2-3 Sugars, fats, snack foods _____ — Soft drinks _____ — Alcoholic beverages _____ <2 Sodium intake should be less than 2,300 mg/day; saturated fatty acids should be ≤10% of total calories; and dietary cholesterol should be ≤300 mg/day. The American Heart Association and the Institute of Medicine currently recommend restricting sodium intake to 1,500 mg/day.

G-P-M-L

Gravida (G)-Parity, or # deliveries (P)-Miscarriages (M)-Living (L),

Interview Sequence

Greeting the patient and establishing rapport. Taking notes. Establishing the agenda for the interview. Inviting the patient's story. Identifying and responding to emotional cues. Expanding and clarifying the patient's story. Generating and testing diagnostic hypotheses. Sharing the treatment plan. Closing the interview and the visit. Taking time for self-reflection.

ROS: Female Genito-Reproductive

Gynecologic History: age of menarche LMP,age at menopause, abnormal masses, amount ofbleeding (menstrual, intermenstrual, postcoital,post menopausal), leukorrhea, pruritis, history of VD and itstreatment, serology, libido, sexual difficulties, frequencyof intercourse, last PAP, results.Obstetric History: pregnancies abortions (spontaneousand induced), full term deliveries, complications,infertility.Contraception methodsIs there a history of sexual abuse/rape?

HEENT ROS

Head: Headache, head injury, dizziness, lightheadedness. Eyes: Vision, glasses or contact lenses, last examination, pain, redness, excessive tearing, double or blurred vision, spots, specks, flashing lights, glaucoma, cataracts. Ears: Hearing, tinnitus, vertigo, earaches, infection, discharge. If hearing is decreased, use or nonuse of hearing aids. Nose and sinuses: Frequent colds, nasal stuffiness, discharge, or itching, hay fever, nosebleeds, sinus trouble.Throat (or mouth and pharynx): Condition of teeth and gums, bleeding gums, dentures, if any, and how they fit, last dental examination, sore tongue, dry mouth, frequent sore throats, hoarseness.

Male Genitalia ROS

Hernias, discharge from or sores on the penis, testicular pain or masses, scrotal pain or swelling, history of sexually transmitted infections and their treatments. Sexual habits, interest, function, satisfaction, birth control methods, condom use, and problems. Concerns about HIV infection

INTERPRET

I Introductions: Make sure to introduce all the individuals in the room. During the introduction, include information as to the roles individuals will play. N Note Goals: Note the goals of the interview. What is the diagnosis? What will the treatment entail? Will there be any follow-up? T Transparency: Let the patient know that everything said will be interpreted throughout the session. E Ethics: Use qualified interpreters (not family members or children) when conducting an interview. Qualified interpreters allow the patient to maintain autonomy and make informed decisions about his or her care. R Respect Beliefs: Limited English Proficient (LEP) patients may have cultural beliefs that need to be taken into account as well. The interpreter may be able to serve as a cultural broker and help explain any cultural beliefs that may exist. P Patient Focus: The patient should remain the focus of the encounter. Providers should interact with the patient and not the interpreter. Make sure to ask and address any questions the patient may have prior to ending the encounter. If you don't have trained interpreters on staff, the patient may not be able to call in with questions. R Retain Control: It is important as the provider that you remain in control of the interaction and not let the patient or the interpreter take over the conversation. E Explain: Use simple language and short sentences when working with an interpreter. This will ensure that comparable words can be found in the second language and that all the information can be conveyed clearly. T Thanks: Thank the interpreter and the patient for their time. On the chart, note that the patient needs an interpreter and who served as an interpreter this time.

Cranial Nerve Exam

If not already examined, check sense of smell, strength of the temporal and masseter muscles, corneal reflexes, facial movements, gag reflex, and strength of the trapezia and sternomastoid muscles. -lesions in brainstem alter eye movements -nystagmus - cerebellar or brain stem dysfunction (in MS) -Bells Palsy - weakness of the whole side of face including eyebrow and forehead -Lesion of brain itself will spare the eyebrow and forehead of droopiness -If Vagus nerve CN X is effected, uvula and soft palate won't raise in the affected side Palpates clenched masseter muscles (CN V) - while palpating the temporal and masseter muscles, in turn ask the pt to clench the teeth. Tests upper (i.e. raises eyebrows or wrinkles forehead) and lower (i.e. smile or puff out cheeks) CN VII - ask pt to raise both eyebrows, frown, close both eyes tight so you can't open them for him/her, show upper and lower teeth, smile, puff out cheeks Tests head rotation against resistance or shoulder shrug against resistance (CN XI - spinal accessory) - don't let me bring your shoulders down as you ask pt to "shrug both shoulders upward against your hands" Observes midline protrusion of tongue (CN XII) problem if it deviates - abnormality = protruded tongue will deviate to the unaffected side. Ask pt to also move tongue side to side Tests facial sensation bilaterally: upper, middle, and lower (CN V)

BMI

If the BMI is above 25, assess the patient for additional risk factors for heart disease and other obesity-related diseases: hypertension, high LDL cholesterol, low HDL cholesterol, high triglycerides, high blood glucose, family history of premature heart disease, physical inactivity, and cigarette smoking. Patients with a BMI over 25 and two or more risk factors should pursue weight loss, especially if the waist circumference is elevated. Underweight <18.5 Normal 18.5-24.9 Overweight 25.0-29.9 Obesity I 30.0-34.9 II 35.0-39.9 Extreme obesity III ≥40 -If the BMI is 35 or greater, measure the patient's waist circumference just above the hips. Risk for diabetes, hypertension, and cardiovascular disease increases significantly if the waist circumference is 35 inches or more in women and 40 inches or more in men. Weight in pounds, height in inches (1) Body Mass Index Chart (see table on the next page) Image Not Available Weight in kilograms, height in meters squared Image Not Available Either (4) "BMI Calculator" at Web site www.nhlbisupport.com/bmi

Arrhythmias

Ignore the effects of an occasional premature contraction. With frequent premature contractions or atrial fibrillation, determine the average of several observations and note that your measurements are approximate. Ambulatory monitoring for 2 to 24 hours is recommended -Palpation of an irregularly irregular rhythm indicates atrial fibrillation. For all irregular patterns, an ECG is needed to identify the type of rhythm

Breasts, Axillae, and Epitrochlear Nodes Exam

In a woman, inspect the breasts with her arms relaxed, then elevated, and then with her hands pressed on her hips. In either sex, inspect the axillae and feel for the axillary nodes. Feel for the epitrochlear nodes. -at least in women, made a fair estimate of the shoulders' range of motion

obstructive breathing

In obstructive lung disease, expiration is prolonged because narrowed airways increase the resistance to air flow. Causes include asthma, chronic bronchitis, and COPD. -Prolonged expiration is common in COPD.

Temperature

In the early morning hours, it may fall as low as 35.8°C (96.4°F), and in the late afternoon or evening, it may rise as high as 37.3°C (99.1°F). Rectal temperatures are higher than oral temperatures by an average of 0.4 to 0.5°C (0.7 to 0.9°F), but this difference is also quite variable. In contrast, axillary temperatures are lower than oral temperatures by approximately 1°, but take 5 to 10 minutes to register and are generally considered less accurate than other measurements. -Hyperpyrexia refers to extreme elevation in temperature, above 41.1°C (106°F), while hypothermiarefers to an abnormally low temperature, below 35°C (95°F) rectally. -Causes of fever include infection, trauma such as surgery or crush injuries, malignancy, blood disorders such as acute hemolytic anemia, drug reactions, and immune disorders such as collagen vascular disease

Brief Psychotic Disorder

In this disorder, at least one of the following psychotic symptoms must be present: delusions, hallucinations, disordered speech such as frequent derailment or incoherence, or grossly disorganized or catatonic behavior. The disturbance lasts at least 1 day but less than 1 month, and the person returns to his or her prior functional level.

Diet for Hypertension

Increase foods high in potassium Baked white or sweet potatoes, white beans, beet greens, soybeans, spinach, lentils, kidney beans Bananas, plantains, many dried fruits, orange juice Tomato sauce, juice, and paste Decrease foods high in sodium Canned foods (soups, tuna fish) Pretzels, potato chips, pickles, olives Many processed foods (frozen dinners, ketchup, mustard) Batter-fried foods Table salt, including for cooking

Ear Exam

Inspect the auricles, canals, and drums. Check auditory acuity. If acuity is diminished, check lateralization (Weber test) and compare air and bone conduction (Rinne test).

Rectal Exam in Man

Inspect the sacrococcygeal and perianal areas. Palpate the anal canal, rectum, and prostate. If the patient cannot stand, examine the genitalia before doing the rectal examination. -The patient is lying on his left side for the rectal examination (or standing and bending forward).

Serial 7s

Instruct the patient, "Starting from a hundred, subtract 7, and keep subtracting 7...." Note the effort required and the speed and accuracy of the responses. Writing down the answers helps you keep up with the arithmetic. Normally, a person can complete serial 7s in 1½ minutes, with fewer than four errors. If the patient cannot do serial 7s, try 3s or counting backward. -Poor performance may result from delirium, the late stage of dementia, mental retardation, loss of calculating ability, anxiety, or depression. Also consider the possibility of limited education.

Physical Exam

Integument HEENT Neck Chest (Breast, CV, Respiratory) - no breast exams in this course, write denies, date of last breast exam Abdomen Back Extremities/peripheral vascular (pulses listed & graded) Musculoskeletal (muscle strength graded) Genitalia Neurological

Factitious Disorder

Intentional production or feigning of physical or psychological signs when external reinforcers (e.g., avoidance of responsibility, financial gain) are not clearly present

Malingering

Intentional production or feigning of physical or psychological signs when external reinforcers (e.g., avoidance of responsibility, financial gain) are present

Peripheral Vascular ROS

Intermittent claudication; leg cramps; varicose veins; past clots in the veins; swelling in calves, legs, or feet; color change in fingertips or toes during cold weather; swelling with redness or tenderness.

Neologisms

Invented or distorted words, or words with new and highly idiosyncratic meanings

Stepped Care Approach to Somatic Symptoms in Primary Care

Is the somatic symptom likely to be... Clinician action might be... Acutely serious? (<5% of cases) Expedited diagnostic workup Minor/self-limited? (70%-75% of cases) Address patient expectations Symptom-specific therapy - Follow-up in 2-6 weeks Chronic or recurrent? (20%-25% of cases) Screen for depression and anxiety Caused or aggravated by a depressive or anxiety disorder? Antidepressant therapy and/or cognitive-behavioral therapy (CBT) Due to a functional somatic syndrome? Syndrome-specific therapy Antidepressant therapy and/or CBT Persistent and medically unexplained? Regular, time-limited clinic visits Consider mental health referral Symptom management strategies, if evidence-based (e.g., behavioral treatments, pain self-management programs, pain or other specialty clinics, complementary and alternative medicine) Rehabilitative rather than disability approach

Management Guidelines for Patients With Medically Unexplained Symptoms

Is the somatic symptom likely to be... Clinician action might be... General Aspects Show empathy and understanding for the complaints and frustrating experiences the patient has had so far (e.g., explain that medically unexplained symptoms are common). Develop a good patient-physician relationship; try to be the "coordinator" of diagnostic procedures and care. Diagnosis Explore not only the history of complaints and former treatments, but any impairment, anxiety, and psychosocial issues. Use screeners and self-report questionnaires to enhance detection; use symptom diaries to assess course and factors influencing symptoms. When the patient presents with a new symptom, examine the relevant organ system. Provide the results of investigations to give clear reassurance that there is no serious physical disease. Avoid unnecessary diagnostic tests or surgical procedures. Treatment Provide regularly scheduled visits (e.g., every 4-6 weeks), especially in the case of a history of very frequent healthcare utilization. Explain that treatment is coping, not curing (when pathology cannot be found or does not explain degree of complaints). Referral Suggest coping strategies like regular physical activity, relaxation, distraction. If referral is necessary to start psychotherapy or psychopharmacotherapy, prepare the patient for the treatment and provide reassurance that you will continue to be the patient's doctor.

five stages in our response to loss or the anticipatory grief of impending death

Kübler-Ross -denial and isolation, anger, bargaining, depression or sadness, and acceptance. -may occur sequentially or overlap in any order or combination.[

Problem List

List the most active and serious problems first, and record their date of onset. -Some clinicians make separate lists for active or inactive problems; others make one list in order of priority. -on follow up visits, helps you remember to check the status of problems the patient may not mention -allows other members of the health care team to review the patient's health status at a glance. -can be symptoms, signs, past health events such as a hospital admission or surgery, or diagnoses. - includes problems that need attention now as well as problems that need future observation and attention

orthostatic hypotension

Measure blood pressure and heart rate in two positions—supine after the patient is resting from 3 to 10 minutes, then within 3 minutes after the patientstands up. Normally, as the patient rises from the horizontal to the standing position, systolic pressure drops slightly or remains unchanged, while diastolic pressure rises slightly. -a drop in systolic blood pressure of 20 mm Hg or greater or in diastolic blood pressure of 10 mm Hg or greater within 3 minutes of standing.[43]-[45] -A fall in systolic pressure of 20 mm Hg or more, especially when accompanied by symptoms and tachycardia, indicates orthostatic (postural) hypotension.Causes include drugs, moderate or severe blood loss, prolonged bed rest, and diseases of the autonomic nervous system.

Past Health History

Medical: illness listed with year of diagnosis (T2DM, 2006) Surgical: procedures listed with year of diagnosis (Procedure, Year) Hospitalizations: reason listed with year of hospitalization Trauma/Injuries: diagnosis with year Psychiatric: diagnosis with year Medications: Listed with year started - dosage, frequency, route Allergies: denies to food, drugs, latex, environmental agents(if allergies present, then document reaction). Denies to food, drugs etc Immunizations(age appropriate) type & year Childhood illnesses Transfusion: year and if any reaction 56 year old - no infancy immunizations, "Up to date" Certain - pneumovax, flu, hep B, hep A should be listed out Herpes zoster - shingles

Illusions

Misinterpretations of real external stimuli Illusions may occur in grief reactions, delirium, acute and posttraumatic stress disorders, and schizophrenia.

Musculoskeletal ROS

Muscle or joint pain, stiffness, arthritis, gout, backache. If present, describe location of affected joints or muscles, any swelling, redness, pain, tenderness, stiffness, weakness, or limitation of motion or activity; include timing of symptoms (e.g., morning or evening), duration, and any history of trauma. Neck or low back pain. Joint pain with systemic features such as fever, chills, rash, anorexia, weight loss, or weakness.

Speech

Note the slow speech of depression; the accelerated rapid, loud speech inmania. Be alert for abnormalities of spontaneous speech such as: • Hesitancies and gaps in the flow and rhythm of words • Disturbed inflections, such as a monotone • Circumlocutions, in which phrases or sentences are substituted for a word the person cannot think of, such as "what you write with" for "pen" • Paraphasias, in which words are malformed ("I write with a den"), wrong ("I write with a bar"), or invented ("I write with a dar"). These abnormalities suggest aphasia. The patient may have difficulty talking or understanding others.

nutrition screening checklist

Nutrition Screening Checklist I have an illness or condition that made me change the kind and/or amount of food I eat. Yes (2 pts) _____ I eat fewer than 2 meals per day. Yes (3 pts) _____ I eat few fruits or vegetables, or milk products. Yes (2 pts) _____ I have 3 or more drinks of beer, liquor, or wine almost every day. Yes (2 pts) _____ I have tooth or mouth problems that make it hard for me to eat. Yes (2 pts) _____ I don't always have enough money to buy the food I need. Yes (4 pts) _____ I eat alone most of the time. Yes (1 pt) _____ I take 3 or more different prescribed or over-the-counter drugs each day. Yes (1 pt) _____ Without wanting to, I have lost or gained 10 pounds in the last 6 months. Yes (2 pts) _____ I am not always physically able to shop, cook, and/or feed myself.

Obesity: Stages of Change Model and Assessing Readiness

Precontemplation Unaware of problem, no interest in change` "I'm not really interested in weight loss. It's not a problem." Provide information about health risks and benefits of weight loss "Would you like to read some information about the health aspects of obesity?" Contemplation Aware of problem, beginning to think of changing "I know I need to lose weight, but with all that's going on in my life right now, I'm not sure I can." Help resolve ambivalence; discuss barriers "Let's look at the benefits of weight loss, as well as what you may need to change." Preparation Realizes benefits of making changes and thinking about how to change "I have to lose weight, and I'm planning to do that." Teach behavior modification; provide education "Let's take a closer look at how you can reduce some of the calories you eat and how to increase your activity during the day." Action Actively taking steps toward change "I'm doing my best. This is harder than I thought." Provide support and guidance, with a focus on the long term "It's terrific that you're working so hard. What problems have you had so far? How have you solved them?" Maintenance Initial treatment goals reached "I've learned a lot through this process." Relapse control "What situations continue to tempt you to overeat? What can be helpful for the next time you face such a situation?"

Problem Oriented / Focused History

Problem Oriented/Focused History is taken when and individual presents with a specific problem. SOAP note Data elicited will include that relevant to the problem (e.g. 23 y/o WF presents with burning upon urination). It is important to identify the manner of presentation (acute/gradual); current status (why presenting today); severity, location, influencing factors; duration of symptoms; type (e.g. pain, sharp/dull/aching); associated factors which are related to the reason for the visit.

Judgement

Process of comparing and evaluating alternatives when deciding on a course of action; reflects values that may or may not be based on reality and social conventions or norms -patient's responses to family situations, jobs, use of money, and interpersonal conflicts. "How do you plan to get help after leaving the hospital?" "How are you going to manage if you lose your job?" "If your husband starts to abuse you again, what will you do?" "Who will take care of your financial affairs while you are in the nursing home?" -Judgment may be poor in delirium, dementia, mental retardation, and psychotic states. Anxiety, mood disorders, intelligence, education, income, and cultural values also influence judgment. -Note whether decisions and actions are based on reality or, for example, on impulse, wish fulfillment, or disordered thought content. -Disorientation is common when memory or attention is impaired, as in delirium.

Psychotic Disorder due to a General Medical Condition

Prominent hallucinations or delusions may be experienced during a medical illness. For this diagnosis, they should not occur exclusively during the course of delirium. The medical condition should be documented and judged to be causally related to the symptoms.

hyperpnea, hyperventilation

Rapid deep breathing has several causes, including exercise, anxiety, and metabolic acidosis. In the comatose patient, consider infarction, hypoxia, or hypoglycemia affecting the midbrain or pons. Kussmaul breathing is deep breathing due to metabolic acidosis. It may be fast, normal in rate, or slow.

skin ROS

Rashes, lumps, sores, itching, dryness, changes in color; changes in hair or nails; changes in size or color of moles.

Recent memory

Recent memory is impaired in dementia and delirium. Amnestic disordersimpair memory or new learning ability and reduce a person's social or occupational functioning, but they do not have the global features of delirium or dementia. Anxiety, depression, and mental retardation may also impair recent memory.

Digit Span

Recite a series of digits, starting with two at a time and speaking each number clearly at a rate of about one per second. Ask the patient to repeat the numbers back to you. If this repetition is accurate, try a series of three numbers, then four, and so on as long as the patient responds correctly. Jot down the numbers as you say them to ensure your own accuracy. If the patient makes a mistake, try once more with another series of the same length. Stop after a second failure in a single series. -Causes of poor performance include delirium, dementia, mental retardation, and performance anxiety. When choosing digits, use street numbers, zip codes, telephone numbers, and other numerical sequences that are familiar to you, but avoid consecutive numbers, easily recognized dates, and sequences that are familiar to the patient. -Now, starting again with a series of two, ask the patient to repeat the numbers to you backward. Normally, a person should be able to repeat correctly at least five digits forward and four backward.

Obsessions

Recurrent, uncontrollable thoughts, images, or impulses that a person considers unacceptable and alien

Spelling backwards

Say a five-letter word, spell it, for example, W-O-R-L-D, and ask the patient to spell it backward.

Diagnostic Reasoning

Scientific process in which the practitioner suspects the cause of a patient's symptoms and signs based on previous knowledge Gathers relevant information Selects necessary tests Recommends therapy or have a plan By using diagnostic reasoning the following is accomplished: Determines & focuses on what needs to be asked and examined Performs exams & diagnostic tests accurately Clusters abnormal findings & normal findings Analyzes and & interprets findings Develops a list of differential diagnoses or actual Symptom Analysis- Severity - pain scale 0-10 Location - specific anatomical location Influencing factors - what makes it better and worse Duration - length of time Type - burning, stabbing, sharp, aching Associated symptoms - what other sx occur alongside the problem, ex: abdominal pain -> possibly nausea, vomiting, diarrhea, constipation, change in bowel habits, melena, hematochezia - can be negative, significant if don't have it too Identify the most important clues Understand & Perform advanced exam techniques Test differential or competing diagnoses See a pattern for the information gathered Develop Clinical Judgment-spend time with patients, focused listening, gain experience in subtle clues -90% of your dx will come from your history, listen look at verbal and nonverbal cues, right questions, significant positive and negative findings

Perceptions

Sensory awareness of objects in the environment and their interrelationships (external stimuli); also refers to internal stimuli such as dreams or hallucinations When you heard the voice speaking to you, what did it say? How did it make you feel?" Or, "After you've been drinking a lot, do you ever see things that aren't really there?" Or, "Sometimes after major surgery like this, people hear peculiar or frightening things. Have you experienced anything like that?"

Hearing Loss Patient

Several questions help you determine whether the patient belongs to the deaf culture or the hearing culture: when the hearing loss occurred relative to the development of speech and language; the kinds of schools the patient attended; and responses to written questionnaires. Patients may use American Sign Language, a unique language with its own syntax. These patients typically have with a low English reading level and prefer certified ASL interpreters during their visits.[67] -Alternatively, time-consuming handwritten questions and answers may be the only solution, but be sure to assess literacy first.

bradypnea

Slow breathing may be secondary to diabetic coma, drug-induced respiratory depression, and increased intracranial pressure.

Visual Acuity

Snellen chart, 20ft from chart, cover 1 eye and then the other -Use SNELL chart, ask pt to stand up, cover one eye and read the smallest print they can identify more than half the letters.

Circumstantiality

Speech characterized by indirection and delay in reaching the point because of unnecessary detail, although components of the description have a meaningful connection. Many people without mental disorders speak circumstantially.

Clanging

Speech in which a person chooses a word on the basis of sound rather than meaning, as in rhyming and punning speech. For example, "Look at my eyes and nose, wise eyes and rosy nose. Two to one, the ayes have it!"

Incoherence

Speech that is largely incomprehensible because of illogic, lack of meaningful connections, abrupt changes in topic, or disordered grammar or word use. Shifts in meaning occur within clauses. Flight of ideas, when severe, may produce incoherence.

Hallucinations

Subjective sensory perceptions in the absence of relevant external stimuli. The person may or may not recognize the experiences as false. Hallucinations may be auditory, visual, olfactory, gustatory, tactile, or somatic. (False perceptions associated with dreaming, falling asleep, and awakening are not classified as hallucinations.) - Hallucinations may occur in delirium, dementia (less commonly), posttraumatic stress disorder, schizophrenia, and alcoholism.

SOAP

Subjective, Objective, Assessment, and Plan

Blocking

Sudden interruption of speech in midsentence or before completion of an idea. The person attributes this to losing the thought. Blocking occurs in normal people.

Suicide

Suicide ranks as the 11th leading cause of death in the United States. It is the second leading cause of death among 25 to 34 year olds and the third leading cause of death among 15 to 24 year olds.[49] There are almost 11 completed suicides per 100,000 population annually.[50] Suicide rates are four times higher in men, who are more likely to use firearms and less likely to use poison than women. The highest suicide rates are in men 75 years of age or older: 36 per 100,000. Suicide rates reach 12 per 100,000 in young adults ages 15 to 24 years and are especially high in American Indian/Alaska natives ages 15 to 24, reaching 20 per 100,000. Suicide attempts are even higher, especially among female black and Hispanic high school students

Phys Exam: Neck

Supple (or full ROM), No masses or lymphadenopathy. No jugular venous distention at 45 degrees. Carotid pulses equal with good upstroke, no bruits noted. Trachea midline, no thyromegaly. -palpate lymph nodes with first three fingers in circular motion: around ears preauricular in front of ear, behind ear, base of skill, mandibular angle, submandibular 1/2 way, submental under chin, anterior cervical chain (in front of sternocleidomastoid muscle), posterior cervical chain (behind and posterior to sternocleidomastoid muscle) back of trapezius, supraclavicular (above collar bone), axillary - deep, with gloves on -fixed, non-moveable - malignancy or infection/Cold -palpate thyroid with and without swallowing - isthmus and lobes -palpate carotid BIL - not at same time -ausculatate carotid BIL - patient holds breath, use Bell "L" low pitched sound -going to press very lightly with my stethoscope now -Palpates lymph nodes in the following areas: (using the pads of the second and third fingers, palpate in gentle rotary motion) p. 250 o Around ears : preauricular nodes (infront of ears) &amp; posterior auricular (right behind ears - superficial to mastoid process) o Anterior cervical chain (in front of sternocleidomastoid muscle) o Posterior cervical chain (behind and posterior to sternocleidomastoid muscle) from occipital down. o *Added - Tosillar (angle of mandible), Submandibular (rest of jaw line), Submental (midline bit behind tip of mandible) o Supraclavicular (above collarbone) o Axillary - don&#39;t forget these - even though not part of neck exam - can do when examining arms Palpates thyroid without swallowing (isthmus and lobes) - place fingers below cricoid cartilage - both hands - standing behind patient. Find landmarks, the notched thyroid cartilage and the cricoid cartilage below it, locate thyroid isthmus, usually overlying the second, third, and fourth tracheal rings. Displace trachea to the right with the fingers of the left hand; with the right hand fingers, palpate laterally for right lobe of thyroid. Examine left lobe in same fashion Palpates thyroid with swallowing (isthmus and lobes): Ask pt to flex neck slightly forward to relax sternomastoid muscles, place fingers of both hands on pt's neck so your index fingers are just below the cricoid cartilage. As pt to sip and swallow water and feel for thyroid isthmus rising up under finger pads (not always palpable). Palpates carotids bilaterally - one at a time. Auscultates carotids bilaterally- patient holds breath - bell L - low pitch sounds press lightly diaphragm - High pitch sounds. Press lightly using bell check for bruit "swish" *Pt must hold their breath! So you don't hear lung sounds - tell them to breathe in between sides

Neck ROS

Swollen glands," goiter, lumps, pain, or stiffness in the neck

Phys Exam: Abdomen

Symmetrical, flat with no lesions, scars, herniations, or abnormal pulsations. Soft, nontender, with normoactive bowel sounds in all four quadrants. No bruits or hums, No organomegaly. Normal tympany throughout. Femoral pulses equal. -have patient lay flat -inspect -auscultate before palpation or manipulation and listen for bruit in middle -percuss all 4 quadrants - tympany -percuss liver span from top to bottom - in female bottom and up - until you hear change from tympany to dullness in female, or resonance to dullness in man, right upper quadran, liver should be midclavicular 6-12cm (dull over organs) -palpate all 4 quadrants - light 1cm and deep 4cm -feel midline for aorta -(only time the patient lies down - cover them with sheet from genital down - open bed extension Auscultates before manipulation or palpation - listen with diaphragm all 4 quadrants. Then listen to aorta above umbilicus or at rib division with both diaphragm and bell. The use bell to listen to liver (on right side) and spleen (on left) for friction rubs. Also listen for bruits over the renal arteries, iliac arteries, and femoral arteries with both diaphragm and bell. Percusses all 4 quadrants if small pt can do one percussion per quadrant if bigger 2 taps Percusses liver span - on the Right midclavicular line. Start a bit below the umbilicus in the right lower quadrant percussing upward and identify lower border of dullness. Then starting at nipple line percuss from lung resonance down toward liver dullness. Then measure the distance between both points. from top and bottom - usually found between 6-12 cm in midclavicle - tell them "your liver is normal." Palpates all 4 quadrants - watch pts face as you do this - palpate lightly first then deeply Feels midline for aorta

Phys Exam: Chest

Symmetrical, no bony deformities, AP diameter not increased, no tenderness, or adenopathy noted. Lungs resonant throughout, clear to auscultation. Fremitus equal bilaterally. Breasts symmetrical, no masses, retraction, discharge, tenderness or lymphadenopathy. Heart: no lifts, heaves or thrills noted PMI 5th LICS at MCL. regular S1, S2 normal, no S3 or S4, No murmurs, rubs gallops, or clicks noted. -chest expansion - on back thumbs together at about the level of 10 th rib (lower back). and apart -percuss lung fields BIL and symetrically on skin, anteriorly and posteriorly - side to side down and across, hear resonance -auscultate lung fields BIL and symetrically on skin - anteriorly and posteriorly - same areas you percuss you ascultate -ask patient to take deep breaths through open mouth during ausculation -Position hands medially enough to raise a loose fold of skin on each side between your thumb and the spine. Ask the patient to inhale deeply. Watch the distance between your thumbs as they move apart during inspiration - feel for the range and symmetry of rib cage as it expands and contracts. Percusses lung fields bilaterally and symmetrically on skin- both anteriorly and posteriorly - use the middle finger of both hands to press on skin and to tap. tap in ladder like pattern omitting the area over the scapulae. don't percuss over bone/ribs Auscultates lung fields bilaterally and symmetrically on skin- both anteriorly and posteriorly - ask person to breath with their mouth open - Asks patient to take deep breaths through open mouth -head elevated -observe precordium (look at anterior chest) -palpate chest wall or point of maximum impulse - apex, 5th intercostal space, left clavicular line -use both diaphragm and bell to auscultate - aortic (R 2nd), pulmonic (L 2nd), tricuspid (L3 and L4) and mitral (5th left mid clavicular line) Positions patient with head elevated - ask them to lower their gown and observe chest Observes precordium (looks at anterior chest) Palpates chest wall or point of maximum impulse - HOB @ 30 palm of the right hand placed across the pt's left chest. Heel of the palm rest along the sternal border with extended fingers lying below the left nipple. PMI = MCL 5 th ICS - then feel with with index Uses both diaphragm and bell (if stethoscope has bell) to auscultate Auscultates all 4 areas (aortic, pulmonic, mitral, tricuspid) APTM right 2 nd ICS left 2 nd ICS, etc. Do both diaphragm and Bell

blood pressure

The cut-off for normal home, ambulatory, and automated office measurements, 135/85, is lower than for office measurements Ambulatory blood pressure monitoring is fully automated and allows recording over an extended period of time -Averaging several blood pressure measurements is best, regardless of the setting. There are numerous short-term biological variations in blood pressure. The accuracy of clinic and home blood pressure measurements improves significantly when at least two measurements are taken, with additional gains in accuracy up to at least four readings.[30] The variance between office and research systolic blood pressure reaches up to 15 mm Hg. Self-monitoring of blood pressure by well-instructed patients using approved devices improves blood pressure control, especially when it is done two times daily at the upper arm with automatic readouts Width of the inflatable bladder of the cuff should be about -40% of upper arm circumference (about 12-14 cm in the average adult). •Length of the inflatable bladder should be about 80% of upper arm circumference (almost long enough to encircle the arm). •The standard cuff is 12 × 23 cm, appropriate for arm circumferences up to 28 cm. -If the cuff is too small (narrow), the blood pressure will read high; if the cuff is too large (wide), the blood pressure will read low on a small arm and high on a large arm. -For the obese arm, use a cuff 15 cm in width. If the upper arm is short despite a large circumference, use a thigh cuff or a very long cuff. If the arm circumference is >50 cm and not amenable to use of a thigh cuff, wrap an appropriately sized cuff around the forearm, hold the forearm at heart level and feel for the radial pulse.[27] Other options include using a Doppler probe at the radial artery or an oscillometric device. For the very thin arm, consider using a pediatric cuff. -Using a small cuff overestimates systolic blood pressure in obese patients

Posttraumatic Stress Disorder

The event, the fearful response, and the persistent re-experiencing of the traumatic event resemble those in acute stress disorder. Hallucinations may occur. The person has increased arousal, tries to avoid stimuli related to the trauma, and has numbing of general responsiveness. The disturbance causes marked distress, impairs social, occupational, or other important functions, and lasts for more than a month.

History

The history is an important part of the health assessment of a patient since it is a story of their health. The history is the vehicle used to elicit data which is needed to enable the practitioner to: a) formulate hypotheses about the health/illness b) develop strategies for assessment c) propose and implement a plan of care. The practitioner must learn when it is appropriate to perform each of these histories. Additionally, the practitioner needs to be able to identify when it is necessary to expand the history obtained during an episodic or problem oriented visit to be more comprehensive.

Thought processes

The logic, coherence, and relevance of the patient's thought as it leads to selected goals; how people think Abnormalities occurs in people with obsessions. Seen in schizophrenia, manic episodes, and other psychotic disorders. Most frequently noted in manic episodes. Observed in schizophrenia, psychotic disorders, and aphasia. Observed in severe psychotic disturbances (usually schizophrenia). Blocking may be striking in schizophrenia. Seen in Korsakoff's syndrome from alcoholism. Occurs in schizophrenia and other psychotic disorders. Occurs in manic episodes and schizophrenia. Occurs in schizophrenia and manic episodes

Hypomanic Episode

The mood and symptoms resemble those in a manic episode but are less impairing, do not require hospitalization, do not include hallucinations or delusions, and have a shorter minimum duration—4 days.

Aortic Regurgitation

The patient should sit, lean forward, and exhale while you listen for the murmur

Acute Stress Disorder

The person has been exposed to a traumatic event that involved actual or threatened death or serious injury to self or others and responded with intense fear, helplessness, or horror. During or immediately after this event, the person has at least three of these dissociative symptoms: (1) a subjective sense of numbing, detachment, or absence of emotional responsiveness; (2) a reduced awareness of surroundings, as in a daze; (3) feelings of unreality; (4) feelings of depersonalization; and (5) amnesia for an important part of the event. The event is persistently re-experienced, as in thoughts, images, dreams, illusions, and flashbacks, or distress from reminders of the event. The person is very anxious or shows increased arousal and tries to avoid stimuli that evoke memories of the event. The disturbance causes marked distress or impairs social, occupational, or other important functions. The symptoms occur within 4 weeks of the event and last from 2 days to 4 weeks.

Memory

The process of registering or recording information, tested by asking for immediate repetition of material, followed by storage or retention of information. Recent or short-term memory covers minutes, hours, or days; remote or long-term memory refers to intervals of years.

Constructional ability

The task here is to copy figures of increasing complexity onto a piece of blank unlined paper. Show each figure one at a time and ask the patient to copy it as well as possible. - another approach, ask the patient to draw a clock face complete with numbers and hands. If vision and motor ability are intact, poor constructional ability suggests dementia or parietal lobe damage. Mental retardation may also impair performance.

clinical data

The vertical red bars designate sensitivity (a/a + c) and specificity (d/b + d), and the horizontal red bars designate positive predictive value (a/a + b) and negative predictive value (d/c + d).

Tavistock Principle

These principles construct a framework for analyzing health care situations that extend beyond our direct care of individual patients to complicated choices about the interactions of health care teams and the distribution of resources for the well-being of society. -A broadly representative group, which initially met in Tavistock Square in London in 1998, has continued to develop an evolving document of ethical principles for guiding health care behavior for both individuals and institutions across the health care spectrum. -Rights: People have a right to health and health care. -Balance: Care of the individual patient is central, but the health of populations is also our concern. -Comprehensiveness: In addition to treating illness, we have an obligation to ease suffering, minimize disability, prevent disease, and promote health. -Cooperation: Health care succeeds only if we cooperate with those we serve, each other, and those in other sectors. -Improvement: Improving health care is a serious and continuing responsibility. -Safety: Do no harm. -Openness: Being open, honest, and trustworthy is vital in health care.

MMSE - Mini Mental State Exam

This brief test is useful in screening for cognitive dysfunction or dementia, and following their course over time. Orientation to Time "What is the date?" Registration "Listen carefully; I am going to say three words. You say them back after I stop. Ready? Here they are ... HOUSE (pause), CAR (pause), LAKE (pause). Now repeat those words back to me." [Repeat up to five times, but score only the first trial.] Naming "What is this?" [Point to a pencil or pen.] Reading "Please read this and do what it says." [Show examinee the words on the stimulus form.] CLOSE YOUR EYES

Obsessive-Compulsive Disorder

This disorder involves obsessions or compulsions that cause marked anxiety or distress. Although they are recognized at some point as excessive or unreasonable, they are very time-consuming and interfere with the person's normal routine, occupational functioning, or social activities or relationships.

Generalized Anxiety Disorder

This disorder lacks a specific traumatic event or focus for concern. Excessive anxiety and worry, which the person finds hard to control, are about a number of events or activities. At least three of the following symptoms are associated: (1) feeling restless, keyed up, or on edge; (2) being easily fatigued; (3) having difficulty in concentrating or having the mind going blank; (4) irritability; (5) muscle tension; (6) difficulty in falling or staying asleep, or restless, unsatisfying sleep. The disturbance causes significant distress or impairs social, occupational, or other important functions.

benefits of examining from the right side

This is the standard position for the physical examination and has several advantages compared with the left side: estimates of jugular venous pressure are more reliable, the palpating hand rests more comfortably on the apical impulse, the right kidney is more frequently palpable than the left, and examining tables are frequently positioned to accommodate a right-handed approach.

principles of test selection and use

To help remember this, experts state "when the Sensitivity of a symptom or sign is high, a Negative response rules out the target disorder; the acronym for this property is "SnNout."12 Likewise, when the Specificity is high, a Positive test result rules in the target disorder. The acronym is "SpPin."12

GI ROS

Trouble swallowing, heartburn, appetite, nausea. Bowel movements, stool color and size, change in bowel habits, pain with defecation, rectal bleeding or black or tarry stools, hemorrhoids, constipation, diarrhea. Abdominal pain, food intolerance, excessive belching or passing of gas. Jaundice, liver or gallbladder trouble, hepatitis.

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.

Partnering

When building your relationships with patients, be explicit about your commitment to an ongoing partnership. Make patients feel that regardless of what happens with their illness, you envision continuing their care. Even as a student, especially in a hospital setting, this support can make a big difference.

Thought content

What the patient thinks about, including level of insight and judgment You mentioned a few minutes ago that a neighbor was responsible for your entire illness. Can you tell me more about that?" Or, in another situation, "What do you think about at times like these?" You may need to make more specific inquiries. If so, use terms that are tactful and accepting. "When people are upset like this, sometimes they can't keep certain thoughts out of their minds," or "... things seem unreal. Have you experienced anything like this?" Compulsions, obsessions, phobias, and anxieties are often associated with neurotic disorders. See Table 5-3, Anxiety Disorders. Delusions and feelings of unreality or depersonalization are more often associated with psychotic disorders. See Table 5-4, Psychotic Disorders. Delusions may also occur in delirium, severe mood disorders, and dementia.

Lab & Diagnostic Results

What you have, not what you plan to order(goes into plan section) - what the patient brings you If patient comes in and complaining of abdominal pain, they say to you I went to Stat Health on Saturday. Stat Health ordered a CT scan, and they come in with the CT scan results - this is where you write the results of the scan. Most likely no results of anything in this course.

Blind Patient

When meeting with a blind patient, shake hands to establish contact and explain who you are and why you are there. If the room is unfamiliar, orient the patient to the surroundings and report if anyone else is present. It still may be helpful to adjust the light. Encourage visually impaired patients to wear glasses whenever possible. Remember to give full explanations because postures and gestures are unseen.

Testing for Aphasia

Word Comprehension-Ask the patient to follow a one-stage command, such as "Point to your nose." Try a two-stage command: "Point to your mouth, then your knee." Repetition-Ask the patient to repeat a phrase of one-syllable words (the most difficult repetition task): "No ifs, ands, or buts." Naming-Ask the patient to name the parts of a watch. Reading Comprehension-Ask the patient to read a paragraph aloud. Writing-Ask the patient to write a sentence.

Social Phobia

a marked, persistent fear of one or more social or performance situations that involve exposure to unfamiliar people or to scrutiny by others. Those afflicted fear that they will act in embarrassing or humiliating ways, as by showing their anxiety. Exposure creates anxiety and possibly a panic attack, and the person avoids precipitating situations. He or she recognizes the fear as excessive or unreasonable. Normal routines, occupational or academic functioning, or social activities or relationships are impaired.

Specific Phobia

a marked, persistent, and excessive or unreasonable fear that is cued by the presence or anticipation of a specific object or situation, such as dogs, injections, or flying. The person recognizes the fear as excessive or unreasonable, but exposure to the cue provokes immediate anxiety. Avoidance or fear impairs the person's normal routine, occupational or academic functioning, or social activities or relationships.

Cultural Competence

a set of attitudes, skills, behaviors, and policies that enable organizations and staff to work effectively in cross-cultural situations. It reflects the ability to acquire and use knowledge of the health-related beliefs, attitudes, practices, and communication patterns of clients and their families to improve services, strengthen programs, increase community participation, and close the gaps in health status among diverse population groups -understanding of and respect for the cultures, traditions, and practices of a community -reduced to a static decontextualized set of traits and beliefs for particular ethnic groups that objectifies patients as "other," implicitly reinforcing the perspectives of the dominant, often Western, culture.[42],[43] - Instead, "culture is ever-changing and always being revised within the dynamic context of its enactment." -However, "this dynamic is often compromised by various sociocultural mismatches between patients and providers."[44] -Such mismatches arise from providers' lack of knowledge about patient beliefs and lived experiences as well as unintentional or intentional enactment of stereotypes and bias during patient encounters.

ROS: Eyes

acuity, glasses, contact lenses, prosthetics, last eye exam (date, where they got it), pain, redness, excessive tearing, double vision, blurred vision, cataracts, glaucoma.

Kappa (κ) measurement of interobserver

agreement. Measures the degree of observer agreement, or precision, of a clinical finding compared to agreement by chance alone.

Agorophobia

an anxiety about being in places or situations where escape may be difficult or embarrassing, or help unavailable. Such situations are avoided, require a companion, or cause marked anxiety.

ROS Hematologic/Hematopoietic

anemia, abnormal bleeding, adenopathy (swollen glands), bruise easily

anxiety or depression

anxious facial expressions, fidgety movements, cold and moist palms, inexpressive or flat affect, poor eye contact, or psychomotor slowing

Mental status exam

appearance and behavior; speech and language; mood; thoughts and perceptions; and cognitive function, which includes orientation, attention, memory, attention, and higher cognitive functions such as information and vocabulary, calculations, abstract thinking, and constructional ability. -If the patient's consciousness, attention, comprehension of words, or ability to speak seem impaired, assess these deficits promptly. Such patients cannot give a reliable history, and you will not be able to test most of the other mental functions.

Patient with Personal Problems

ask about the different approaches the patient has considered and related pros and cons, others who have provided advice, and what supports are available for different choices -Letting the patient talk through the problem with you is more valuable and therapeutic

Rectal temperature

ask the patient to lie on one side with the hip flexed. Select a rectal thermometer with a stubby tip, lubricate it, and insert it about 3 cm to 4 cm (1½ inches) into the anal canal, in a direction pointing to the umbilicus. Remove it after 3 minutes, then read. Alternatively, use an electronic thermometer after lubricating the probe cover. Wait about 10 seconds for the digital temperature recording to appear -Rapid respiratory rates tend to increase the discrepancy between oral and this temperatures. In these situations, this temperatures are more reliable.

Confidentiality

can be one of the most challenging principles. As a clinician, you are obligated not to repeat what you learn from or know about a patient. This privacy is fundamental to our professional relationships with patients. In the daily flurry of activity in a hospital, it is all too easy to let something slip. You must be on your guard.

cardiac / respiratory distress

clutching of the chest, pallor, diaphoresis, or labored breathing, wheezing, and coughing

Visual Field by Confrontation

cover same eye, wiggle fingers on diagnol -ask pt to look into your eyes. as you return the pt's gaze, plaxe your hands about 2 ft apart lateral to the pt's ears. Wiggle both fingers simultaneously and bring them slowly forward curving inward along the imaginary surface of the bowl toward the central vision of line. Ask the pt to tell you as soon as he/she sees the finger movement.

schizophreniform disorder

has symptoms similar to those of schizophrenia, but they last less than 6 months, and the functional impairment seen in schizophrenia need not be present.

Phys Exam: Rectal

deferred for HNG 515 students Anal musculature strong, anal wink reflex intact, No lesions, masses, hemorrhoids noted, guaiac negative.

Weight loss

defined as loss of 5% or more of usual body weight over a 6-month period -decreased food intake due to anorexia, depression, dysphagia, vomiting, abdominal pain, or financial difficulties; defective gastrointestinal absorption or inflammation; and increased metabolic requirements. Ask about abuse of alcohol, cocaine, amphetamines, or opiates, or withdrawal from marijuana, all associated with weight loss. Heavy smoking also suppresses appetite. -Causes of weight loss include gastrointestinal diseases; endocrine disorders(diabetes mellitus, hyperthyroidism, adrenal insufficiency); chronic infections, HIV/AIDS; malignancy; chronic cardiac, pulmonary, or renal failure; depression; and anorexia nervosa or bulimia. -Weight loss with relatively high food intake suggests diabetes mellitus, hyperthyroidism, or malabsorption. Consider also binge eating (bulimia) with clandestine vomiting. -Who cooks and shops for the patient? Where does the patient eat? With whom? Are there any problems with obtaining, storing, preparing, or chewing food? Does the patient avoid or restrict certain foods for medical, religious, or other reasons? -Poverty, old age, social isolation, physical disability, emotional or mental impairment, lack of teeth, ill-fitting dentures, alcoholism, and drug abuse increase the likelihood of malnutrition. -Drugs associated with weight loss include anticonvulsants, anti depressants, levodopa, digoxin, metformin, and thyroid medication.1 -If the BMI falls below 18.5, investigate possible anorexia, bulimia, or other serious medical conditions. -Causes of weight loss include malignancy, diabetes mellitus, hyperthyroidism, chronic infection, depression, diuresis, and successful dieting.

Aphasia

disorder of language -Remember that deficiencies in vision, hearing, intelligence, and education may also affect performance. Two common kinds of aphasia—Wernicke's and Broca's - A person who can write a correct sentence does not have aphasia.

Delirium/dementia

documented or suspected brain lesions, psychiatric symptoms, or reports from family members of vague or changed behavioral symptoms need further systematic assessment. Patients may have subtle behavioral changes, difficulty taking medications properly, problems attending to household chores or paying bills, or loss of interest in their usual activities. Other patients may behave strangely after surgery or during an acute illness

ROS: Gastrointestinal

dysphagia, appetite, dietary habits, foodintolerance, pyrosis, abdominal pain, nausea, vomiting, hematemesis, excessive belching orflatus, change in bowel habits, diarrhea, constipation, frequency of bowel movements, hemorrhoids, melena, mucous in stool, hernia, liver orgallbladder disease (hepatitis, jaundice, stones), pancreatitis, use oflaxatives or antacids, history of eating disorders, date of last colonoscopy

ROS: Urinary

dysuria , frequency, urgency, hesitancy, polyuria,incontinence, decreased urinary stream, nocturia, urinary infections, calculi, prostate.

Psychogenic pain

involves the many factors that influence the patient's report of pain—psychiatric conditions like anxiety or depression, personality and coping style, cultural norms, and social support systems.

Pathologic Process

involving diseases of a body structure. There are several such processes, variably classified, including congenital, inflammatory or infectious, immunologic, neoplastic, metabolic, nutritional, degenerative, vascular, traumatic, and toxic.

Wellness Health History

example -This is a (age, race, sex) here today for an annual physical. Last physical was (date) in this office. (Or where they had last exam and who provided it) Denies major illness, hospitalizations, surgeries since last visit (or if they had write it) Reports feeling well today, denies health concerns (if problem it turns into CC not wellness). For this course, your patient (Male or Female) must be at least 50 years old to do a Wellness Health History No chief complain or HPI in wellness health history Be familiar with screening - app or book for both wellness and CC -Focus of wellness visit is prevention - immunizations, Gyn guidelines - mammography, Pap smear CDC - immunizations -If there is no chief complaint, then the HPI is replaced with a this -Example -This is a (age, race, sex) here today for an annual physical. Last physical was (date) in this office. Denies major illness, hospitalizations, surgeries since last visit. Reports feeling well today, denies health concerns.

facial expression

eye contact. Is it natural? Sustained and unblinking? Averted quickly? Absent? -Watch for the stare of hyperthyroidism; the immobile face of parkinsonism; the flat or sad affect of depression. Decreased eye contact may be cultural or may suggest anxiety, fear, or sadness.

Schizoaffective disorder

features of both a major mood disturbance and schizophrenia. The mood disturbance (depressive, manic, or mixed) is present during most of the illness and must, for a time, be concurrent with symptoms of schizophrenia (listed above). During the same period of time, there must also be delusions or hallucinations for at least 2 weeks without prominent mood symptoms.

Health promotion

focus health promotion and counseling on depression, suicide risk, and dementia, three important conditions often overlooked. Also screen routinely for addiction to alcohol or drugs.

body odor

fruity odor of diabetes or the scent of alcohol. -Breath odors can indicate the presence of alcohol, acetone (diabetes), pulmonary infections, uremia, or liver failure.

Info and vocab

helpful for distinguishing mentally retarded adults (whose information and vocabulary are limited) from those with mild or moderatedementia (whose information and vocabulary are fairly well preserved).

health maintenance

immunizations, find out whether the patient has received vaccines for tetanus, pertussis, diphtheria, polio, measles, rubella, mumps, influenza, varicella, hepatitis B, Haemophilus influenzae type B, pneumococci, and herpes zoster. For screening tests, review tuberculin tests, Pap smears, mammograms, stool tests for occult blood, colonoscopy and cholesterol tests, together with results and when they were last performed.

Schizophrenia

impairs major functioning, as at work or school or in interpersonal relations or self-care. For this diagnosis, performance of one or more of these functions must have decreased for a significant time to a level markedly below prior achievement. In addition, the person must manifest at least two of the following for a significant part of 1 month: (1) delusions; (2) hallucinations; (3) disorganized speech; (4) grossly disorganized or catatonic behavior;* and (5) negative symptoms such as a flat affect, alogia (lack of content in speech), or avolition (lack of interest, drive, and ability to set and pursue goals). Continuous signs of the disturbance must persist for at least 6 months. Subtypes of this disorder include paranoid, disorganized, and catatonic schizophrenia.

dual diagnosis

interaction of anxiety and depression in patients with substance abuse, both must be treated for the patient to achieve optimal function -chronic medical illnesses, a group that is especially vulnerable to depression and anxiety -the prevalence of depression and anxiety exceeds 50% and increases with the total number of reported physical symptoms

Neuropathic pain

is a direct consequence of a lesion or disease affecting the somatosensory system. -Over time, may become independent of the inciting injury, becoming burning, lancinating, or shock-like in quality, -It may persist even after healing from the initial injury has occured. -Mechanisms postulated to evoke it include central nervous system brain or spinal cord injury from stroke or trauma; peripheral nervous system disorders causing entrapment or pressure on spinal nerves, plexuses, or peripheral nerves; and referred pain syndromes with increased or prolonged pain responses to inciting stimuli. -These triggers appear to induce changes in pain signal processing through "neuronal plasticity," leading to pain that persists beyond healing from the initial injury.

Nociceptive (somatic) pain

is linked to tissue damage to the skin, musculoskeletal system, or viscera (visceral pain) but the sensory nervous system is intact, as in arthritis or spinal stenosis. It can be acute or chronic. It is mediated by the afferent A-delta and C-fibers of the sensory system. The involved afferent nociceptors can be sensitized by inflammatory mediators and modulated by both psychological processes and neurotransmitters like endorphins, histamines, acetylcholine, serotonin, norepinephrine, and dopamine.

ROS: Musculoskeletal

joint pain, stiffness, edema, heat, rubor (redness) ,deformity, stiffness (limited motion/activity), myalgias (muscle pain or cramps), weakness, bone fractures, arthritis,gout, backache, sciatica.

seven attributes of present illness

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; and (7) associated manifestations

Derailment

loosening of association Speech in which a person shifts from one subject to others that are unrelated or related only obliquely without realizing that the subjects are not meaningfully connected.

utilitarianism

providing the greatest good for the greatest number, building on the work of John Stuart Mill;

pain

wincing, sweating, protectiveness of a painful area, facial grimacing, or an unusual posture favoring one limb or body area