46 Questions
What is an example of the technique of echoing?
Repeating the patient's words
What type of finding is pain in the right lower quadrant?
Subjective finding
Which of the following is an objective finding?
Accelerated heart rate
What type of information is the patient's report of a cut over their eye?
Subjective information
Which examination technique involves striking the middle finger of one hand against the middle finger of the other?
Percussion
Where should the clinician begin the examination of a patient who complains of always feeling tired and hungry?
Lower extremities
What is an example of an open-ended question?
How many steps can you climb?
What is the primary focus of the FIFE model in patient care?
To understand the patient's emotional and intellectual landscape
Why is it important to use the FIFE model in patient care?
To avoid missing aspects of a patient's illness experience
What is the purpose of percussion?
To determine the size and health of internal organs
What is the purpose of echoing in patient interviewing?
To encourage the patient to continue their narrative
What is an example of a leading question?
That chest pain is probably from your heart, isn’t it?
What is the main difference between subjective and objective findings?
Subjective findings rely on the patient's report, while objective findings are measurable
What is an example of a clarifying question?
His pain was that also located above the belly button as yours is?
What is the purpose of encouraging with continuers in patient interviewing?
To encourage the patient to expand on their narrative
What is the primary goal of the FIFE model in patient care?
To understand the patient's emotional and intellectual landscape
What is the benefit of using the FIFE model in patient care?
It ensures that no aspects of the patient's illness experience are missed
What is an example of echoing in patient interviewing?
Just like?
What is the purpose of clarifying questions in patient interviewing?
To clarify the patient's concerns
What is the benefit of encouraging with continuers in patient interviewing?
It encourages the patient to expand on their narrative
What is the main difference between subjective and objective data in a health history?
Subjective data is what the patient tells you, while objective data is what you detect during the examination
What is the purpose of the review of systems in a health history?
To gather information about the patient's symptoms and health status
Which of the following is a component of the SOAP note?
Subjective, objective, assessment, and plan
What is the purpose of the US Preventative Service Task Force?
To develop screening recommendations for patients
What is the term for the probability that a person with a disease has a positive test result?
Sensitivity
When conducting a physical examination, what is the recommended order to optimize patient comfort and ensure that nothing is missed?
Head and neck, posterior thorax, abdomen, lower extremities
What is the purpose of the clinical reasoning process?
To generate hypotheses and develop a diagnosis and treatment plan
What is included in the assessment and plan component of the SOAP note?
The diagnosis and differential diagnosis, and the plan for each problem
What is the primary component of the past history that a physician assistant omitted during the patient's first visit?
Immunizations
What is the medical term that defines obesity in a patient?
A patient with a body mass index (BMI) >30
What is the purpose of the health maintenance and screening component of healthcare?
To prevent and detect health problems through screenings and vaccinations
What is the primary purpose of the CAGE questionnaire?
To identify alcohol abuse
The CAGE questionnaire is primarily used to evaluate for which of the following?
Alcohol misuse
What is the primary reason for starting a physical examination from the head and neck?
To minimize the number of changes in patient position
What is the most important consideration when dealing with the patient's symptoms?
Ruling out potential life-threatening problems
What is the primary component of the past history that includes childhood illnesses and adult illnesses?
Health maintenance behaviors
What is the suspected diagnosis given the patient's symptoms?
Myocardial infarction (MI)
What is the recommended approach to conducting a physical examination?
Proceeding from the top down to optimize patient comfort
Why did the patient experience intense substernal chest pain?
Due to heavy lifting at work
What step of clinical reasoning did the PA fail to follow?
Give special consideration to potential life-threatening problems
What is the primary purpose of inquiring about a patient's family history?
To identify potential risk factors for the present illness
Why is eliciting information about the patient's family history of digestive disorders not the correct answer?
Because it is not the most important next step
What is the primary advantage of using the CAGE questionnaire in a patient evaluation?
It is a quick and effective screening tool for alcohol misuse
What is the primary concern when dealing with the patient's symptoms?
Ruling out potential life-threatening problems
What is the primary difference between a patient's past history and present illness?
The past history focuses on previous illnesses, while the present illness focuses on current symptoms and diagnoses
What is the potential consequence of not considering life-threatening problems first?
Delayed treatment of a myocardial infarction (MI)
Study Notes
Health History Components
- Identifying patient information: gathering data about the patient, including their chief complaint, medical history, and personal and social history
- Source of history: identifying the source of the patient's information, such as the patient themselves, family members, or medical records
- Chief complaint: the patient's primary reason for seeking medical attention
- History of present illness: a detailed description of the patient's symptoms, including their onset, duration, and severity
- Past medical history: a review of the patient's previous medical conditions, illnesses, and surgeries
- Family history: a review of the patient's family medical history, including genetic disorders and illnesses
- Personal and social history: a review of the patient's lifestyle, including their occupation, diet, and social habits
- Review of Systems: a review of the patient's symptoms and medical history, organized by body system
Subjective vs. Objective Data
- Subjective data: information provided by the patient, including their symptoms, feelings, and experiences
- Objective data: information gathered by the clinician through observation, examination, and laboratory tests
Physical Examination
- Setting the stage: preparing the patient and the environment for the examination
- Preparing equipment: gathering necessary equipment, such as a stethoscope and blood pressure cuff
- Making the patient comfortable: ensuring the patient's physical and emotional comfort during the examination
- Suggested Head-to-Toe Physical Examination: a systematic approach to examining the patient's body, from head to toe
- Documenting findings: recording the results of the examination, including any abnormalities or concerns
Clinical Reasoning, Assessment, and Plan
- Clinical reasoning: the process of gathering and interpreting information to develop a diagnosis and treatment plan
- Gathering initial patient information: collecting data through the health history and physical examination
- Organizing and interpreting information: analyzing the data to identify patterns and relationships
- Generating hypotheses: developing potential diagnoses based on the data
- Testing hypotheses: evaluating the hypotheses through further examination, testing, and consultation
- Planning the diagnostic and treatment strategy: developing a plan to diagnose and treat the patient's condition
SOAP Notes
- Subjective: documenting the patient's subjective data, including their symptoms and experiences
- Objective: documenting the patient's objective data, including examination findings and laboratory results
- Assessment: documenting the clinician's interpretation of the data, including the diagnosis and treatment plan
- Plan: documenting the plan for further diagnosis and treatment, including medications, procedures, and follow-up care
Health Maintenance and Screening
- US Preventative Service Task Force: a organization that recommends screening and preventive services for various populations
- Screening recommendations: guidelines for screening tests, such as mammograms and colonoscopies
- BMI assessment and diabetes screening: assessing the patient's body mass index and screening for diabetes
- Substance use disorders screening: screening for substance abuse and dependence
- Screening for intimate partner violence and elder abuse: screening for signs of abuse and neglect
- STI screening: screening for sexually transmitted infections
- HIV screening: screening for HIV infection
- Immunizations: administering vaccinations to prevent infectious diseases
Evaluating Clinical Evidence
- Evaluating diagnostic tests: assessing the validity and reliability of diagnostic tests
- Validity: the accuracy of a diagnostic test in identifying a disease or condition
- Sensitivity: the ability of a diagnostic test to detect a disease or condition in people who have it
- Specificity: the ability of a diagnostic test to exclude a disease or condition in people who do not have it
- Critical appraisal of clinical evidence: evaluating the quality and relevance of research evidence to inform clinical practice
Test your knowledge of the components of a health history, including identifying patient information, source of history, chief complaint, and history of present illness.
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