Podcast
Questions and Answers
What is the primary role of a clinical pharmacist?
What is the primary role of a clinical pharmacist?
Which component is NOT included in the clinical assessment process?
Which component is NOT included in the clinical assessment process?
The SCHOLAR approach is used to identify what aspect of a symptom?
The SCHOLAR approach is used to identify what aspect of a symptom?
What differentiates a comprehensive assessment from a focused assessment?
What differentiates a comprehensive assessment from a focused assessment?
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What constitutes clinical assessment in healthcare?
What constitutes clinical assessment in healthcare?
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Which of the following symptoms is associated with the respiratory system?
Which of the following symptoms is associated with the respiratory system?
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What does the 'O' in the 'OLD CARTS' acronym refer to?
What does the 'O' in the 'OLD CARTS' acronym refer to?
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Which attribute of a symptom does the 'A' in 'SCHOLAR' represent?
Which attribute of a symptom does the 'A' in 'SCHOLAR' represent?
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In the context of a focused assessment, what is the primary goal?
In the context of a focused assessment, what is the primary goal?
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What are the suggested initial actions during a review of systems (ROS)?
What are the suggested initial actions during a review of systems (ROS)?
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Which of these symptoms is a common gastrointestinal issue?
Which of these symptoms is a common gastrointestinal issue?
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What does the 'L' in the 'SCHOLAR' acronym stand for?
What does the 'L' in the 'SCHOLAR' acronym stand for?
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Which of the following is NOT a symptom of the genitourinary system?
Which of the following is NOT a symptom of the genitourinary system?
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What does the 'C' in the 'OLD CARTS' acronym represent?
What does the 'C' in the 'OLD CARTS' acronym represent?
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Which of the following findings is considered a cardiovascular symptom?
Which of the following findings is considered a cardiovascular symptom?
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What does the 'Chief Complaint' (CC) section of a comprehensive health history primarily document?
What does the 'Chief Complaint' (CC) section of a comprehensive health history primarily document?
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Which component is NOT typically included in the Review of Systems (ROS)?
Which component is NOT typically included in the Review of Systems (ROS)?
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What vital signs are evaluated during the clinical assessment?
What vital signs are evaluated during the clinical assessment?
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The 'History of Present Illness' (HPI) section requires a:
The 'History of Present Illness' (HPI) section requires a:
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Which aspect is assessed under the Social History (SHx)?
Which aspect is assessed under the Social History (SHx)?
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What factors would be recorded in the 'Allergies and Intolerances' section?
What factors would be recorded in the 'Allergies and Intolerances' section?
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Which of the following is included in the assessment of 'Psychiatric (PSYCH)' symptoms?
Which of the following is included in the assessment of 'Psychiatric (PSYCH)' symptoms?
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In the context of the 'Head, Ears, Eyes, Nose, Throat' (HEENT) section, which is NOT a symptom assessed?
In the context of the 'Head, Ears, Eyes, Nose, Throat' (HEENT) section, which is NOT a symptom assessed?
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Which of the following accurately describes 'Family History (FHx)'?
Which of the following accurately describes 'Family History (FHx)'?
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Which body system is included in the assessment of the 'Review of Systems' (ROS)?
Which body system is included in the assessment of the 'Review of Systems' (ROS)?
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Study Notes
Introduction to Clinical Assessment
- Clinical Assessment: Evaluation of a patient's physical condition based on information from physical examination, laboratory tests, and patient history.
- Clinical Pharmacists: Provide comprehensive medication management and patient care in a variety of settings, collaborating with other healthcare providers to optimize patient outcomes.
- Clinical Assessment Process: Includes patient assessment, medication therapy evaluation, development and implementation of care plans, follow-up, medication monitoring, and documentation.
Understanding Clinical Assessment
- Clinical assessment requires integration of knowledge and skills.
- The steps involve conducting a comprehensive health history and a head-to-toe review of systems.
Comprehensive Health History
- The comprehensive health history comprises nine sections:
- Identifying Data: Date, time, age, gender, occupation, and marital status.
- Chief Complaint (CC): The reason the patient seeks care, quoted in their own words.
- History of Present Illness (HPI): Detailed, chronological account of the presenting problem, including symptoms, treatments, and risk factors.
- Past Medical History (PMHx): Chronic illnesses, surgeries, obstetric/gynecological history, psychiatric history, and immunizations.
- Medication History (MHx): List of prescription and non-prescription medications, vitamins, supplements, and alternative health products.
- Allergies and Intolerances: Date of reaction and symptoms.
- Family History (FHx): Presence or absence of specific illnesses in family members.
- Social History (SHx): Education, ethnicity, home situation, support system, interests, lifestyle, activities of daily living, exercise, and diet.
- Review of Systems (ROS): Documents presence/absence of common symptoms related to each major body system.
Review of Systems (ROS)
- The ROS encompasses 10 major body systems:
- Vital Signs (VS): Temperature, heart rate, respiratory rate, blood pressure, height, and weight.
- Psychiatric (PSYCH) and Neurologic (NEURO): Evaluates mental status, mood, behavior, cognitive function, sleep, and neurological symptoms.
- Skin, Hair, and Nails (DERM): Assesses skin integrity, rashes, lesions, color changes, hair loss, and nail abnormalities.
- Head, Ears, Eyes, Nose, Throat (HEENT): Evaluates head, ears, vision, sinuses, and throat function.
- Respiratory (RESP): Assesses breathing patterns, cough, wheezing, sputum production, and chest pain.
- Cardiovascular (CV): Elicits information related to heart rate, palpitations, chest pain, and blood pressure.
- Gastrointestinal (GI): Assesses digestion, bowel habits, abdominal pain, and changes in appetite.
- Genitourinary (GU): Evaluates urinary patterns, reproductive health, sexual function, and pain.
- Peripheral Vascular System (PVS): Evaluates extremities, circulation, swelling, pain, and pulses.
- Musculoskeletal (MSK): Evaluates joint pain, stiffness, swelling, muscle weakness, and deformities.
Attributes of a Symptom
- The “SCHOLAR” approach helps analyze symptoms in more detail:
- Symptoms: What are the main and associated symptoms?
- Characteristics: What are the symptoms like?
- History: What has been done so far? Have similar symptoms occurred in the past?
- Onset: When did it start?
- Location: Where is the problem?
- Aggravating Factors: What makes it worse?
- Relieving Factors: What makes it better?
Comprehensive vs. Focused Assessment
- Comprehensive assessment: Ideal for new patients, provides a foundational understanding of the patient, helps identify or rule out physical causes, and strengthens the relationship.
- Focused assessment: Efficient for established patients, addresses specific concerns and symptoms, assesses symptoms restricted to a specific body system, and uses relevant examination methods.
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Description
This quiz covers essential concepts in clinical assessment, including the evaluation of physical conditions, the role of clinical pharmacists, and the comprehensive health history process. Test your understanding of integrating knowledge and skills in patient care and the assessment process. Perfect for students and professionals in healthcare.
