NR509 Week 2 Midterm Study Guide.pdf

o Comprehensive or focused? § The comprehensive examination is a basic H2T examination but does more than assess body systems § For the focus examination, you will select the methods relevant to a thorough...

o Comprehensive or focused? § The comprehensive examination is a basic H2T examination but does more than assess body systems § For the focus examination, you will select the methods relevant to a thorough assessment of the target problem. Techniques of examination (Note: Be familiar with specific techniques in body system chapters) IPPA: Inspect; Palpate; Percuss; Auscultate. Abdominal assessment: inspection, auscultation, percussion, palpation The head-to-toe physical assessment Chapter 5 Clinical Reasoning, Assessment, and Plan The clinical reasoning processes Kahneman describes two different thoughts processes when making decisions, a theory known as “dual processing. o System 1 or the intuitive system is fast and an automatic reaction to information that functions on mental shortcuts called heuristics, which are formulaic response patterns based on formed habits. These are difficult to change or manipulate. o System 2 or the hypotheticodeductive system is a more tempered, controlled thought process. It is subject to conscious judgments and attitudes and uses logic and probabilities to come to a conclusion. § This process is time and resource intensive and requires more cognitive effort. The problem list o Make a list of problem identified during the interview o After you complete the clinical record for the current patient encounter, it is good clinical practice to generate a Patient Problem List that summarizes the patient’s problems to be included on the patient’s summary page in the electronic health record (EHR). This list lives outside of any particular clinical note and includes all of the patient’s significant problems. In contrast, the problem list documented with the assessment and plan for a particular encounter includes only those problems identified or addressed then. o list the most active and serious problems first and record their date of onset. The differential diagnosis (DDx) list o List all possible explanations for CC o Always include “worst case scenario” o Most likely listed first o Support with pertinent positives and pertinent negatives o The summary statement  o In your clinical documentation, the problem representation is called the Summary Statement. o A summary statement should not simply be a recitation of the facts. The elements of an effective summary statement include a restated patient’s chief complaint and its clinical context with the salient historical information, physical examination findings, and study data results. A summary statement: o Is the chief complaint placed in context of patient’s overall health status o Includes pertinent parts of the history, physical examination, and lab data o Is succinct and short (no more than two to three sentences) o Demonstrates your clinical reasoning skills o Should make a case for the diagnosis o Is a distillation of your understanding of the case Beginning of assessment part of SOAP Restated CC Significant medical /family/social history Physical exam findings Diagnostics results No more than 2-3 sentences Assessment (medical diagnoses) o Each problem is listed in order of priority and expanded with an explanation of supporting findings and a differential diagnosis, followed by a plan for addressing that problem. Planning (treatment and interventions) o make a list of all of the patient’s problems addressed during the clinical encounter The key characteristics included are the patient information (age) and the chief complaint (duration, quality, associated symptoms). Only the salient characteristics are included. For example, the chronic duration of 3 months rules out many acute life-threatening processes such as meningitis, subarachnoid hemorrhage, and stroke. The clinical context here is her history of migraines since childhood. The key parts of the physical examination include pertinent positives (elevated blood pressure that might be related to hypertensive causes of headaches) and pertinent negatives (normal neurologic examination) that make serious space-occupying lesions causing increased intracranial pressure less likely. Nausea and vomiting are discussed under “headache” on the problem list. Despite their different anatomic location, they are recognized as part of a cluster of clinical findings that are all related to a common diagnosis. A single elevated blood pressure reading does not qualify as a diagnosis of hypertension. Therefore, this abnormal physical examination finding is reported as “elevated blood pressure” in the problem list. Most likely the patient symptom of stress incontinence and the physical examination finding of cystocele are discussed together under a single diagnosis, as they are causally related. Chapter 6 The CAGE questionnaire was developed to identify alcohol abuse. It comprises questions concerning Cutting down, Annoyance, Guilty feelings, and Eye-openers. Although many patients may have dual diagnoses or multiple substances that they abuse, it has been validated as an effective tool in initial screening for alcohol abuse Chapter 7 Evaluating Clinical Evidence. Rationale: High specificity means that a test is negative for most of the people who actually do not have the condition tested for, thus a negative result strongly predicts that the person does not have disease. Because high specificity does not address false negatives (negative results in individuals who actually have the disease), a highly specific test is good at ruling out true positive cases but may or may not be good at ruling it truly negative cases (this is determined by sensitivity). In this case, if a test shows that the patient is positive for strep, the patient is very likely to have strep, because the specificity is high. Using elements of the physical examination as diagnostic tests E.g., Positive Murphy sign suggestive of inflammatory irritation of the gallbladder Evaluating diagnostic tests Sensitivity is the probability that a person with disease has a positive test. Sensitivity is also known as the true positive rate. Specificity is the probability that a nondiseased person has a negative test. Specificity is also known as the true negative rate. Likelihood ratios >1 are associated with positive results and an increased probability for disease. Likelihood ratios 10–15 mm Hg between the right and left arm should be recognized as abnormal and in need of further evaluation. Subclavian steal syndrome (reversal of blood flow in some arteries due to occlusion of the subclavian artery) and aortic dissection (a tearing of the inner layer of the aorta) may both present with this blood pressure discrepancy, and both are considered medical emergencies. The accepted normal values for blood pressure are lower for ambulatory measurements compared with office measurements. Rationale: Blood pressure