Study Guide Quiz 1 PDF

Study Guide Quiz 1 37 questions covering Modules 1 and 2 Module objectives completed and in the “Assessment” folder on google drive Week 1 Know the difference between subjective and objective information ○ Subjective Information from the client's point of view (“symptoms”), including feelings, perce...

Study Guide Quiz 1 37 questions covering Modules 1 and 2 Module objectives completed and in the “Assessment” folder on google drive Week 1 Know the difference between subjective and objective information ○ Subjective Information from the client's point of view (“symptoms”), including feelings, perceptions, and concerns obtained through interviews Chief complaint: the reason the patient is seeking assistance, written in quotes on your ROS HPI: History of present illness, a detailed description of the primary problem using symptom analysis ○ Objective Observable and measurable data (“signs”) obtained through observation, physical examination, and laboratory and diagnostic testing Understand the components of a full and focused exam ○ Comprehensive Assessment Identifying data and source of the history; reliability CC HPI PQRST Past medical history Including immunizations, allergies and responses, screening exams, childhood illnesses Family history Age and health Genogram ○ 2-3 generations Personal and social history Tobacco use (Pack years), ETOH (be specific!!), Occupation, nutrition, exercise (How much? How often? For how long?), stress management, sleep Review of systems Head to toe subjective data Be sure to use pertinent negatives (“denies chest pain”) or positives (c/o SOB) ○ Never written as “no problems” ○ Focused Assessment Identifying data CC HPI PQRST Data from PMH, FH, SH, that pertain to complaint ROS that pertains to complaint ○ Last question of any interview Is there anything else you want to tell me? This study source was downloaded by 100000879392735 from CourseHero.com on 05-06-2024 15:11:14 GMT -05:00 https://www.coursehero.com/file/38834963/study-guide-1-completedpdf/ Review the approaches to discussing sensitive topics ○ Be aware of self and how personal judgments affect way of thinking ○ Confidentiality is of high importance ○ Patient’s autonomy can not be ignored ○ Be direct and firm ○ Do not apologize for questions ○ Do not preach ○ Do not push too hard ○ Must be ready to explain why you need to ask ○ Explore patient's feelings ○ Offer patient opportunity to ask questions ○ Questions should be gender neutral Are your partners men, women, or both? ○ Legalities Notification in cases of sexual abuse etc Cultural competence ○ Any culture has 4 basic characteristics Learned from birth through language and socialization Shared by all members of the same group Can be adapted to situations Dynamic and ever changing ○ Assess What are the pts personal beliefs about health? What religious influences may affect care? What language is primary? What are the roles in the family? Are there special dietary practices that may influence compliance or recovery? ○ Important to Recognize diversity Demonstrate respect to the unfamiliar Identify own cultural beliefs Don’t stereotype Learn the facts Develop plan with culture in mind Review the different specific assessment tools ○ 2 question depression screening: In The last month have you been bothered by : Little interest or pleasure in doing things? ○ Yes No Feeling down, depressed, or hopeless? ○ Yes No If the patient’s response to both questions is no, it is negative If the patient responded yes to either question it requires further assessment. ○ MMSE Mini Mental State Exam Standardized screening tool of mental status This study source was downloaded by 100000879392735 from CourseHero.com on 05-06-2024 15:11:14 GMT -05:00 https://www.coursehero.com/file/38834963/study-guide-1-completedpdf/ ○ ○ ○ ○ Max: 30 Depressed clients w/o dementia score 24-30 Score of 20 or less is found with dementia, delirium, schizophrenia or an affective disorder MOCA Montreal Cognitive Assessment A brief (10 min) screening tool for mild cognitive impairment More sensitive for the early or mild impairment which is a risk factor for dementia Normal score of 26-30 Lower score require more in-depth assessment Beck's Depression scale Assess severity of depression in adults and adolescents (13 and up) without a diagnosis of a psychiatric illness Not a sole diagnostic measure Highly reliable Score of < 15: mild depression Score 15-30: Moderate depression Score > 30: Severe depression PHQ-9 Rates the frequency of symptoms to score severity Can be utilized multiple times to show trends Question 9 asks about suicide ideation Score 5-9: minimal symptoms Score 10-14: mild depression Score 15-19: major depression, moderately severe Score > 20: major depression, severe Duke Activity Index A self-administered questionnaire that measures a patient's functional capacity. It can be used to get a rough estimate of a patient's peak oxygen uptake. Assesses the functional capacity of patients with cardiovascular disease (CVD) Final score ranges between zero and 58.2 points. The higher the score, the better the functional capacity Review the components of the HPI ○ A complete, clear and chronologic description of the problems prompting the patient's visit ○ Symptom Analysis P: precipitating/palliative/provocative Q: Quantity or Quality R: Region/Radiation S: Severity T: Timing Includes onset, duration, and frequency Most important: HAVE YOU EVER HAD THIS BEFORE? Make sure to shout it at them Week 2 Review risk factors and findings ○ Important topics for health promotion and counseling This study source was downloaded by 100000879392735 from CourseHero.com on 05-06-2024 15:11:14 GMT -05:00 https://www.coursehero.com/file/38834963/study-guide-1-completedpdf/ Optimal weight, nutrition, and diet BMI > 25 risk for heart disease, HTN, high LDL, low HDL, high triglycerides, hyperglycemia, Blood pressure and dietary sodium A difference of 5g of salt intake a day is linked to a 23% difference in the rate of stroke and a 17% difference in the rate of total cardiovascular disease Daily dietary intake of 2300 mg is tolerable Exercise Go exercise. Findings have found this. Tobacco cessation Adults age 55-80 who at are a high risk for lung cancer undergo annual lung cancer screening with low dose CT scans Know the issues related to sensitive topics ○ See above Understand the different types of prevention ○ Primary prevention Can prevent or arrest disease process by promoting healthier lifestyle or immunizations Ex: wearing a seat belt, wearing a helmet, exercising, eating healthy, flu shot/vaccinations, brushing your teeth, sunscreen All the things which are anticipatory guidance ○ Secondary prevention Detecting and treating early asymptomatic disease Ex: Blood pressure screenings, colon cancer screening, mammograms, pap smear ○ Tertiary prevention Substantial reduction in subsequent morbidity and mortality in an present illness Trying to prevent them from getting sicker Preventing a diabetic ulcer that leads to amputation Ex: Diabetic classes, heart failure guidelines, rehab for someone with a stroke, cardiac rehab Review the components of an exam in relation to billing as to type and time ○ Problem: focused; Chief Complaint, brief HPI Ex: Hurt finger, that's all that needs to be addressed ○ Expanded problem focused: CC, Limited exam of affected body area or organ system and other symptomatic or related organ system Ex: COPD: listen to heart and lungs, check for clubbing (I examined more than one system but they are all related) ○ Detailed: CC, extended HPI, problem pertinent ROS and a few additional pertinent PMH, SH &/or FH related to problem Extend exam above ○ Comprehensive CC, extended HPI, full ROS, complete past, family, and social history A general multi system exam or complete exam of single organ system ○ Complexity of medical decision making This study source was downloaded by 100000879392735 from CourseHero.com on 05-06-2024 15:11:14 GMT -05:00 https://www.coursehero.com/file/38834963/study-guide-1-completedpdf/ Four types Straightforward Low complexity Moderate complexity High complexity Review the type/definition of each of the 5 billing levels ○ Levels of Evaluation and Management History Problem focused ○ CC, brief HPI Expanded problem focused ○ CC, brief HPI, pertinent problem system review Detailed: ○ CC, extended HPI, problem pertinent ROS and other addition PMH, SH and /or FH Comprehensive ○ CC, extended HPI, full ROS, complete PMI, FH and SH Examination Problem focused ○ Limited exam of affected body area Expanded problem focused ○ Limited exam of affected body area and other symptoms related to affected system Detailed ○ Extended exam of above Comprehensive ○ A general multi system exam or complete exam of single organ system Medical decision making Straightforward Low complexity Moderate complexity High complexity Contribution Counseling ○ Discussion of results, prognosis, risks benefits, risk factor reduction, patient and family education Coordination of care ○ When counseling/coordination of care composes > 50% of encounter time it is considered the key to qualify for a level Nature of presenting problem ○ Minimal minimal ○ Self-limited or minor Runs a definite and predictable course ○ Low severity Risk of morbidity w/o treatment is low, full recover q/o functional impairment is likely ○ Moderate severity This study source was downloaded by 100000879392735 from CourseHero.com on 05-06-2024 15:11:14 GMT -05:00 https://www.coursehero.com/file/38834963/study-guide-1-completedpdf/ ○ Risk of morbidity w/o treatment is moderate, mod risk for mortality, uncertain prognosis High severity Risk of mortality w/o treatment is high to extreme, moderate to high risk of mortality, prolonged functional impairment This study source was downloaded by 100000879392735 from CourseHero.com on 05-06-2024 15:11:14 GMT -05:00 https://www.coursehero.com/file/38834963/study-guide-1-completedpdf/ Powered by TCPDF (www.tcpdf.org)