CS Exam II Outline - clinical notes PDF

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clinical notes...

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Test%Review%Outline% % 1. Greeting** a. Shake*patient*hand* b. Identify*yourself*and*explain*your*role* c. Remark*confidentiality* d. Ask*the*general*data*(5*things)* i. Name* ii. Age* iii. Marital*Status* iv. Profession* v. Religion* 2. Chief*Complain*(open*ended*questions)* a. How*can*I*help*you?*/*Why*are*you*here*today?* b. Can*you*tell*me*more*about*it?** i. Try*to*get*as*much*information*from*the*patient*(the*whole*story)* c. Anything*else?* 3. Set*the*agenda* a. Tell*the*patient*you*will*be*asking*questions* b. Specify*it*will*take*10-*15*min* c. Ask*if*they*have*time* 4. HPI* a. Asses*the*complaint*per*LIQOPPPRAAA*/*DOCPPPFAAA% * Location*–*can*you*point*where*it*hurts?* Intensity*–*on*a*scale*on*1/10*how*much?* Quality*–*how*would*you*describe*your*pain?* Onset*–*when*did*the*pain*began?* Precipitating%events*–*where*you*doing*something*specific* when*the*pain*started?* Previous%episodes*–*has*this*ever*happened*before?* Progression*–*is*the*pain*getting*better*or*worse?* Radiation*–*is*the*pain*moving*or*staying*in*the*same* place?* Alleviating%factors*–*anything*making*the*pain*go*away?* Aggravating%factors*–*anything*making*the*pain*worst?* Associated%symptoms*–*are*you*feeling*anything*else* related*to*your*pain?*

Description*–*what*are*you*feeling?* Onset*–*when*did*it*began?* Continuity*–*does*it*comes*and*go*or*is*it*constant?* Precipitating%events*–*where*you*doing*something*specific* when*the*pain*started?* Previous%episodes*–*has*this*ever*happened*before?* Progression*–*is*the*pain*getting*better*or*worse?* Frequency*–*how*often*do*you*feel*this/this*happens?* Alleviating%factors*–*anything*making*the*pain*go*away?* Aggravating%factors*–*anything*making*the*pain*worst?* Associated%symptoms*–*are*you*feeling*anything*else* related*to*your*pain?

5. Patient’s*perspective* a. How*do*you*fell*about*all*this?* b. What*do*you*think*is*causing*this?* c. How*is*this*affecting*your*life?* d. Expectations*for*this*visit?* 6. Summarization* a. Repeat*what*you*understood*from*the*patient*(be*as*specific*as*possible)* b. Specify*to*the*patient*to*correct*you*if*they*think*you*left*something*out*or* forgot*something*or*got*a*piece*of*information*wrong.*

7. Transitions* a. Always*make*a*brief*introduction*when*you*change*sections*previewing*the* types*of*questions*you*will*be*asking* 8. PMI* a. Asses*pass*medical*history*per*PAM%HITS%FOSS* i. Prenatal*–*any*complications*during*the*patient’s*own*pregnancy?* ii. Allergies*–*do*you*have*any*allergies?* iii. Medications*–*do*you*currently*take*any*medications?* iv. Hospitalizations*–*any*previous*hospitalizations?* v. Immunizations*–*are*your*immunizations*are*up*to*date?* vi. Trauma/Travel*–*have*you*suffered*from*any*trauma/*accidents?*Have* you*recently*traveled*to*other*countries*outside*of*the*DR?* vii. Family%History*–*Ask*about*2-3*generations*(parents,*grandparents,* siblings)*Have*your*[insert*relatives]*suffered*from*any*diseases*or* illnesses?* 1. E.g.*diabetes,*arthritis,*heart*disease,*cancer,*congenital* disorders…* viii. Obstetrics*(if*patient*is*a*female)* 1. 2. 3. 4. 5. 6.

when*was*your*first*menstruation?*Your*last?* Do*you*consider*your*menstrual*period*to*be*regular*or* irregular?* How*many*days*between*menstrual*period?* How*many*pads/tampons*per*day?* Any*pain*along*with*your*menstrual*period?* Have*you*ever*been*pregnant?*

7. 8.

a. How*many*times?* b. Did*all*came*to*term?* c. Have*you*had*any*abortions?* d. Did*you*have*a*vaginal*birth*or*Cesarean*section?* Last*visit*to*gynecologist?* Last*time*since*last*pap.*Smear?* a. What*were*the*results*of*that*pap.*Smear?*

ix. Psychiatrics%–*have*you*ever*been*diagnosed*with*a*psychiatric* condition?* 1. If*so,*do*you*currently*take*any*medications?* x. Social%history*per*WHARTED* 1. Work*–*what*do*you*do?* 2. Household*–*who*do*you*live*with?*/*conditions*of*the*household* (access*to*clean*water…)* 3. Alcohol%consumption*(CAGE)* a. Cut-down:*have*you*tried*to*cut*down?* b. Annoyed:*do*you*feel*annoyed*when*someone*points*out* your*drinking*habits?* c. Guilty:*have*you*ever*felt*guilty*about*your*drinking?* d. Eye%opener:*Have*you*ever*had*a*drink*first*thing*in*the* morning?* 4. Recreational%drugs:*Do*you*use/consume*any*recreational*drugs?* a. Which*type*of*drug(s)?* b. How*do*you*use*it*(inhaled/injectable…)?* c. Last*time*you*used*it?* 5. Tobacco%consumption:*do*you*consume*any*tobacco*products?* a. How*low*have*you*been*smoking?*

b. How*many*packs*per*year?* c. Have*you*ever*tried*to*quit?* 6. Exercise:*do*you*practice*any*exercise*apart*from*daily* movements?* 7. Diet:*what*is*your*daily*diet?* xi. Sexual%history% 1. What*is*your*sexual*preference?* 2. How*many*numbers*of*sexual*partners*in*the*past*year?* 3. How*many*numbers*of*sexual*partners*in*the*past*6*months?* 4. Do*you*use*condoms?* 5. Any*history*of*previously*diagnosed*sexually*transmitted* diseases/infections?* 6. Last*HIV*test?* 9. ROS* a. Ask*2-3*questions*per*system* i. Head*(ear,*eyes,*nose,*throat)* ii. neck* iii. respiratory* iv. cardiovascular* v. muscular* vi. gastro* vii. urinary* viii. genital* ix. endocrine* b. Minimum*of*10*questions* c. Stick*to*yes/no*questions* 10. Clarify*what*you*understand*with*the*patient* 11. Summarization* 12. Closure* 13. Plan* a. Work*a*plan*for*the*patient.* b. Negotiate*with*the*patient*for*a*work*plan.* c. State*a*follow-up*plan.*...