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ADVANCED HEALTH
ASSESSMENT AND DIAGNOSTIC
REASONING
Subjective Data - CORRECT ANSWER -Things the pt tells you Objective data - CORRECT ANSWER -What your seeing, observing, or examining The chief compliant should use the - CORRECT ANSWER -Patient's own words History of present illness nomics - CORRECT ANSWER --OLDCARTS (onset, location, duration, characteristics, aggravating/alleviating, radiation, timing, severity) -OPQRST (onset, provocation, quality, radiation, severity, timing) Concerning health history findings - CORRECT ANSWER --Changes in weight -Fatigue or weakness -Fever, chills, and night sweats Concerning health history findings: changes in weight - CORRECT ANSWER --Rapid or gradual - rapid changes over a few days suggest changes in fluid, not tissue -Weight gain: nutrition vs. medical causes -Weight loss: medical vs. psychosocial causes Concerning health history findings: fatigue and weakness - CORRECT ANSWER -Medical vs. psychosocial Fatigue - CORRECT ANSWER -A sense of weariness or loss of energy Weakness - CORRECT ANSWER -A demonstrable loss of muscle muscle power Concerning health history findings: fever, chills, and night sweats - CORRECT ANSWER --Ask about exposure to illness or any recent travel -Some medications may cause elevated temperature
What are the types of pain? - CORRECT ANSWER --Nociceptive (somatic) -Neuropathic -Idiopathic -Psychogenic -Chronic Nociceptive (somatic) - CORRECT ANSWER --Damage to tissue or viscera but sensory nerves intact -Described as dull, pressing, pulling, throbbing, boring, spasmodic, or colicky Neuropathic - CORRECT ANSWER --Direct trauma to the peripheral or central nervous system -Described as shock like, stabbing, burning, pins and needles Idiopathic - CORRECT ANSWER -No identifiable etiology Psychogenic - CORRECT ANSWER -Related to factors that influence the patient's report of pain (psychiatric conditions, personality and coping style, cultural norms, social support systems) ChronicN - CORRECT ANSWER --Not due to cancer or illness lasting > 3-6 months -Lasting > 1 month beyond the course of an illness -Recurring at intervals over months or years All notes should start with the following documentation: - CORRECT ANSWER --Date of encounter -Patient name (age is also important) -Informant and reliability SOAP format - CORRECT ANSWER --Subjective -Objective -Assessment
A patient presents a routine check-up. You see that the patient's vital signs have already been recorded as follows: T 98.4 F, HR 74, R 18, BP 180/98 What would be the MOST appropriate action related to this patient's vital signs? -A. The blood pressure should be repeated at the next visit -B. Repeat the blood pressure and verify in contralateral arm -C. Check the heart rate again to see if it is regular -D. Listen to the patient's lungs for adventitious sounds - CORRECT ANSWER - B Your patient presents with a chief complaint of chest pain. Which of the following would be the most appropriate first question/statement? -A. Tell me about your chest pain -B. Does your pain radiate to any other area? -C. How many steps can you climb before the pain begins? -D. Do you have any nausea/vomiting/diarrhea? -E. When did your pain start? - CORRECT ANSWER - A In which of the following sections would you use the OLDCARTS mnemonic to attain the required information? -A. Chief complaint -B. History of present illness -C. Social history -D. Personal history -E. Review of systems - CORRECT ANSWER - B Identify if the following are subjective or objective -A. The patient presented with a chief complaint of fever for the last 6 days----B.The patient is well groomed and appears withdrawn -C.You obtained vital signs at this visit -D.The patient denies ever smoking, admits to 2-12oz beers daily, and denies any illicit drug use -E.The patient has ring shaped burns on the forearms resembling the coil of a stove -F.The patient's chest pain radiates to the left arm - CORRECT ANSWER --A: S -B: O
- C:O
-D: S
-E: O
-F: S
A 32 year-old patient is undergoing a physical examination and you document a BMI of 13.2 kg/m2. You recognize: -A. This is a normal BMI -B. This is considered underweight -C. This is considered obesity -D. This is considered severe obesity - CORRECT ANSWER - B A 50 year-old patient reports smoking 1 pack of cigarettes per day since age 20. How would you document this information? -A. 1 PPD x 30 years smoking history -B. 1 PPD smoking history since age 20 -C. 30 pack-years -D. Current smoker with 1 PPD - CORRECT ANSWER - C A patient presents with a superficial burn to the forearm and is complaining of 4/10 pain. Which type of pain is the patient experiencing? -A. Nociceptive or somatic -B. Neuropathic -C. Idiopathic -D. Psychogenic - CORRECT ANSWER - A Types of abdominal pain - CORRECT ANSWER --Somatic/visceral/tension -Inflammatory -Ischemic Warning signs of a surgical abdomen - CORRECT ANSWER --Intractable pain (not responsive to conventional care) followed by vomiting
-Biliary tract disease -Hyperlipidemia (triglycerides) -Medication induced (diabetic medications) -Vascular disease -Hyperparathyroidism with hypercalcemia -Renal transplant patients Pancreatitis: subjective findings - CORRECT ANSWER --Severe abdominal pain (RUQ and or epigastric pain) with radiation to back -Pain is usually intractable inflammatory pain -Severe nausea and vomiting -Subjective fever Pancreatitis: physical examination - CORRECT ANSWER --Abdominal tenderness (+ Murphy's examine) -Abdominal distention -Hypoactive bowel sounds -Signs of severe disease/shock (tachycardia, hypotension, shallow respirations, ascites) -Diaphoresis Pancreatitis: diagnositcs - CORRECT ANSWER --Amylase and lipase: elevated -Leukocytosis - more indicative of necrotizing pancreatitis and should consider a CRP to help confirm -Upright abdominal film -CT scan of abdomen - gas around the pancreas confirms necrotizing pancreatitis Cholecystitis: plan - CORRECT ANSWER --Severity of illness: inpatient admit vs. outpatient management -Refer to surgery vs GI Pancreatitis: plan - CORRECT ANSWER -Inpatient admission (fluids and rest) Appendicitis: risk factors - CORRECT ANSWER --Common in ages 10-30 years
-No other obvious risk factors -Gynecologic disorders and gastroenteritis commonly present as acute appendicitis -Peritonitis development in approximately 36 hours (from 3rd stage) Appendicitis: subjective findings - CORRECT ANSWER --Severe RLQ abdominal pain (starts generalized to the abdomen - umbilicus - RLQ (radiates to the right testicle in males) -Nausea -Loss of appetite -Feeling of the need to defecate (pressure in the peritoneum) -Increased pain with movement and cough -Subjective fever Appendicitis: physical examination - CORRECT ANSWER --RLQ rebound tenderness
- Rosving's, obturator, and Psoas sign -Fever Appendicitis: diagnostic - CORRECT ANSWER --Leukocytosis -Physical examination plays a large part in diagnosis -CT scan (preferred) or abdominal ultrasound Appendicitis: plan - CORRECT ANSWER -Surgical management Diverticulitis: risk factors - CORRECT ANSWER -- > 60 years of age
- Connective tissues diseases -Marfan's syndrome -Chronic constipation -History of diverticula Diverticulitis: subjective findings - CORRECT ANSWER --Generalized of LLQ abdominal pain -Subjective fever -Constipation or diarrhea
GERD: diagnosis - CORRECT ANSWER --Typically, clinical diagnosis -Trial of PPI agents -Endoscopy (when do not improve with PPI or avoidance of triggers) -Ambulatory pH monitoring and LES pressure monitoring (if everything else is negative) PUD: subjective findings - CORRECT ANSWER --H pylori infection -NSAID -Systemic corticosteriod use -Age > 50-55 years (gastric ulcer) Types of PUD - CORRECT ANSWER --Gastric ulcer -Duodenal ulcer Gastric ulcer - CORRECT ANSWER --Epigastric pain with radiation to the back, relieved by antacids, bloating, belching, unexplained weight loss and possible hematemesis -Intractable pain indicates possible rupture -Pain worsens after eating -Nausea and anorexia Duodenal ulcer - CORRECT ANSWER --Epigastric pain with radiation to the back, relieved by antacids, bloating, belching, unexplained weight loss and possible hematemesis -Pain improves with eating -Typically responds to conventional therapy -Wakes patient early in the morning - acts up when GI tract is empty PUD: physical examination - CORRECT ANSWER --Physical exam is typically normal -Possible slight abdominal tenderness -Peritoneal signs - with rupture, duodenum ruptures into pancreas and may present as acute pancreatitis PUD: diagnostics - CORRECT ANSWER --Stool guaiac
-Failed PPI trial -Endoscopy -H. Pylori testing -Serum gastrin levels (if H. pylori testing and history is negative) Indications for EGD (endoscopy) - CORRECT ANSWER --B - bleeding -O - odynophagia (painful swallowing) -W - weight loss (unplanned) -E - early satiety -D - dysphagia (painful or difficulty swallowing) Ectopic pregnancy: historical risk factors - CORRECT ANSWER --Medical history that prevents migration of the egg or prevents implantation in uterus -History of or current tubal infection -History of infertility -History of PID -Previous abdominal or tubal surgery -Previous tubal pregnancy -Use of an intrauterine device Ectopic pregnancy: subjective findings - CORRECT ANSWER --Amenorrhea followed by spotting -Sudden onset of severe abdominal pain -Back pain Ectopic pregnancy: physical examination - CORRECT ANSWER --Tenderness on pelvic examination with palpable mass and blood in the cul-de-sac -Abdominal distending with peritoneal signs (suggestive of rupture) Ectopic pregnancy: diagnostics - CORRECT ANSWER --Urine or serum hCG -Pelvic ultrasound -Culdocentesis (less common diagnostic) - detects blood in the cul-de-sac -Immediate laparoscopy or laparotomy (if rupture is suspected)
Which is NOT a sign indicating the presence of peritonitis: A. Rebound tenderness B. Voluntary guarding C. Borborygmus D. Rigidity - CORRECT ANSWER - C Which of the following diagnoses is consistent with obturator sign? A. Cholecystitis B. Appendicitis C. Diverticulitis D. IrritableBowelSyndrome - CORRECT ANSWER - B Pain and tenderness to palpation in the LLQ is most likely consistent with which diagnosis? A. Cholecystitis B. Appendicitis C. Diverticulitis D. IrritableBowelSyndrome - CORRECT ANSWER - C A patient presents with severe sharp pain in the RUQ after eating a fatty meal. You would expect A. A positive Murphy's sign. B. A positive Cullen's sign. C. Absence of bowel sounds. D. Presence of bloody stool - CORRECT ANSWER - A Lung and Thorax: common symptoms - CORRECT ANSWER --Chest pain
- SOB -Wheezing -Cough -Hemoptysis
Chest pain may arise from: - CORRECT ANSWER --Cardiac -Vascular -Gastrointestinal -Muscoskeletal -Skin pathology -Anxiety Begin assessment with - CORRECT ANSWER -Broad questions How should someone determine the severity of dyspnea? - CORRECT ANSWER --Based on the patient's daily activities -Example - asking about stairs in home and/or how they do with stairs Wheezing is - CORRECT ANSWER --Musical respiratory sounds that may be audible to the patient and others -Whistling sound Cough - CORRECT ANSWER --Ask whether the cough is dry or produces sputum, or phlegm -Ask patient to describe the volume of any sputum and its color, odor, and consistency What is the leading cause of preventable death in the US? - CORRECT ANSWER -Smoking Tactile Fremitus - CORRECT ANSWER --Palpable vibrations -Use ball or ulnar surface of hand -Patient speaks "ninety-nine" Percussion - CORRECT ANSWER -Use to side-to-side later pattern to percuss Auscultation - CORRECT ANSWER --Listen with diaphragm of stethoscope -Instruct pt breathe with mouth open -Use same ladder pattern
-Family hx Asthma: subjective findings - CORRECT ANSWER --SOB -Report of wheezing -Non-productive cough, persistent -Chest tightness -Sleep disturbances -Exercise intolerance -Atopic dermatitis -Symptoms increasing with activity at night Asthma: physical examination - CORRECT ANSWER --Inspiratory and/or expiratory wheezing -Respiratory distress (use of accessory muscles) -Hyperresonance on percussion (severe exacerbations) Asthma: diagnostics - CORRECT ANSWER --Peak flow (monitoring) -Pulmonary function test: obstructive airway disease, fully or partially reversible, results are based on post administration of a short acting bronchodilator Asthma: plan - CORRECT ANSWER --Stepwise pharmacology -Allergen avoidance -Smoking cessation COPD: risk factors - CORRECT ANSWER --Cigarette smoking -Occupational exposures -Family hx - alpha 1, anti-trypsin deficiency (caucasian < 45 years old) COPD: subjective findings - CORRECT ANSWER --SOB -Report of wheezing (intermittently) -Persistent cough (may or may not report mucous production) -Chest tightness
-Activity intolerance -Symptoms are progressive COPD: physical examination - CORRECT ANSWER --Diminished lung sounds -Increased AP chest diameter -Can result in right sided HF (or pulmonale) COPD: diagnostic - CORRECT ANSWER --Chest x-ray -Pulmonary function testing COPD laboratory findings - CORRECT ANSWER --Hypokalemia -Hypochloremia -Increased NaHCO Emphysema vs. Chronic Bronchitis - CORRECT ANSWER --Emphysema: AP diameter - increased, percussion - hyper resonance, no mucous production -Chronic bronchitis: AP diameter - normal, percussion - normal or dull, copious thick blood tinged mucous production Pneumonia: subjective findings - CORRECT ANSWER --Report of productive cough with thick, yellow/green mucus production -Subjective report of: fever, chills, malaise -Chest discomfort Pneumonia: physical examination - CORRECT ANSWER --Fever -Crackles
- egophany -Increased remits -Dullness to percussion -Tachycardia and tachypnea
-Manage cause Pneumothorax: historical risk factors - CORRECT ANSWER --Trauma to the anterior thorax (blunt) -Tall, thin males (Marfan syndrome)
- COPD -Marijuana smoking -Air travel Pneumothorax: subjective findings - CORRECT ANSWER --SOB -Pleuritic chest pain Pneumothorax: physical examination - CORRECT ANSWER --Tachycardia -Tachypnea -Hyperresonance on percussion -Diminished or absent lung sounds -Tracheal shift (tension pneumothorax) Pneumothorax: diagnostic - CORRECT ANSWER -Chest x-ray: visible pleural line with air noted in the pleural space, absence of lung markings Which of the following statements about percussion is true? A. Use the lightest percussion that produces a clear note B. Percussion should be done up and down each side of the chest rather than side to side (one side of the chest to the other) C. Strike using the pad of your tapping finger D. The heart normally produces an area of tympany to the left of the sternum from the 3rd to 5th rib interspaces - CORRECT ANSWER -A Which of the following breath sounds are most often auscultated over the majority of both lungs? A. Vesicular B. Bronchial C. Bronchovesicular
D. Noneoftheabove - CORRECT ANSWER - A You are evaluating a patient complaining of sharp chest pain and SOB after sustaining a MVC with blunt trauma to the chest. Air bags were deployed, and the steering wheel was bent. During your physical examination you note absent breath sounds in the left upper chest and hyperresonance on percussion. What is the most likely diagnosis? A. Pneumothorax B. Hemothorax C. Asthma exacerbation D. COPD exacerbation - CORRECT ANSWER - A A patient has just been diagnosed with pneumonia. Which of the following subjective findings would be most likely to be present in this patient? A. Current temperature of 102.5 F B. Chills C. Ronchi D. Wheezing on examination E. Reported cough F. White foamy sputum production noted with cough G. Consolidation on chest x-ray H. Fatigue - CORRECT ANSWER -B, E, H Which of the following lung sounds would you expect to find in a patient diagnosed with heart failure? A. Crackles B. Rhonchi C. Wheezes D. Pleural friction rub - CORRECT ANSWER - A 4 step approach to evaluating murmurs - CORRECT ANSWER -1. Determine the location of the murmur
- Is the murmur systolic or diastolic
- Is the valve opened or closed
