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NR 509 Midterm Study Guide Week 3
NR 509 Midterm Study Guide
Week 3
Ch. 1 ● Basic and Advanced Interviewing Techniques
Basic Interviewing Techniques
● Active listening: Active listening means closely attending to what the patient is communicating, connecting to the patient's emotional state, and using verbal and nonverbal skills to encourage the patient to expand on his or her feelings and concerns. ● Empathic responses: Empathy has been described as the capacity to identify with the patient and feel the patient's pain as your own, then respond in a supportive manner. ● Guided questioning: Guided questions show your sustained interest in the patient's feelings and deepest disclosures and allows the interviewer to facilitate full communication, in the patient's own words, without interruption. ● Nonverbal communication: Nonverbal communication includes eye contact, facial expression, posture, head position and movement such as shaking or nodding, interpersonal distance, and placement of the arms or legs—crossed, neutral, or open. ● Validation: Validation helps to affirm the legitimacy of the patient's emotional experience. ● Reassurance: Reassurance is an appropriate way to help the patient feel that problems have been fully understood and are being addressed. ● Partnering: When building rapport with patients, express your commitment to an ongoing relationship. ● Summarization: Giving a capsule summary of the patient's story during the course of the interview to communicate that you have been listening carefully. ● Transitions: Inform your patient when you are changing directions during the interview. ● Empowering the patient: Empower patients to ask questions, express their concerns, and probe your recommendations in order to encourage them to adopt your advice, make lifestyle changes, or take medications as prescribed. Advanced Interview Techniques
○ Determine scope of assessment: Focused vs. Comprehensive: ■ Comprehensive: Used patients you are seeing for the first time in the office or hospital. Includes all the elements of the health history and complete physical examination. ● Is appropriate for new patients in the office or hospital ● Provides fundamental and personalized knowledge about the patient ● Strengthens the clinician–patient relationship ● Helps identify or rule out physical causes related to patient concerns ● Provides a baseline for future assessments ● Creates a platform for health promotion through education and counseling ● Develops proficiency in the essential skills of physical examination ■ Focused: For patients you know well returning for routine care, or those with specific “urgent care” concerns like sore throat or knee pain. You will adjust the scope of your history and physical examination to the situation at hand, keeping several factors in mind: the magnitude and severity of the patient’s prob- lems; the need for thoroughness; the clinical setting—inpatient or outpatient, primary or subspecialty care; and the time available. ● Is appropriate for established patients, especially during routine or urgent care visits ● Addresses focused concerns or symptoms ● Assesses symptoms restricted to a specific body system ● Applies examination methods relevant to assessing the concern or problem as thoroughly and carefully as possible ○ Being aware of your reactions helps develop your clinical skills. ○ Your success in eliciting the history from different types of patients grows with experience, but take into account your own stressors, such as fatigue, mood, and overwork. ○ Self-care is also important in caring for others. Even if a patient is challenging, always remember the importance of listening to the patient and clarifying his or her concerns. ● Components of the Health History ● Initial information ■ Date and time of history-time is especially important in emergent
chickenpox, rheumatic fever, scarlet fever, and polio. Also include any chronic childhood illness ■ Adult illnesses: Provide information in each of the 4 areas: ● Medical: diabetes, hypertension, hepatitis, asthma and HIV; hospitaliations; number and gender of sexual partners; and risk taking sexual practices. ● Surgical: dates, indications, and types of operations ● Obstetric/gynecologic: Obstetric history, menstrual history, methods of contraception, and sexual function. ● Psychiatric: Illness and time frame, diagnoses, hospitalizations, and treatments. Health Maintenance: Find out if they are up to date on immunizations and screening tests. ○ Family history ■ Outlines or diagrams age and health, or age and cause of death, of siblings, parents, and grandparents ■ Documents presence or absence of specific illnesses in family, such as hypertension, coronary artery disease, elevated cholesterol levels, stroke, diabetes, thyroid or renal disease, arthritis, tuberculosis, asthma or lung disease, headache, seizure disorder, mental illness, suicide, substance abuse, and allergies, and symtoms reported by patient. ■ Ask about history of breast, ovarian, colon, or prostate cancer ■ Ask about Genetically transmitted diseases Personal or social history ■ Describes educational level, occupation, family of origin, current household, personal interests, and lifestyle ■ Capture the patients personality and interests, sources of support, coping style, strengths, and concerns ■ Includes lifestyle habits that promote health or create risk, such as exercise and diet, safety measures, sexual practices, and use of alcohol, drugs, and tobacco ■ Expanded personal and social history personalizes your relationship with the patient and builds a rapport ○ Review of systems
■ Documents presence or absence of common symptoms related to each of the major body systems ■ Understanding and using Review of Systems questions may seem challeng- ing at first. These “yes-no” questions should come at the end of the inter- view. Think about asking a series of questions going from “head to toe.” It is helpful to prepare the patient by saying, “The next part of the history may feel like a hundred questions, but it is important to make sure we have not missed anything.” ■ Most Review of Systems questions pertain to symptoms, but on occasion, some clinicians include diseases like pneumonia or tuberculosis. ■ Note that as you elicit the Present Illness, you may also draw on Review of Systems questions related to system(s) relevant to the Chief Complaint to establish “pertinent positives and negatives” that help clarify the diagnosis. ■ For example, after a full description of chest pain, you may ask, “Do you have any history of high blood pressure
... palpitations... shortness of breath... swelling in your ankles or feet?” or even move to questions from the Respiratory or Gastrointestinal Review of Systems ■ The Review of Systems questions may uncover problems that the patient has overlooked, particularly in areas unrelated to the Present Illness. Significant health events, such as past surgery, hospitalization for a major prior illness, or a parent’s death, require full exploration. Keep your technique flexible. ■ Remember that major health events discovered during the Review of Systems should be moved to the Present Illness or Past History in your write-up. ■ ■ Some experienced clinicians do the Review of Systems during the physical examination, asking about the ears, for example, as they examine them. If the patient has only a few symptoms, this combination can be efficient. If there are multiple symptoms, however, this can disrupt the flow of both the history and the examination, and necessary note taking becomes awkward
● Subjective versus Objective Data ● Subjective versus Objective Data (pg. 7) Subjective Data (symptoms) Objective Data (signs) What the patient tells you What is observed during physical examination Patients history, from Chief Laboratory information, test
Complaint through Review of Systems data ● Documentation Documentation needs to be CLEAR, CONCISE, COMPREHENSIVE. SOAP (subjective, objective, assessment, & plan) note is used for providers of various backgrounds/specialties to communicate with each other. Ch. 2
**1. Clinical Decision Making
- Critical Thinking and Reasoning
- Differential Diagnoses** Differential Diagnosis: A list with potential causes of patient specific problem/CC - A chief complaint (CC) must be identified first. - The differential diagnosis will include all medical disease that may possibly explain problem/ CC. - The differential diagnosis must include the most likely diagnosis and even at times the most serious diagnoses that have serious consequences if undiagnosed and untreated. - The differential diagnosis list should begin with the most likely explanation or etiology for the problem/CC. EX: C/O vomiting blood 1. Peptic ulcer 2. Cirrhosis with bleeding esophageal varices 3. Acute hemorrhagic gastritis
**2. Quality
- Quantity or severity
- Timing, including onset, duration, and frequency
- The setting in which it occurs
- Factors that have aggravated or relieved the symptom
- Associated manifestations** ○ ● Adaptive Questioning ( pg. 69-71) ● Adaptive questioning also known as guided questioning ● ● Techniques of Guided Questioning ● ●Moving from open-ended to focused questions ● Using questioning that elicits a graded response ● ●Asking a series of questions, one at a time ● ●Offering multiple choices for answers ●Clarifying what the patient means ● ●Encouraging with continuers ● ●Using echoing ● Challenging Patients Challenging Patients: The silent patient. The confusing patient. The patient with impaired capacity. The talkative patient. The angry or disruptive patient. The patient with a language barrier. The patient with low literacy or low health literacy. The hearing impaired patient. The blind patient. The patient with limited intelligence. The patient seeking personal advice. The seductive patient. Ch. 4 ● General Approach to the Physical Examination ● Interview Facilitation ○ Use open-ended questions-helps to encourage the patient to describe what they are experiencing ○ Listen and ask common-sense questions ○ Follow a thorough and systematic sequence to history taking and physical
examination ○ Keep an open mind toward both the patient and the clinical data ○ Always include "the worst-case scenario" in your list of possible explanations of the patient's problem, and make sure it can be safely eliminated ○ Analyze any mistakes in data collection or interpretation ○ Confer with colleagues and review the pertinent clinical literature to clarify uncertainties ○ Apply the principles of evaluating clinical evidence to patient information and testing ○ As you talk with and examine the patient, heighten your focus on the patient’s mood, build, and behavior ○ 1. Reflect on your approach to the patient: When greeting the patient identify yourself as a student, beginners spend more time in certain areas and that is ok but just warn the patient that you may want to listen to their heart a little longer but that does not mean anything is wrong ■ Avoid interpreting your findings, you are not the patients primary care provider ■ Avoid negative reactions or showing distaste when finding abnormalities ○ 2. Adjust the lighting and the environment: set the stage so that both you and the patient are comfortable; good lighting and a quiet environment enhance what you see and hear however may be hard to arrange ○ 3. Check your equipment: The following equipment is needed: ■ An ophthalmoscope and an otoscope. If you are examining children, the otoscope could allow pneumatic otoscopy. ■ ●A flashlight or penlight ■ ● Tongue depressors ■ A ruler and a flexible tape measure, preferably marked in centimeters ■ ●Often a thermometer ■ ●A watch with a second hand ■ ●A sphygmomanometer ■ ●A stethoscope with the following characteristics: ■ ●Ear tips that fit snugly and painlessly. To get this fit, choose ear tips of the proper size, align the ear pieces with the angle of your ear canals, and adjust the spring of the connecting metal band to a comfortable tightness. ■ ●Thick-walled tubing as short as feasible to maximize the transmission of sound: ∼30 cm (12 inches), if possible, and no longer than 38 cm (15 inches) ■ ●A bell and a diaphragm with a good changeover mechanism ■ ●A visual acuity card
Also look for elevation, firmness to palpate, growing progressively over several weeks. Self skin exams are recommended by the ACS and AAD. They should be done in a well lit room with a full length mirror. Patients with a family history of melanoma, prior history of melanoma, or history of high sun exposure should do exams more frequently. Teach patient the appearance of different skin cancers and provide internet reliable resources for patients. Usually seen in fair colored patients. ● Primary and Secondary Skin Lesion Nomenclature ● Psoriasis (Hollier page 139) https://www.aad.org/practicecenter/quality/clinical- guidelines/psoriasis ● Characterized by a chronic, pruritic, inflammatory skin disorder characterized by rapid proliferation of epidermal cells. Exacerbations are common. ● Most common forms (plaque psoriasis, plaque like lesions) ● Unknown etiology but common with family history, Beta hemolytic strep in children. Risk factors: ● Strep, family hx, stress, diabetes, obesity, local trauma, sunburn, drugs (lithium, beta blockers, systemic steroids/ rebound effect) ● Assessment findings: ● Silvery white scales on erthymatous base, pruritis, common distribution of elbows, knees, scalp, gluteal cleft, finger/toenails, nails may be pitted in 50% of patients ● Positive Auspitz sign (bleeding when lesions scraped) ● Intergluteal leasions are pink/smooth PROFOUND NEGATIVE SELF IMAGE/ SELF ESTEEM Differential diagnosis:
● Scalp- Seborrheic dermatitis ● Trunk- pityriasis rosea, tinea corporis ● Candida infections ● Contact dermatitis ● Eczema Diagnostic studies: ● Swab for strep, biopsy, ESR/CRP usually elevated Prevention: ● Avoid sun, sudden withdrawl from steroids, stimulating drugs (ACE inh, BB, NSAIDS, PCN, Salicylates, sulfonamides, tetracyclines) Non-pharm management: ● Warm soaks, UV radiation, Oatmeal bath, wet dressings (burows solution) Pharmacological management: ● 80% of patients have mild disease and require only topical agents ● Hollier page 140 list of steroids from high to low potency. Lowest hydrocortisone 1.0 or 2.5 % BID for 2 weeks, caution face. *Consult Dermatologist since this is a chronic condition ● Tinea ● Tinea: group of fungal infections affecting various parts of the body. It is common. More prevalent in summer months, warm climates. ● Hair shedding and breakage at the hair shaft caused by tinea capitis (ringworm). There are round scaling patches of alopecia, mostly seen in children. There may be “black dots” of broken hairs and comma or corkscrew hairs on dermoscopy. Usually caused by Trichophyton tonsurans from humans, and less commonly, Microsporum canis from dogs or cats. Boggy plaques are called kerions. Assessment findings
Ch. 7 ● Lymph Nodes
Lymph Nodes
Are variably classified. Chapter 7 pg. 259 has a chart of the classification and the direction of how the lymph nodes drain. Nodes are normally round or ovoid, smooth and smaller than the submandibular gland. The gland is larger and has a lobulated, slightly irregular surface. **Note that the tonsillar, submandibular, and submental nodes drain portions of the mount and throat as well as the face. **Lymphatic drainage patterns are helpful for assessing possible malignancy or infection. To look for this, look for enlargement of the neighboring regional lymph nodes; when a node is enlarged or tender, look for source in its nearby drainage area.
Techniques for examining lymph nodes:
First inspect the neck- is it symmetrical? Do you see any masses or scars? Look for enlargement of the parotid or submandibular glands, and note any visible lymph nodes. **If you see a scar from a past thyroid surgery, this is a clue to an unsuspected thyroid or parathyroid disease. Second, palpate the lymph nodes:
- Use pads of your index finger and middle fingers, press gently, moving the skin over the underlying tissues in each area.
- Make sure the patient is relaxed, with the neck flexed slightly forward and if needed, turned slightly toward the side being examined.
- **You can usually examine both sides at once, noting both the presence of lymph nodes as well as asymmetry. However, for the submental node, it is helpful to feel with one hand while bracing the top of the head with the other hand.
- Sequence for the following nodes: ⮚ Preauricular- in front of the ear ⮚ Posterior auricular- superficial to the mastoid process (behind the ear). ⮚ Occipital- at the base of the skull posteriorly ⮚ Tonsillar- at the angle of the mandible ⮚ Submandibular- midway between the angle and the tip of the mandible. These nodes are usually smaller and smoother than the lobulated submandibular gland against which they lie. ⮚ Submental- in the midline a few cm’s behind the tip of the mandible.
⮚ Superficial cervical- superficial to the sternocleidomastoid ⮚ Posterior cervical- along the anterior edge of the trapezius ⮚ Deep cervical chain- deep to the sternocleidomastoid and often inaccessible to examination. **Hook your thumb and fingers around either side of the sternocleidomastoid muscle to find them. ⮚ Supraclavicular- deep in the angle formed by the clavicle and the sternocleidomastoid. ⮚ **Enlargement of the supraclavicular node, especially on the left, suggest possible metastasis from a thoracic or an abdominal malignancy.
- Note the following when assessing lymph nodes: ⮚ Node size ⮚ Shape ⮚ Delimitation (discrete or matted together) ⮚ Mobility ⮚ Consistency ⮚ Tenderness
- Small, mobile, discrete, nontender nodes, sometimes called “shotty” are frequently found in normal people.
- Describe enlarged lymph nodes in two dimensions, maximal length and width, for example, 1 cm x 2 cm. Also note any overlying skin changes (erythema, induration, drainage or breakdown).
- If enlarged or tender nodes, if unexplained call for (1) re-examination of the regions they drain and (2) careful assessment of the lymph nodes in other regions to identify regional from generalized lymphadenopathy.
- Techniques for preauricular and cervical lymph nodes: ⮚ Using the pads of the second and third fingers palpate the preauricular nodes with a gentle rotary motion. Then examine the posterior auricular and occipital lymph nodes. ⮚ **Tender nodes suggest inflammation; hard or fixed nodes suggest malignancy. ⮚ Palpate the anterior superficial and deep cervical chains, located anterior and superficial to the sternocleidomastoid. Then palpate the posterior cervical chain along the trapezius and along the sternocleidomastoid. ⮚ Flex the patient’s neck slightly forward toward the side being examined. ⮚ Examine the supraclavicular nodes in the angle between the clavicle and the sternocleidomastoid. ⮚ ***If you feel supraclavicular lymph nodes, a through work-up is warranted.
- Generalized lymphadenopathy is seen in multiple infectious, inflammatory, or malignant conditions such as HIV or AIDS, infectious mononucleosis, lymphoma, leukemia, and sarcoidosis.
- Occasionally, you mistake a band of muscle or an artery for a lymph node. Unlike a muscle or an artery, you should be able to roll a node in two directions: up and down, and side to side. Neither a muscle nor an artery will pass this test.
Copper wiring: sometimes the arteries, especially those close the disc, become full and somewhat tortuous and develop an increased light reflex with a bright coppery luster, called copper wiring. Silver wiring: occasionally the wall of a narrowed artery becomes opaque so there is no visible blood called silver wiring. AV Crossing is when the arterial walls lose their transparency, changes appear in the arteriovenous crossing. Decreased transparency of the retina probably also contributes to Concealment or AV Nicking and Tapering. Concealment or AV Nicking: the vein appears to stop abruptly on either side of the artery. Tapering: the vein appears to taper down the either side of the artery. Banking: the vein is twisted on the distal side of the artery and forms a dark wide knuckle. Superficial Retinal Hemorrhages: small, linear, flame-shaped, red streaks in the fundi, shaped by the superficial bundles of the nerve fibers that radiate from the optic disc in the pattern illustrated ( 0= optic disc, F=fovea). Sometimes the hemorrhages are seen in severe hypertension papiledema and occlusion of the retinal vein among the other conditions. An occasional superficial hemorrhage has a white center consisting of fibrin, which has many causes. Preretinal hemorrhage: develops when the blood escapes into the potential space between the retina and vitreous. This hemorrhage is typically larger than retinal hemorrhages. Because it is anterior to the retina, it obscures any underlying retinal vessels. In an erect patient, red cells settle, creating a horizontal line of demarcation between plasma above and cells below. Causes include a sudden increase in intracranial pressure. Deep Retinal Hemorrhages: small, rounded, slightly irregular red spots that are sometimes called dot or blot hemorrhages. They occur in a deeper layer of the retina than flame-shaped hemorrhages. Diabetes is a common cause. Microaneurysms: Tiny, round, red spots commonly seen in and around the macular area. They are minute dilations of the very small retinal vessels, the vascular
connections are too small to be seen with an opthalmoscope. A hallmark of diabetic retinopathy. Hypertensive Retinopathy: marked arteriolar-venous crossing changes are seen, especially along the inferior vessels. Copper wiring of the arterioles is present. A cotton-wool spot is seen just superior to the disc. Incidental disc drusen are also present but are unrelated to the hypertension. Hypertensive Retinopathy with Macular Star: note the punctate exudates are readily visible, some are scattered, others radiate from the fovea to form a macular star. Note the two small, soft exudates about 1 disc diameter from the disc. Find the flame-shaped hemorrhages sweeping toward 7,8, 10 o’clock, These two fundi show changes typical of severe hypertension retinopathy, which is often accomplished by the papliledema. (see page 283 for picture to better understand). Diabetic Retinopathy: (see page 284 for pictures) Ch. 8 ● Lung/Thorax Assessment and Modification for Age ● Normal VS. Abnormal Findings and Interpretation ● Lung Sounds -Auscultation is the most important examination technique for assessing air flow through the tracheobronchial tree. Auscultation involves (1) listening to the sounds generated by breathing, (2) listening for any adventitious (added) sounds, and (3) if abnormalities are suspected, listening to the sounds of the patient’s spoken or whispered voice as they are transmitted through the chest wall. Before beginning auscultation, ask the patient to cough once or twice to clear mild atelectasis or airway mucus that can produce unimportant extra sounds. -Listen to the breath sounds with the diaphragm of your stethoscope after instructing the patient to breathe deeply through an open mouth. Always place the stethoscope directly on the skin. Clothing alters the characteristics of the breath sounds and can introduce friction and added sound -Normal breathing is quiet and easy—barely audible near the open mouth as a faint whish. When a healthy person lies supine, the breathing movements of the thorax are relatively slight. -Audible high-pitched inspiratory whistling, or stridor, is an ominous sign of upper
