NR 509 Mid-term study guide(version1)Graded A+
Ch. 1
• Basic and Advanced Interviewing Techniques
• Basic o Gather a sensitive and nuanced hx. o Perform thorough and accurate
exam o Improve pt. rapport
o Focus your assessment
o Sent guideposts that direct clinical decision making o Avoid interpreting your
findings- may be premature. o Warn pt. that your assessment may take longer
but that doesn’t mean negative findings
• Advanced o With time and practice- able to integrate:
o Empathetic listening o Ability to interview pts of all ages, genders, races,
ethnicities, etc.
o Improved techniques to examine different body systems
o Differentiate level of sick vs. not sick o Improved process of clinical reasoning
leading to diagnosis and plan o Will grow and begin clinical reasoning from first
impression of meeting pt. o ID Sx. And abnormal findings, linking underlying pa
xtho o Establish and test explanatory hypotheses
• Components of the Health History
• Identifying data – age, gender, marital status, occupation o Source of hx. - usually
pt. but could be family or friend, letter of referral or clinical record
o Establish the source of referral is necessary
• Reliability - pt. memory, trust, mood
• Chief Complaint - one or more symptoms or concerns causing pt. to seek care o
Try and keep this in patients own words “my stomach feels awful”
• Present illness - amplifies CC o **Complete, clear and chronologic description of
the problems prompting the pts. Visit including onset, setting it developed how it
manifests and tx.
To date o Includes pt. thoughts and feelings about
illness o *pertinent positives and pertinent
negatives* o May include meds, allergies, tobacco,
ETOH…
o Seven attributes of a symptom 1. Location 2. Quality 3. Quantity or severity 4.
Timing (onset, duration, frequency) 5. Setting it occurs 6.
Factors that aggravate or relieve 7. Associated manifestations o Consider
placing PMHx in this area to support potential problem (hx. Of
CAD with pt. presenting with CP) o
How these sx are affecting ADLs
o Medications taking to help or than may exacerbate
• Past medical hx . – list illnesses (childhood and adult) with dates
, o Surgeries
o OBGYN
o Health maintenance o psych
o Immunizations, screenings, lifestyle issues and home safety
• Family hx. – include parents, siblings and grandparents o Outline current age or
age at death, medical hx. / illnesses, reason of death
• Personal and social hx . – education, family origin, current household, interests
and lifestyle, relationship? Stress, job, important life experiences, financial status,
religion, retirement plan, leisure activities, friends/ support
• Review of symptoms o Documents presence or absence of common symptoms
related to each of the major body symptoms
o Start- General, skin, HEENT, neck, breasts, respiratory, cardiovasc., GI, peripheral
vasc., urinary, genitals, musculoskeletal, psych, neuro, hematologic, endocrine.
• All this health hx. is done with the following
o Physical exam
o Clinical reasoning o Assessment
o Plan
o The quality clinical record o Comprehensive vs. focused?
• Comprehensive o New pt.
o Identifies or rules out causes related to concerns o Lengthy or difficult pt.
complaint o Platform for health promotion
o Has potential for increased health care savings and decreased testing o Can be
seen as a diagnostic test
• Focused o Problem focused
o Good for routine or urgent visits o Symptoms related to specific body system.
• **** MAKE SURE THE DATE IS ALWAYS ON THE HEALTH HX****
• Subjective Data
• What the patient tells you
• “the symptoms and hx. From chief complaint through review of systems
Pain, reports “headache”
• Objective Data
• What you observe or detect through exam, lab results and test data
• Psychical exam findings or signs
• Height 5’3, weight 73kg, purulent discharge, etc.
• SOAP Note Documentation
• Subjective, objective, assessment, plan
• Make sure pertinent negatives or positives are specifically described
• Avoid excessive detail
• Described what you saw now what you did
• Take measurements
• Make sure tone is professional Chap 2.
, • Evaluating Clinical Evidence
• Initial step in evaluating diagnostic testing is ensuring validity of results
• “does the test accurately identify whether a pt. has a disease?”
• Compare to the “gold standard”
• Test sensitivity and specificity of testing o Sensitivity- probability that a pt. with
the disease has a + test o “true positive rate o Specificity- the probability that a
non-diseased pt. has a negative test.
o Known as the true negative rate
• A negative result from a test with a test with high sensitivity (very low false neg.
rate) usually excludes the disease. o SnNout- sensitive test with
negative result rules OUT o SpPIN- specific test with a positive
result rules IN disease.
• Positive predictive value (PPV )- probability that a person with a + test has the
disease o Prostate Ca screening where a man with a PSA value greater than
4.0ng/mL has only a 30% probability of having prostate Ca found on biopsy
• Negative predictive value (NPV)- probability that a person with a – test does not
have the disease o Among men with a PSA level of 4.0ng/mL or below, 85% are
found to be Ca free on biopsy.
• Prevalence of disease - important to understand the prevalence of the disease
you are looking into- patient population- age, gender, location etc.
• Likelihood ratios - probability of obtaining a given test result in a diseased patient
divided by the probability of obtaining a given test result in a non-diseased pt.
o A higher value (much >1) indicates that a positive test is much more likely to be
coming from a diseased person than from a non-diseased person, increasing
confidence that a person with a + result has the disease
• Bayes Theorem - relates the direct probability of a hypothesis conditional on a
given body of data conditional on the hypothesis
• Fagan Nomogram - terms of probability of having a disease.
o Read the pretest probabilities from the line on left then take a straight edge and
draw a line through the likelihood ration in the middle and read the posttest line
on the right
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