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NURS 62222HA MIDTERM 2 STUDY GUIDE LATEST
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NURS 62222HA MIDTERM 2 STUDY GUIDE LATEST
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HA MIDTERM 2.Week 1: Comprehensive Health History
● Describe and organize the process of obtaining subjective patient data.
of diagnoses are made based on history alone, PE adds 10% 80% ○
Always start with open ended questions and to clarify and focus, use closed ended questions. ○
Restate to confirm accuracy of the information
Subjective what a patient feels/describes with words; symptoms/patient history/what the ○
patient is telling us; shouldn’t be in the physical exam/objective part
ID- age, gender, source of information, new or established patient, reliable source ■
(patient, family), insurance status, date and time of visit, marital status
.CC- what prompted the patient to seek healthcare - quote pt ■
History of presenting illness- OLDCARTS (Onset, Location/radiation, Duration, ■
(Character, Aggravating/Associated factors, Relieving factors, Timing and Severity
(PMH- diagnosis, dates, sequence, management, children (pregnancy and birth history ■
Past Surgical History - type, dates, any complications, transfusions ■
Medications- Rx: name, dose, route, frequency (when last used), OTC, herbal,■
.vitamins, oral contraceptives; current and those that have been discontinued
Allergies- drug, environmental, food, latex and the date they found out/reaction they ■
had- triggers, duration, severity, have they been treated for it, any emergency visits
,related to allergy
Social history- habits (sleep, exercise, caffeine, smoking (2nd hand exposure), ETOH, ■
drug use, occupation, religious/cultural beliefs, sexual orientation
Add screenings, nutrition (24 diet recall), safety and mental health is a ●
comprehensive exam (annual and physicals) rather than a focused
exam like document above
Immunizations- vaccine and year, any adverse reactions ■
”Don’t say “up-to-date”, say “unknown” or “no known record ●
Mention vaccines appropriate for specific patient (PNA, tDAP, influenza, ●
(shingles, etc
Family history ■
(Focused = r/t CC (chest pain and + family history of premature CAD ●
Comprehensive- family history for 3 generations (MGM, MGF, PGM, PGF, M, F, ●
siblings, children) (always start with grandparents, parents, siblings, and
(children
Reproductive history- always ask LMP and any possibility of pregnancy, number of ■
pregnancies (miscarriage?) GPAL, type of delivery, contraceptive use, sexually active,
.history of STI
ROS- general, cardiac, respiratory must be included in every history ■
Focused = only pertinent symptoms that were not covered in HPI (compliments ●
,HA MIDTERM 2.
(- the HPI including pertinent + and
Comprehensive = review all systems
●
General/constitutional ○
Skin ○
HEENT ○
Respiratory ○
Cardiovascular ○
GI ○
GU ○
Musculoskeletal ○
Neurological ○
Endocrine ○
Psych ○
Objective physiological manifestation observed directly; signs/the findings of the physical exam; ○
shouldn’t be in the patient history section
Focused = include systems that are pertinent to list of differential diagnoses (usually ■
(the same as ROS
Comprehensive = include all systems ■
.(Elicit a chief complaint and obtain all critical elements of the history of a present illness (HPI ●
Chief complaint: 2-3 words from the patient, try to quote directly what they are saying ○
HPI: utilize OLDCARTS to obtain all information; complaints of a specific body system need to ○
be included (pertinent – and +) and if more than 1 body system symptom, each
symptom merits its own paragraph and a full description/OLDCARTS
O- onset ■
L- location/radiation ■
D- duration ■
C- characteristics ■
A- aggravating/associated symptoms ■
R- relieving factors ■
T- timing ■
S- severity ■
.Use OLD CARTS to identify the seven dimensions/attributes of a symptom ●
■ Onset—when did it start?
■ Location/Radiation—where is it located?
■ Duration—how long has this gone on?
,HA MIDTERM 2.
■ Character—does it change with any specific activities? Does the patient use
any descriptive words to describe the quality of the symptom?
■ Aggravating factors – what makes it worse?
■ Relieving factors – what makes it better?
■ Timing—is it constant, cyclic, or does it come and go?
■ Severity—how bothersome, disruptive, or painful is the problem?
Differentiate the components of the Review of Systems (ROS). (ROS IS SUBJECTIVE- what the ●
(patient tells you
Cardinal Symptoms ○
General/ Constitutional: Wellbeing, energy, fever, chills, night sweats, weight changes, sleep ○
.Skin: Rashes, lesions, changing or suspicious nevi ○
HEENT: Headaches, ear pain, hearing loss, tinnitus, vertigo, eye pain, discharge, photophobia, ○
.or visual disturbances. Nasal discharge, sinus pain, pharyngitis
Respiratory: Cough, shortness of breath, wheezing, sputum,hemoptysis, dyspnea, pleurisy ○
Cardiovascular: Chest pain, palpitations, dyspnea on exertion, exertional leg pain, peripheral ○
edema
Gastrointestinal: Abdominal pain, nausea or vomiting, melena,hematochezia, constipation, ○
diarrhea, GERD, dysphagia
Genitourinary: Female - vaginal discharge, dysuria, pelvic pain ○
Males - dysuria, hesitancy, frequency, urethral discharge ○
Musculoskeletal: Myalgias, arthralgias, stiffness, gait, mobility ○
Neurological: Headaches, dizziness, sensation, weakness, memory loss, LOC ○
Endocrine: Heat / cold intolerance, polyuria, polyphagia, polydipsia ○
Psych: Anxiety, depression, suicidal ideation homicidal ideation○
Describe techniques used interview process to obtain a health history ●
Communication – respect, non-judgmental, systemic manner, enough time ○
General principles- introduction, start with open ended followed by closed ended ○
Interviewing skills- encourage participation, focus on discussion (don’t get ahead of
what ○
patient is saying), use pauses effectively, place symptoms in sequence, reflect,
clarify, summarize
Unhelpful interviewing techniques- ask “how” or “why”, using probing or persisting questions, ○
using inappropriate or technical jargon, giving advice or false reassurance,
changing the subject or interrupting, jumping to conclusions, asking leading
questions, focusing on the diagnosis and not the symptom
.Identify the components of the complete physical exam ●
, HA MIDTERM 2.
The interview- listen to the story ○
Begin the patient encounter (review chart, review identifying information, note, record date/time, ○
(knock on the door
Subjective information-- HISTORY SYMPTOMS, SAYS ○
List of differential diagnosesàhelp to focus on specific body systems ○
ROS-- yes or no answers ○
Objective information-- PHYSICAL EXAM VITAL SIGNS, OBSERVE ○
Assessment-- include acute/current diagnoses and chronic diagnoses ○
Plan-- include diagnostics, therapeutics, education, follow up/referral for acute and chronic ○
conditions
Week 2: Intro to Professional Documentation and Diagnostic Reasoning
.Correctly categorize subjective and objective data in SOAP format ●
Chief complaint, differential diagnoses ○
S: Subjective ○
HPI ■
Review of systems ■
O: Objective ○
Vital Signs ■
Physical Exam ■
A: Assessment ○
Diagnosis
■
P: Plan ○
Diagnostic
■
Therapy ■
Education ■
Follow up ■
Referral ■
Differentiate between a comprehensive history and physical and a focused history and exam ●
Focused Assessment Comprehensive Assessment
Is appropriate for established Is appropriate for new patients
patients, especially during routine in the office or hospital
or urgent care visits
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