NU 610: Module 1 Study Guide
1. diagnostic process: -process of collecting data and generating a working hypothesis for cause of patient's signs and
symptoms (subjective and objective data)
-begins with history taking (CC & HPI)
-develop a differential diagnosis based on the history
-systematically rule out differentials
-diagnostic studies to confirm or rule out suspicions
2. subjective data: what the pt tells you
3. chief complaint: what the pt came in for
-very brief, may use quotations when documenting
4. history of present illness (HPI): -history leading up to the complaint and circumstances of the complaint; be
detailed!
-OLD CART(S) (Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Treatment, Severity)
5. subjective data continued: -Past medical history (PMH)
-Past surgical history (PSH)
-Health Maintenance
-Medication list
-Allergies
-Family History
-Social History
, 6. review of systems: -organized by body systems, pertinent positives and negatives
-ex) general: (-)fever, (+) weight gain, (-) fatigue, (+) increased appetite
7. objective data: -what the provider observes
-what is seen, felt, heard, smelled, NOT the pt's POV
-vital signs, including weight, height, BMI
-physical examination (depends on pt complaint)
-pediatrics: requires patience and distraction, sitting in parent's lap can be helpful, examine the area most upsetting last
8. objective data continued: -lab, x-ray, scans, spirometry, etc.
-consider which test is best: cost, convenience, sensitivity/specificity
-Do you need a test? Will it make a difference in tx? What is the risk of missing the diagnosis?
9. differential diagnosis: -consider all the possible diagnoses for the symptom
-frame the differential diagnoses (can use the ones that make the most sense for that complaint)
-look at the evidence you have collected in order to rule out possible diagnoses
-explore each ditterential (use exam to find evidence: pos findings may be more indicative of the diagnosis bc of greater specificity; neg
findings may be less indicative but are still important and contributes evidence for ruling out a ditterential, also evidence that it WAS
evaluated and considered)
10. differential diagnosis framework: -anatomic framework (works well for chest pain, abd. pain)
-organ/system framework (works well for broad symptoms like fatigue)
-pivotal points (opposing descriptor of symptoms, "old vs. new", "bilateral vs. unilateral", "acute vs. chronic")
11. limiting differentials: -after you organize the ditterentials, work through the history and exam, eliminate possibilities to
narrow the list
-each pt is individual, making some diseases irrelevant as a possibility (ex. appendicitis in a pt who had an appendec- tomy)
1. diagnostic process: -process of collecting data and generating a working hypothesis for cause of patient's signs and
symptoms (subjective and objective data)
-begins with history taking (CC & HPI)
-develop a differential diagnosis based on the history
-systematically rule out differentials
-diagnostic studies to confirm or rule out suspicions
2. subjective data: what the pt tells you
3. chief complaint: what the pt came in for
-very brief, may use quotations when documenting
4. history of present illness (HPI): -history leading up to the complaint and circumstances of the complaint; be
detailed!
-OLD CART(S) (Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Treatment, Severity)
5. subjective data continued: -Past medical history (PMH)
-Past surgical history (PSH)
-Health Maintenance
-Medication list
-Allergies
-Family History
-Social History
, 6. review of systems: -organized by body systems, pertinent positives and negatives
-ex) general: (-)fever, (+) weight gain, (-) fatigue, (+) increased appetite
7. objective data: -what the provider observes
-what is seen, felt, heard, smelled, NOT the pt's POV
-vital signs, including weight, height, BMI
-physical examination (depends on pt complaint)
-pediatrics: requires patience and distraction, sitting in parent's lap can be helpful, examine the area most upsetting last
8. objective data continued: -lab, x-ray, scans, spirometry, etc.
-consider which test is best: cost, convenience, sensitivity/specificity
-Do you need a test? Will it make a difference in tx? What is the risk of missing the diagnosis?
9. differential diagnosis: -consider all the possible diagnoses for the symptom
-frame the differential diagnoses (can use the ones that make the most sense for that complaint)
-look at the evidence you have collected in order to rule out possible diagnoses
-explore each ditterential (use exam to find evidence: pos findings may be more indicative of the diagnosis bc of greater specificity; neg
findings may be less indicative but are still important and contributes evidence for ruling out a ditterential, also evidence that it WAS
evaluated and considered)
10. differential diagnosis framework: -anatomic framework (works well for chest pain, abd. pain)
-organ/system framework (works well for broad symptoms like fatigue)
-pivotal points (opposing descriptor of symptoms, "old vs. new", "bilateral vs. unilateral", "acute vs. chronic")
11. limiting differentials: -after you organize the ditterentials, work through the history and exam, eliminate possibilities to
narrow the list
-each pt is individual, making some diseases irrelevant as a possibility (ex. appendicitis in a pt who had an appendec- tomy)
