Exam 1 Study Guide - Summary Advanced Health Assessment ACTUAL TEST 2023

Exam 1 Study Guide - Summary Advanced Health Assessment ACTUAL TEST 2023 Assessment Real world information/ application General information- review texts, ask your preceptor or clinical supervisor, if not found let us know. This is not all inclusive, nor is it a study guide as ALL content in the text is important. And all information in the book is “testable” content. The below information is to help you see areas/ content that are important to know and will frequently be used. As you read and study, it would be wise to consume the text so to speak. All of the words could be treated as a vocabulary list. That vocabulary list will help with definitions. Then, identify what are the assessments a person would see with those words. To help in the clinical assessment; what differentiates one dx from another. For example with a dx of URI….. what assessments (hx and subjective, and objective findings) discriminate between sinusitis, viral URI, bronchitis, influenza, copd, asthma, otitis media, strep throat, etc. 1. Differentiate Subjective vs Objective assessment (pg 6) a. Subjective data i. Symptoms, what the patient tells you b. Objective data i. Signs, what you observe Subjective data Objective data What the patient tells you What you detect during the examination, laboratory information, and test data The symptoms and history, from chief complaint through review of symptoms All physical examination findings, or signs Mrs. G is a 54 year old hairdresser who reports pressure over her left chest “like an elephant sitting there”, which goes into her left neck and arm Mrs. G is an older, overweight, white female, who is pleasant and cooperative. Height 5’ 4”, weight 150lbs, BMI 26, BP 160/80, HR 96, and regular, respiratory rate 24, temperature 97.5F 2. Differentiate between Chief complaint, HPI, past hx, ROS etc (pgs 9-10) a. Chief complaint: one or more symptoms or concerns causing pt to seek care; make every attempt to quote the patients own words i. “my stomach hurts and I feel awful” ii. no specific complaints: “I have come for my regular check-up” b. HPI (History of present illness): Complete, clear, and chronologic description of the problems prompting the patient’s visit, including the onset of the problem, the setting in which it developed, its manifestations, and any treatments to date; ROS “pertinent positives and negatives i. Components: lOMoARcPSD| 1. Each principle symptom should be well characterized 2. Risk factors for CAD 3. Reveal pt response to his or her symptoms and what effect the illness has had on the patients life 4. Each symptom merits its own paragraph and a full description 5. Medications should be noted, including name, dose, route and frequency of use 6. Allergies including specific reactions 7. Tobacco use, including the type 8. Alcohol and drug use c. Past history: i. Components: 1. Childhood illnesses 2. Adult illnesses a. Medical b. Surgical c. OBGYN d. Psychiatric 3. Health maintenance a. Immunizations b. Screening tests d. Family history: Outline or diagram the age and health, or age and cause of death, of each immediate relative including parents, grandparents, siblings, children, and grandchildren e. Personal and social history: captures the patient’s personality and interests, sources of support, coping style, strengths, and co