NR 509 ADV PHYSICAL ASSESSMENT MIDTERM NOTES

Chapter 1 Approach to Clinical Encounter Clinician-centered approach: the clinician takes charge of the interaction to meet his own need to acquire the symptoms, details and other data that will help him ID the disease. Patient-centered approach recognizes the importance of patients’ expression of personal concerns, feelings and emotions and evokes the personal context of the patient’s symptoms and disease. ▪ Following the pts lead without adding any additional information from the clinician’s perspective Disease: explanation that the clinician uses to organize symptoms that lead to a clinical diagnosis Illness: is a construct that explains how the pt exp. the disease - Effects relationship, function and sense of well-being **the clinical interview needs to incorporate both the clinician’s and the pts views of reality, disease and illness. Feelings (fears or concerns about the problem) Ideas (about the nature of the cause of the problem) Function (effects) Expectations (of the disease, clinician, healthcare- could be based on past experience) Structure and Sequence of the Clinical Encounter 1. Initiating the session 2. Information gathering 3. Physical Examination 4. Explaining and Planning 5. Closing the Session Social Determinants of Health ***See Table 1-1 Example of a Comprehensive Clinical Record: The Case of Pt MN Chapter 2 Interviewing, Communication, and Interpersonal Skills 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. - Requires a wiliness to suffer some of the pts pain **Use people first language Disclosing Serious News - The SPIKES Protocol o Setting up the interview o Assessing the pts Perception o Obtaining the pts Invitation o Giving Knowledge and info to the pt o Addressing the pts Emotions with empathetic responses o Strategy and Summary Some patients present a confusing array of multiple symptoms. They seem to have every symptom that you ask about, or “a positive review of systems. Chapter 3 Health History Comprehensive Assessment vs. Episodic Visit Comprehensive: includes all the elements of the health history and the complete phys exam - Pts may not present with a “cc” so the history and examination will need to be detailed focusing on primary care. o Initial information o “CC” o HPI o PMH o Fam Hx o Personal and Social Hx o ROS Episodic: pt will have a chief complaint such as: cough, abdominal pain, sore throat etc- the clinician’s history will focus on the “cc” as they begin Dx and management Basic interviewing techniques include: • Active listening • Empathic responses • Guided questioning • Nonverbal communication • Validation • Reassurance Chief Complain “CC” - Make every attempt to quote the pts own words - Determine if a relationship exist b/t multiple symptoms - Usually, one complaint with accompanying symptoms 7 Attributes of a Symptom 1. Location- where did your pain start, and does it move anywhere? 2. Quality- adjective describing the type of problem 3. Quantity or Severity- nonverbal or verbal descriptions 4. Timing (including onset, duration and frequency) 5. Setting it occurs