NR 509 Midterm Exam Study Guide
, NR 509 Midterm Exam Study Guide
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
, NR 509 Midterm Exam Study Guide
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
