NR 511 Midterm Exam Q & A: Differential Diagnosis &
Primary Care Practicum
Identifying Data - ANSWER Age, Gender, ethnicity
Chief Complaint (CC) - ANSWER Why are the patient is seeking help
History taking should always start w/ the CC, to help identify why they are here to
see you. If there are multiple, identify the one which is the most important to the
client or the highest priority complaint.
History of Present Illness (HPI) - ANSWER What symptoms or concerns do they
have? Uses HPI to explore CC
Pattern of history questions:
OLDCARTS
onset, setting, circumstances
location
duration
characteristics
aggravating/alleviating
radiating
treatments
severity
Past Medical History (PMI) - ANSWER Past medical, surgical, obstetrical, dental,
hospital admission history
Allergies
Med Rx
OTC meds
Family History (FH) - ANSWER any genetic history to report
Try to find 3 generation, their medical problems, ages and age at death.
Social History (SH) - ANSWER What are their behaviors
tobacco, recreational drugs, alcohol, sexual activity and precautions , education
level, employment, home environment
Review of Systems (ROS) - ANSWER Head to toe REVIEW of systems by body
systems
Subjective questioning of the patient:
General, HEENT, Neck, Neuro, Cardiac, Respiratory, GI, GU, Skin, Psych,
Musculo/Skeletal etc
As the patients story is elicited from the remaining hx and ROS, the differential
diagnosis may change or futher be supported.
, The purpose of HPI - ANSWER is to break down the clients chief complaint by using
OLDCARTS. Helps to narrow differential diagnosis, what to assess for the physical
exam, what diagnostics to order.
SOAP Note - ANSWER Subjective
-Includes CC, HPI, PMH, FH, SH, PSH, ROS
Objective
-what is seen, heard, or felt; part of the physical exam and include labs or test
results
Assessment
-is the diagnosis
Plan
-"Evidence based management plan"
-Involves providing care and making treatment and screening choices based on
current research findings
Clinical Decision Making - ANSWER What is needed to make a sound clinical
decision?
-evidence based research
-Clinical practice guidelines
-Published evidence-based algorithms
Specificity - ANSWER A is a tests ability to designate an individual who does not
have a disease as negative (True Negative)
Sensitivity - ANSWER Refers to a tests ability to designate an individual with a
disease as positive (True Positive)
High Specificity - ANSWER means a high percentage of individuals will show a
normal result
Low Specificity - ANSWER Means getting a POSITIVE result, when the disease is
not actually present (False Positive)
or saying ha healthy person has a disease when they do NOT
High Sensitivity - ANSWER Highly sensitive tests will lead to positive finding for
patients with a disease.
Positive Predictive Value - ANSWER The proportion of clients with a positive test
who have the disease.
Predicitive values - ANSWER depend on the prevalence of the disease in a
population
Reliability - ANSWER refers to the consistency or stability of a measure
Primary Care Practicum
Identifying Data - ANSWER Age, Gender, ethnicity
Chief Complaint (CC) - ANSWER Why are the patient is seeking help
History taking should always start w/ the CC, to help identify why they are here to
see you. If there are multiple, identify the one which is the most important to the
client or the highest priority complaint.
History of Present Illness (HPI) - ANSWER What symptoms or concerns do they
have? Uses HPI to explore CC
Pattern of history questions:
OLDCARTS
onset, setting, circumstances
location
duration
characteristics
aggravating/alleviating
radiating
treatments
severity
Past Medical History (PMI) - ANSWER Past medical, surgical, obstetrical, dental,
hospital admission history
Allergies
Med Rx
OTC meds
Family History (FH) - ANSWER any genetic history to report
Try to find 3 generation, their medical problems, ages and age at death.
Social History (SH) - ANSWER What are their behaviors
tobacco, recreational drugs, alcohol, sexual activity and precautions , education
level, employment, home environment
Review of Systems (ROS) - ANSWER Head to toe REVIEW of systems by body
systems
Subjective questioning of the patient:
General, HEENT, Neck, Neuro, Cardiac, Respiratory, GI, GU, Skin, Psych,
Musculo/Skeletal etc
As the patients story is elicited from the remaining hx and ROS, the differential
diagnosis may change or futher be supported.
, The purpose of HPI - ANSWER is to break down the clients chief complaint by using
OLDCARTS. Helps to narrow differential diagnosis, what to assess for the physical
exam, what diagnostics to order.
SOAP Note - ANSWER Subjective
-Includes CC, HPI, PMH, FH, SH, PSH, ROS
Objective
-what is seen, heard, or felt; part of the physical exam and include labs or test
results
Assessment
-is the diagnosis
Plan
-"Evidence based management plan"
-Involves providing care and making treatment and screening choices based on
current research findings
Clinical Decision Making - ANSWER What is needed to make a sound clinical
decision?
-evidence based research
-Clinical practice guidelines
-Published evidence-based algorithms
Specificity - ANSWER A is a tests ability to designate an individual who does not
have a disease as negative (True Negative)
Sensitivity - ANSWER Refers to a tests ability to designate an individual with a
disease as positive (True Positive)
High Specificity - ANSWER means a high percentage of individuals will show a
normal result
Low Specificity - ANSWER Means getting a POSITIVE result, when the disease is
not actually present (False Positive)
or saying ha healthy person has a disease when they do NOT
High Sensitivity - ANSWER Highly sensitive tests will lead to positive finding for
patients with a disease.
Positive Predictive Value - ANSWER The proportion of clients with a positive test
who have the disease.
Predicitive values - ANSWER depend on the prevalence of the disease in a
population
Reliability - ANSWER refers to the consistency or stability of a measure
