H&P Exam 2 with 138 Complete
Solutions
H&P Exam 2 with 138 Complete
Solutions
Developing a differential - ANSWER List of potential diagnoses
Testable hypothesis
Based on history and symptoms
Should result in evidence based final diagnosis
Documentation should support the differential and provide your clinical reasoning
The assessment - ANSWER Educated opinion as to the likely cause of the patient's CC
It could also be the exact cause of the patient's chief complaint if it is known
5 steps: Making a diagnosis - ANSWER 1. Identify abnormal findings
2. Localize findings anatomically
3. Interpret findings in terms of probable cause
4. Make hypotheses about the cause
5. Test the hypotheses and establish a working diagnosis
Identify abnormal findings - ANSWER Make a physical or mental list of any: Symptoms (the patient's
complaints), signs (physical exam findings), diagnostic test results
Localize findings anatomically - ANSWER Determine where the symptoms/signs are coming from
Try to be specific, but regions or systems may have to suffice: Fatigue is general and cannot be localized,
sore throat that is red and swollen is very specific
Interpret findings in terms of probable cause - ANSWER Pathologic - diseases of a structure
Pathophysiologic - derangements of biologic function
Psychopathologic - disorders of mood
,H&P Exam 2 with 138 Complete
Solutions
Make hypotheses about the cause - ANSWER Based on your knowledge, what are the likely causes?
Put together the puzzle pieces: What are your most pressing findings?- What does the literature say
about those findings?
Eliminate possibilities that don't fit
Weigh the likelihood of the remaining possibilities
Always watch for RED FLAGS and rule out LIFE‐ THREATENING CAUSES
Use the "Disease Script" - Demographics, symptoms, signs
Prove What It Is NOT With Negatives
Test the hypotheses and establish a working diagnosis - ANSWER Consider additional history questions,
physical exam testing, diagnostic testing, or consultation
You want to CONFIRM or RULE OUT
Narrow down as specifically as possible
Developing the plan - ANSWER Based on your narrowed down list of differential diagnoses
Is fluid and ever changing
Includes: Diagnostics (including when these should be done), therapeutics, education/supportive care,
disposition
The PATIENT MUST AGREE to the plan
Documenting the A/P - ANSWER All current diagnoses or chief complaints with a DDx list
Other new problems that have developed
Chronic Illnesses and their status
Health maintenance (overdue tests)
Each should have their own plans with all 4 components of a plan!
Problem list definition - ANSWER Summary list of the patient's active problems
, H&P Exam 2 with 138 Complete
Solutions
Gives a quick glance of a patient's health status
There is no set standard for arrangement
Problem list contents - ANSWER Symptoms, signs, or past health events or diagnoses
Typically chronic conditions or the current problem being treated
Recurrent acute illnesses
What is NOT included in problem list - ANSWER Acute events that were cured with no lasting effects
Problem list example - ANSWER 1. Migraine Headaches
2. Elevated BP
3. COPD - Sees Dr. Badlungs
4. Tobacco Use since age 18
5. Obese
6. Family stress
7. Low Back Pain
8. Nephrolithiasis age 24
9. PCN Allergy
Comprehensive health history definition - ANSWER A holistic assessment of all factors affecting a
patient's health status, including information about social, cultural, familial, and economic aspects of the
patient's life as well as any other component of the patient's life style that affects health and well‐being
Comprehensive history benefits - ANSWER Provides fundamental and personalized knowledge about the
patient.
Strengthens the patient‐provider (person‐person) relationship.
Helps identify or rule out physical causes related to patient concerns.
Provides baselines for future assessments.
Solutions
H&P Exam 2 with 138 Complete
Solutions
Developing a differential - ANSWER List of potential diagnoses
Testable hypothesis
Based on history and symptoms
Should result in evidence based final diagnosis
Documentation should support the differential and provide your clinical reasoning
The assessment - ANSWER Educated opinion as to the likely cause of the patient's CC
It could also be the exact cause of the patient's chief complaint if it is known
5 steps: Making a diagnosis - ANSWER 1. Identify abnormal findings
2. Localize findings anatomically
3. Interpret findings in terms of probable cause
4. Make hypotheses about the cause
5. Test the hypotheses and establish a working diagnosis
Identify abnormal findings - ANSWER Make a physical or mental list of any: Symptoms (the patient's
complaints), signs (physical exam findings), diagnostic test results
Localize findings anatomically - ANSWER Determine where the symptoms/signs are coming from
Try to be specific, but regions or systems may have to suffice: Fatigue is general and cannot be localized,
sore throat that is red and swollen is very specific
Interpret findings in terms of probable cause - ANSWER Pathologic - diseases of a structure
Pathophysiologic - derangements of biologic function
Psychopathologic - disorders of mood
,H&P Exam 2 with 138 Complete
Solutions
Make hypotheses about the cause - ANSWER Based on your knowledge, what are the likely causes?
Put together the puzzle pieces: What are your most pressing findings?- What does the literature say
about those findings?
Eliminate possibilities that don't fit
Weigh the likelihood of the remaining possibilities
Always watch for RED FLAGS and rule out LIFE‐ THREATENING CAUSES
Use the "Disease Script" - Demographics, symptoms, signs
Prove What It Is NOT With Negatives
Test the hypotheses and establish a working diagnosis - ANSWER Consider additional history questions,
physical exam testing, diagnostic testing, or consultation
You want to CONFIRM or RULE OUT
Narrow down as specifically as possible
Developing the plan - ANSWER Based on your narrowed down list of differential diagnoses
Is fluid and ever changing
Includes: Diagnostics (including when these should be done), therapeutics, education/supportive care,
disposition
The PATIENT MUST AGREE to the plan
Documenting the A/P - ANSWER All current diagnoses or chief complaints with a DDx list
Other new problems that have developed
Chronic Illnesses and their status
Health maintenance (overdue tests)
Each should have their own plans with all 4 components of a plan!
Problem list definition - ANSWER Summary list of the patient's active problems
, H&P Exam 2 with 138 Complete
Solutions
Gives a quick glance of a patient's health status
There is no set standard for arrangement
Problem list contents - ANSWER Symptoms, signs, or past health events or diagnoses
Typically chronic conditions or the current problem being treated
Recurrent acute illnesses
What is NOT included in problem list - ANSWER Acute events that were cured with no lasting effects
Problem list example - ANSWER 1. Migraine Headaches
2. Elevated BP
3. COPD - Sees Dr. Badlungs
4. Tobacco Use since age 18
5. Obese
6. Family stress
7. Low Back Pain
8. Nephrolithiasis age 24
9. PCN Allergy
Comprehensive health history definition - ANSWER A holistic assessment of all factors affecting a
patient's health status, including information about social, cultural, familial, and economic aspects of the
patient's life as well as any other component of the patient's life style that affects health and well‐being
Comprehensive history benefits - ANSWER Provides fundamental and personalized knowledge about the
patient.
Strengthens the patient‐provider (person‐person) relationship.
Helps identify or rule out physical causes related to patient concerns.
Provides baselines for future assessments.
