NUR 550 MIDTERM EXAMS QUESTIONS AND
ANSWERS SET A+
✔✔Assessment - ✔✔This section is where the diagnosis and differential diagnosis are
listed for the date the note is written.
Sample
Diagnosis: - Strep Pharyngitis
• Differential Diagnosis:
- Viral pharyngitis
- Rheumatic fever
- Scarlet fever
✔✔Plan - ✔✔This is where the treatment plan goes.
- Medications
- Diagnostic tests (i.e. laboratory, radiologic, hearing, etc.)
- Education
- Counseling
- Referrals
- Procedures performed and the outcomes/result(s)
- Return to office date(s)/Follow up
Sample
- Amoxicillin 875mg BID for 10 days
- Rapid Strep test done in office
- Verbal instructions given on warm salt water gargles and spit 3-4 times a day; rest;
increased fluids; rest; no work 2 days note given to patient
- Patient instructed to return to the office in 2 days if no improvement. To report to the
emergency department with difficulty swallowing, breathing, rash develops, or
symptoms worse verbalized understanding.
,✔✔How to Interview a Patient - ✔✔Stay calm!! • Prepare before you go into the room -
Read the chart, familiarize yourself with the patient • Set an agenda - Time, needs,
issues • Look and be professional - If you look the part you have already conquered the
first hurdle
✔✔Set the Stage - ✔✔• Welcome the patient using their name • Introduce yourself and
your role • Remove communication barriers - Family or professional translator • Ensure
patient privacy and comfort • Set the agenda for the visit - What are you going to do
✔✔Why is the Patient Here?
• - ✔✔• Begin with open-ended questions - Requires patients to actually describe their
complaints - Obtain accurate, patient-specific information • Avoid closed-ended
questions - Similar to a long health history survey - Actually takes longer than open-
ended questions
• Be attentive while the patient is speaking - Of yourself • Silence, non-verbal
encouragement , body language -The Patient • Look for non-verbal signs and cues
• Ask question(s) and then ask again, using the patients own words • What is the
patient's personal story • Ask emotion-seeking questions
✔✔Comprehensive or Focused - ✔✔Comprehensive • New patients • Identifies and
rules out physical causes related to patient concerns • Baseline • Health promotion
Focused • Established patients • Focused concerns • Symptoms of specific system(s)
✔✔Comprehensive History - ✔✔• The comprehensive history is to be performed on all
non-emergent, new patients who will be receiving ongoing primary care from a
particular provider or group. • It is also expected within the hospital setting.
Patient Identifiers Reliability Chief Complaint HPI
Past Medical History Family History Social History Review of Systems (ROS)
✔✔Focused History - ✔✔A focused history is performed in emergency situations and/or
when the patient is already under the ongoing care of the clinician and presents with a
specific problem oriented complaint. Identifying data Chief Complaint Data from the
patient's medical history, family history and social history that are pertinent to the chief
complaint Problem oriented ROS
✔✔The Complete Health History - ✔✔Identifying information • Chief complaint or
concern (CC) • History of present illness (HPI) • Past medical history (PMH) • Family
history (FH) • Social history (SH) • Review of systems (ROS)
✔✔Comprehensive Health History: You've Opened the Door! - ✔✔Identifying
Information - Name - Age - Address - Occupation • Source of Referral • PCP • Nearest
relative, contact information • Date and Time • Source of history, reliability
,• Note: this information is very important but is often ignored
✔✔Documenting the Chief Complaint Do Not Confuse the CC and HPI - ✔✔The
primary reason the patient is seeking medical attention, recorded using the patients own
words, in quotes X duration - "abdominal pain" x 3 months - Chest pain • One sentence,
never more than two • Do not editorialize or embellish
- The chief complaint is not your interpretation of why a patient is seeking help, but the
patient's
✔✔History of Present Illness HPI - ✔✔Description of the patient's chief complaint
starting from the last time the patient felt well
Attempt to understand the full story of the development and expression of the chief
complaint in the context of the patient's life
Determine the actual reason for coming in at this particular time. Why Today???
✔✔Health History - ✔✔• History of Present Illness (HPI) "OLDCART" - -
- Onset
- Location/Radiation
- Duration
- Characteristic
- Associated Symptoms
- Relieving /aggravating factors
- Treatments
✔✔LOCATES - ✔✔To help you remember -
L ocation
O ther associated symptoms
C haracter (or quality)
A lleviating/aggravating
T iming
E nvironment/setting
S everity
✔✔PQRSSTA - ✔✔To help you remember -
P rovocative/Palliative
Q uality
R egion
S everity
S etting
T iming
A ssociated symptoms
✔✔True or False: Objective data is more important than subjective, because subjective
data is lacking in quantification?
, Advanced - ✔✔FALSE! • Research suggests: -~80% of diagnoses are made based on
history alone. -Physical exam adds another 10%
✔✔General Survey - ✔✔Subjective Assessment
• Fatigue and Weakness • Fever • Weight Changes • Pain
Health History Common or Concerning Symptoms +Fatigue and Weakness Fatigue-a
nonspecific symptom that refers to a sense of weariness or loss of energy Weakness-
denotes a demonstrable loss of muscle power Important to elicit life circumstances
when symptoms occur- fatigue unrelated to such warrant further investigation
+Fever -an abnormal elevation in body temperature (above 100.4F) Normal
temperatures can vary throughout day Inquire about any recent illnesses? Has the
patient checked their temperature? Night sweats? Chills?
+Weight Changes How is your weight compared to a year ago? How do your clothes fit?
If there is a change in weight- inquire about change in diet or activity. Is it intentional?
Any mechanical factors contributing to weight gain or loss? What medications is patient
taking? Any drugs, alcohol, or smoking?
✔✔General Survey Objective Assessment - ✔✔Apparent State of Health • Level of
Consciousness • Signs of Distress • Skin Color and note lesions • Dress, Grooming, and
Personal Hygiene • Facial Expression
Odors of Breath and Body • Posture, Gait, and Mobility • Height and Weight • BMI •
Waist Circumference
✔✔General Survey - ✔✔Ask patient to walk into room & sit in chair. As they do so,
narrate and comment upon at least 5 of the following 8 items:
skin color
posture
obvious physical deformities
mobility
gait
personal hygiene
mood
affect, hearing, speech (ask 2 or 3 simple questions to assess hearing and speech
✔✔The Vital Signs - ✔✔Offers critical information that will influence the direction of your
visit • Blood pressure and pulse are taken first; respirations should be counted without
patient being aware • Temperature is assess in various sites
✔✔Blood Pressure - ✔✔• "True Blood Pressure"- is the average of blood pressures
over days and weeks • Home and ambulatory blood pressure measurements are more
accurate in predicting cardiovascular disease and end organ damage than traditional
office reading
Width of cuff should be about 40% of arm circumference; length should be about 80%
of upper arm
• Arm should be free of clothing and at hear level
• Ideally patient should be sitting quietly for at least 5 minutes in a chair with feet on floor
ANSWERS SET A+
✔✔Assessment - ✔✔This section is where the diagnosis and differential diagnosis are
listed for the date the note is written.
Sample
Diagnosis: - Strep Pharyngitis
• Differential Diagnosis:
- Viral pharyngitis
- Rheumatic fever
- Scarlet fever
✔✔Plan - ✔✔This is where the treatment plan goes.
- Medications
- Diagnostic tests (i.e. laboratory, radiologic, hearing, etc.)
- Education
- Counseling
- Referrals
- Procedures performed and the outcomes/result(s)
- Return to office date(s)/Follow up
Sample
- Amoxicillin 875mg BID for 10 days
- Rapid Strep test done in office
- Verbal instructions given on warm salt water gargles and spit 3-4 times a day; rest;
increased fluids; rest; no work 2 days note given to patient
- Patient instructed to return to the office in 2 days if no improvement. To report to the
emergency department with difficulty swallowing, breathing, rash develops, or
symptoms worse verbalized understanding.
,✔✔How to Interview a Patient - ✔✔Stay calm!! • Prepare before you go into the room -
Read the chart, familiarize yourself with the patient • Set an agenda - Time, needs,
issues • Look and be professional - If you look the part you have already conquered the
first hurdle
✔✔Set the Stage - ✔✔• Welcome the patient using their name • Introduce yourself and
your role • Remove communication barriers - Family or professional translator • Ensure
patient privacy and comfort • Set the agenda for the visit - What are you going to do
✔✔Why is the Patient Here?
• - ✔✔• Begin with open-ended questions - Requires patients to actually describe their
complaints - Obtain accurate, patient-specific information • Avoid closed-ended
questions - Similar to a long health history survey - Actually takes longer than open-
ended questions
• Be attentive while the patient is speaking - Of yourself • Silence, non-verbal
encouragement , body language -The Patient • Look for non-verbal signs and cues
• Ask question(s) and then ask again, using the patients own words • What is the
patient's personal story • Ask emotion-seeking questions
✔✔Comprehensive or Focused - ✔✔Comprehensive • New patients • Identifies and
rules out physical causes related to patient concerns • Baseline • Health promotion
Focused • Established patients • Focused concerns • Symptoms of specific system(s)
✔✔Comprehensive History - ✔✔• The comprehensive history is to be performed on all
non-emergent, new patients who will be receiving ongoing primary care from a
particular provider or group. • It is also expected within the hospital setting.
Patient Identifiers Reliability Chief Complaint HPI
Past Medical History Family History Social History Review of Systems (ROS)
✔✔Focused History - ✔✔A focused history is performed in emergency situations and/or
when the patient is already under the ongoing care of the clinician and presents with a
specific problem oriented complaint. Identifying data Chief Complaint Data from the
patient's medical history, family history and social history that are pertinent to the chief
complaint Problem oriented ROS
✔✔The Complete Health History - ✔✔Identifying information • Chief complaint or
concern (CC) • History of present illness (HPI) • Past medical history (PMH) • Family
history (FH) • Social history (SH) • Review of systems (ROS)
✔✔Comprehensive Health History: You've Opened the Door! - ✔✔Identifying
Information - Name - Age - Address - Occupation • Source of Referral • PCP • Nearest
relative, contact information • Date and Time • Source of history, reliability
,• Note: this information is very important but is often ignored
✔✔Documenting the Chief Complaint Do Not Confuse the CC and HPI - ✔✔The
primary reason the patient is seeking medical attention, recorded using the patients own
words, in quotes X duration - "abdominal pain" x 3 months - Chest pain • One sentence,
never more than two • Do not editorialize or embellish
- The chief complaint is not your interpretation of why a patient is seeking help, but the
patient's
✔✔History of Present Illness HPI - ✔✔Description of the patient's chief complaint
starting from the last time the patient felt well
Attempt to understand the full story of the development and expression of the chief
complaint in the context of the patient's life
Determine the actual reason for coming in at this particular time. Why Today???
✔✔Health History - ✔✔• History of Present Illness (HPI) "OLDCART" - -
- Onset
- Location/Radiation
- Duration
- Characteristic
- Associated Symptoms
- Relieving /aggravating factors
- Treatments
✔✔LOCATES - ✔✔To help you remember -
L ocation
O ther associated symptoms
C haracter (or quality)
A lleviating/aggravating
T iming
E nvironment/setting
S everity
✔✔PQRSSTA - ✔✔To help you remember -
P rovocative/Palliative
Q uality
R egion
S everity
S etting
T iming
A ssociated symptoms
✔✔True or False: Objective data is more important than subjective, because subjective
data is lacking in quantification?
, Advanced - ✔✔FALSE! • Research suggests: -~80% of diagnoses are made based on
history alone. -Physical exam adds another 10%
✔✔General Survey - ✔✔Subjective Assessment
• Fatigue and Weakness • Fever • Weight Changes • Pain
Health History Common or Concerning Symptoms +Fatigue and Weakness Fatigue-a
nonspecific symptom that refers to a sense of weariness or loss of energy Weakness-
denotes a demonstrable loss of muscle power Important to elicit life circumstances
when symptoms occur- fatigue unrelated to such warrant further investigation
+Fever -an abnormal elevation in body temperature (above 100.4F) Normal
temperatures can vary throughout day Inquire about any recent illnesses? Has the
patient checked their temperature? Night sweats? Chills?
+Weight Changes How is your weight compared to a year ago? How do your clothes fit?
If there is a change in weight- inquire about change in diet or activity. Is it intentional?
Any mechanical factors contributing to weight gain or loss? What medications is patient
taking? Any drugs, alcohol, or smoking?
✔✔General Survey Objective Assessment - ✔✔Apparent State of Health • Level of
Consciousness • Signs of Distress • Skin Color and note lesions • Dress, Grooming, and
Personal Hygiene • Facial Expression
Odors of Breath and Body • Posture, Gait, and Mobility • Height and Weight • BMI •
Waist Circumference
✔✔General Survey - ✔✔Ask patient to walk into room & sit in chair. As they do so,
narrate and comment upon at least 5 of the following 8 items:
skin color
posture
obvious physical deformities
mobility
gait
personal hygiene
mood
affect, hearing, speech (ask 2 or 3 simple questions to assess hearing and speech
✔✔The Vital Signs - ✔✔Offers critical information that will influence the direction of your
visit • Blood pressure and pulse are taken first; respirations should be counted without
patient being aware • Temperature is assess in various sites
✔✔Blood Pressure - ✔✔• "True Blood Pressure"- is the average of blood pressures
over days and weeks • Home and ambulatory blood pressure measurements are more
accurate in predicting cardiovascular disease and end organ damage than traditional
office reading
Width of cuff should be about 40% of arm circumference; length should be about 80%
of upper arm
• Arm should be free of clothing and at hear level
• Ideally patient should be sitting quietly for at least 5 minutes in a chair with feet on floor
