Laboratory Manual Seidel’s Guide to Physical Examination Ball 9780323169523

Laboratory Manual Seidel’s Guide to Physical Examination Ball 9780323169523Contents Chapter 1: The History and Interviewing Process, 1 Chapter 2: Cultural Competency, 7 Chapter 3: Examination Techniques and Equipment, 11 Chapter 4: Vital Signs and Pain Assessment, 16 Chapter 5: Mental Status, 20 Chapter 6: Growth and Measurement, 25 Chapter 7: Nutrition, 29 Chapter 8: Skin, Hair, and Nails, 38 Chapter 9: Lymphatic System, 46 Chapter 10: Head and Neck, 52 Chapter 11: Eyes, 58 Chapter 12: Ears, Nose, and Throat, 65 Chapter 13: Chest and Lungs, 71 Chapter 14: Heart, 79 Chapter 15: Blood Vessels, 86 Chapter 16: Breasts and Axillae, 92 Chapter 17: Abdomen, 98 Chapter 18: Female Genitalia, 107 Chapter 19: Male Genitalia, 114 Chapter 20: Anus, Rectum, and Prostate, 120 Chapter 21: Musculoskeletal System, 126 Chapter 22: Neurologic System, 134 Chapter 23: Sports Participation Evaluation, 145 Chapter 24: Putting it all Together, 150 Chapter 25: Taking the Next Steps: Critical Thinking, 155 Chapter 26: Recording Information, 159 Chapter 27: Emergency or Life-Threatening Situations, 164 Answer Key, 169vii1 The History and Interviewing Process LEARNING OBJECTIVES After studying Chapter 1 in the textbook and completing this section of the laboratory manual, students should be able to: 1. Recognize ethical considerations in patient–examiner relationships. 2. Classify aspects of communication that affect the interview process. 3. Obtain a comprehensive health history. 4. Apply the elements of a clinical presentation to a health history. 5. Organize data according to a clinical history outline. 6. Differentiate between the history and interviewing process used for an adult patient with the process used for patients of special populations such as patients with disabilities, pregnant patients, and frail patients. TEXTBOOK REVIEW Chapter 1: The History and Interviewing Process (pp. 1–20) CHAPTER OVERVIEW This chapter explores the development of your relationships with patients and the building of the histories of your pa- tients. Because you and each patient are involved in a joint effort, the formation of the health history as “building” a history rather than “taking” one reflects each patient’s perspectives and unique status. Effective techniques for develop- ing a patient relationship and facilitating communication with each patient are reviewed. An in-depth discussion of the components and structure of the health history is included. The history is vital to the interpretation of the physical ex- amination. Finally, this chapter offers widely accepted, time-tested approaches to the structure of a history with adapta- tions suggested for patients of both genders and with disabilities. TERMINOLOGY REVIEW CAGE—questionnaire for discussing the use of alcohol, which includes cutting down (C), annoyance by criticism (A), guilty (G), and eye openers (E). Chief concern (CC)—a brief statement of the reason the patient is seeking care. Family history (FH)—blood relatives in the immediate or extended family with illnesses that have features similar to the patient’s concern. Functional assessment—questions concerning the ability to take care of one’s daily needs that are part of the review of systems. History of present illness (HPI)—a step-by-step evaluation of the circumstances that surround the primary reason for the patient’s visit. Intimate partner violence (IPV)—includes a range of abusive behaviors perpetrated by someone who is or was involved in an intimate relationship with the victim.Past medical history (PMH)—the patient’s state of overall health before the present problem. Personal and social history (SH)—work, marriage, sexual, and spiritual experiences; the patient’s use of alcohol, tobacco, and drugs. Review of systems (ROS)—identifies the presence or absence of health-related issues in each body system. Symptom analysis—questions specifying the onset, location, duration, intensity, characteristics, and aggravating and alleviating factors.APPLICATION TO CLINICAL PRACTICE Clinical Case Study Rachael Roman is a 25-year-old woman who presents to your office with a complaint of fatigue. She is a college graduate, but she is currently working as a waitress because she has not been able to secure a job in her field. 1. What is this patient’s chief complaint? 2. What questions would you ask to complete the HPI? 3. What systems should you ask questions about during the ROS? Concepts Application Listed below are patient behaviors that can create tension for the examiner. For each patient behavior listed, provide a behavior by the examiner that could help decrease the tension. (Write your answers in the space provided in the right column.) Patient Behavior Tension Seduction Depression Anxiety Excessive flattery Financial concerns Silence Examiner Behavior to DecreaseCRITICAL THINKING Critical Thinking Case Study 1 Reed Smith is a 35-year-old man who presents to your office with a complaint of left foot pain. He describes this as a severe burning pain on the outside edge of the heel of his left foot. The pain is worse in the morning and when he walks barefoot. The pain improves when he applies ice to his foot. In addition, the patient states, “I have been using Tylenol one or two times per day.” The pain started 2 weeks ago after the patient was walking on the beach. The pain lasts for 2 to 3 hours in the morning and then seems to subside after he is up and walking for a while. 1. Based on the information in this case study, identify each of the following characteristics of the pa- tient’s pain using the mnemonic device “OLDCARTS.” Onset: Location: Duration: Characteristics: Aggravating factors: Relieving factors: Timing: Severity:Critical Thinking Case Study 2 Marci Jones is a 52-year-old woman who presents to your office with sudden burning and stabbing pain in the left orbit. She says her pain is severe, and she is outwardly agitated. She experienced similar pain the day before at about the same time. She denies associated signs or symptoms of nausea or vomiting, aura, new medications, and excessive alcohol use. She reports a 24-year pack history for smoking and says she has high stress on her job, does daily exercise, and follows a prudent diet. PMH is unremarkable with the exception of “spells” of headaches similar to this from time to time. According to the patient, these symptoms occur without warning and resolve after a few hours but usually return the next day. This may go on for a week or more before the symptoms stop until the next episode begins. 1. What components of a health history are present in this case study? 2. What components should have been added to the health history? 3. What components are only partially complete? CONTENT REVIEW QUESTIONS Multiple Choice Circle the correct answer for each of the following questions. 1. Which of the following will best facilitate the inter- view when obtaining a history for a deaf patient who can read lips? a. Speaking loudly b. Using gestures c. Speaking slowly d. Sitting to the side of the patient 2. Approximately what percentage of patients inter- viewed have a sexual orientation other than heterosexual? a. 2% b. 5% c. 10% d. 20% 3. During a history, the patient indicates he has an uncle and a brother with sickle cell disease. Which of the following is an appropriate method to document this information? a. Document this as chief complaint. b. Include it in the family history. c. Include this in past medical history. d. Incorporate this information in the social history.4. Which approach is recommended at the onset of an interview? a. Use a structured approach to ask questions. b. Introduce yourself and include a detailed descrip- tion of your background and qualifications. c. Use an open-ended approach; let the patient explain the problem or reason for the visit. d. Start with the family history and past medical history to determine the underlying problem. 5. Which of the following questions may lead to an inaccurate patient response? a. “Where do you feel the pain?” b. “How does this situation make you feel?” c. “What happened after you noticed your injury?” d. “That was a horrible experience, wasn’t it?” 6. Repeating a patient’s answer is an attempt to a. confirm an accurate understanding. b. discourage patient anger or hostility. c. teach the patient new medical terms. d. test the patient’s knowledge.7. Which of the following history types is unique to a pediatric history? a. Family history b. Developmental history c. Social history d. Past medical history d. DDST 8. When interviewing an adolescent who is reluctant to talk during an interview, it is best to a. tell the patient you must have honest answers to your questions. b. ensure confidentiality regarding information discussed. c. inform the patient that adolescents often have trouble expressing their feelings. d. obtain the history from a parent or other family member. 9. During an interview, your patient admits to feeling worthless and having a sleep disturbance for the past 3 weeks. These are clues that warrant the ex- ploration of a. risk for suicide. b. split personality. c. cognitive function. d. functional assessment. 10. Mrs. Carol Turner is a 38-year-old mother who brings her 1-year-old son in for health care. Which of the following requests to the child’s mother would be most appropriate for the interviewer to make at the beginning of the interview? a. “Mom, please place your son in your lap.” b. “Carol, please place your son in your lap.” c. “Mrs. Turner, please place your son in your lap.” d. “Sweetie, please place your son in your lap.” 11. Which type of questionnaire concerning drug and alcohol use is advocated, although not clinically validated, for adolescent patients? a. TACE b. CAGE c. CRAFFT 12. Jerry, a 26-year-old homosexual man, is having a health history taken. Which question regarding sex- ual activity would most likely hamper trust between Jerry and the interviewer? a. “Are you married, or do you have a girlfriend?” b. “Tell me about your living situation.” c. “Are you sexually active?” d. “Are your partners men, women, or both?”13. A conversation with a parent concerning a 5-year- old child a. violates the child’s need for privacy. b. is inappropriate because the child is able to talk with you. c. provides significant information about family dynamics. d. causes distrust in the child toward the examiner. 14. Long periods of silence during an interview may indicate a. a need for the health care provider to increase the pace of the interview. b. an inability of the patient to communicate. c. time needed to gain courage to discuss a painful topic. d. a need to terminate the interview because of the patient’s inability to pay attention. 15. When questioning a patient regarding a sensitive issue, such as drug use, it is best to a. begin by describing to the patient the effects of drug abuse on health. b. be direct, firm, and to the point. c. explain that the information will be shared only with health care workers. d. apologize to the patient for asking personal questions. 16. Direct questions are designed to a. attack sensitive material head on. b. demonstrate to the patient who is in charge of the interview process. c. ensure confidentiality. d. obtain or clarify specific details about an answer. 17. Interviewers should identify and assess their own feelings, such as hostility and prejudice, in order to a. avoid inappropriate behavior. b. explain their biases to patients. c. express their idiosyncrasies. d. reduce communication barriers. 18. During an interview, a patient describes abdominal pain that often awakens him at night. Which of the following responses by the interviewer would facili- tate the interviewing process? a. “Constipation can cause abdominal pain.” b. “Do you need a sleeping medication?” c. “Pain is always worse at night, isn’t it?” d. “Tell me what you mean by often.”19. When taking a patient’s history, you are asked ques- tions about your personal life. What is the best response to facilitate the interviewing process? a. Answer briefly and then refocus to the patient’s history. b. Give as much detail as possible about the asked information. c. Ignore the question and continue with the patient’s history. d. Tell the patient that it is inappropriate to answer personal questions. 20. During an interview, the patient describes problems associated with an illness and begins to cry. The best action in this situation is to a. stop the interview and reschedule for another time. b. allow the patient to cry and then resume when the patient is ready. c. change the topic to something less upsetting. d. continue the interview while the patient cries in order to get through it quickly.