UC Advanced assessment HEENT abnormal findings

What are the components of a COMPLETE health assessment? CC, HPI, PMH, FH, Social Hx, ROS, Genogram What are the components of a FOCUSED health assessment? CC, HPI, PMH, FH/SH that pertains to complaint, specific system ROS 0:00 / 0:15 Foundation of the HPI is the PQRST format; what does it stand for? Provocative Quality or Quantity Region/Radiation Severity Timing Provocative Components What causes the symptom What makes it worse or better? What do you do for it? Meds/rest? Looking for triggers, relievers, aggravators Quality or Quantity Components How does it feel, look, sound, or smell? How much are you experiencing now? Does it interfere with ADLs? Is it worse, better, or different than the last time? Region/Radiation Where is it located? Does it travel anywhere else in your body? Severity On a scale of 1 - 10, how bad is it? At its worse do you have to sit down, lie down, or slow down? Is it getting better, worse, or the same? Timing When did it begin? Date/time? Type of onset - how did it start? Suddenly or gradually Frequency - how often does it occur? When does it occur? What time of day? Does it wake you up? Does it happen after/before food? Seasonal? Duration - how long does it last? What is the most important question to ask? Have you ever had this before??? What are the components of a PMH? (past med hx) Childhood/adult illness Surgeries with dates Immunizations Pediatric, adolescent, and adult Serious injury/trauma - transfusions Medications Prescription OTC Allergies and response Screening exams Psychiatric/mental health issues What are the components of FH? (family history) CAD, cholesterol DM HTN, stroke CA TB Asthma Bleeding, anemia Alcoholism Weight, mental health What are the components of Social History? Alcohol/Drugs Occupation Nutrition Exercise Home life/support system/housing/safety/SES Exposures/travel Stress management Sleep What are the components of a ROS? (review of systems) Head to toe Complete systematically Documentation - Pt opportunity to address problems, NOT physical component, Pertinent negative (or positive), Denies chest pain , sob Never write as "no problems" Pertinent positives/negatives What are the components to a genogram? 3 generational, points out risk factors, allows for anticipatory guidance What is the screening tool that focuses on detecting pts at high risk for an eating disorder? SCOFF S-Do you make yourself Sick when you feel uncomfortably full? C-Do you worry you have lost Control over how much you eat? O-Have you recently lost more than One stone (14 lbs.) in a 3-month period? F-Do you believe yourself to be Fat when others say you are too thin? F-Would you say that Food dominates your life? **One point for every "yes"; >2 indicates a likely case of anorexia or bulimia What is subjective information? information told to you by the patient about the situation What is objective information? information you have determined through your observation, physical assessment, lab values, and testing. What is the HEADS assessment? Interview approach with teenagers to discuss sensitive topics What does HEADS stand for? H-How are things at home? E-How is school? Grades? Subjects? Education A-What kind of activities do you do? What is affect, ambition, anger? D-Do you use drugs, etoh, does anyone in your family? S-Are you engaging in sex? Sexuality issues? What does CAGE stand for? C-Have you ever been concerned about your drinking? Feel the need to cut down? A-Have you ever felt annoyed by criticism of your drinking? G-Have you ever felt guilty about your drinking or what you did while drinking? E-Have you ever felt the need for a morning eye opener? **YES: physical dependence. 99.8% efficacy rating What does RAFT stand for? R-Do you drink/drugs to relax or fit in? A-Do you drink/drugs while you are alone? F-Do any of your friends use drugs/etoh? Does a family member have a problem? T-Have you ever gotten in trouble b/c ... ? What is the Dukes Activity Status Index? Measures patients' functional capacity - higher score the better the oxygen uptake. Rough estimate of peak oxygen uptake: <15 transplant candidate >20 none to mild impairment