NURS 6023
Steps of the clinical encounter - answer initiating the session, gathering information,
performing a physical exam, explaining and planning, closing the session
a trusting relationship - answer what sets the groundwork for a successful clinical
encounter
the first step - answer when are trust and good rapport established
when gathering information, it is helpful to - answer let the patient tell their story
what is important to the success of the plan - answer shared decision making
social determinant of health - answer conditions in which people are born, grow, work,
live, and age, and the wider set of forces shaping the conditions of daily life
subjective data - answerwhat the patient says
objective data - answerwhat you observe
health history - answerformat for organizing the data you collect from the patient into a
logical order that summarizes their story
comprehensive health history - answerused for new patients or those who are
hospitalized
focused health history - answerused for a more specific or problem oriented visit (like
urgent care)
components of comprehensive health history - answerchief complaint, history of present
illness, past medical history, family history, social history, review of systems
components of HPI - answerOnset, Location, Duration, Characteristics,
Aggravating/Alleviating factors, Radiation, Timing, Setting (OLDCARTS)
when conducting a focused exam, include - answerone body system above and below
the area of concern and a basic cardiovascular and respiratory exam
Four standard techniques for physical exam - answerInspection, palpation, percussion,
auscultation
Techniques for abdominal exam - answerInspection, auscultation, palpation, percussion
, clinical reasoning - answerthe process by which you use the data you gathered to
formulate a hypothesis or a differential diagnosis
To come up with a differential diagnosis, what areas do you think about -
answerVascular Infectious Neoplastic Drug related Inflammatory Congenital Allergic
Traumatic Endocrine (VINDICATE)
What is a SOAP note - answerSubjective, objective assessment and plan; method for
health care professionals to write notes in a patient's chart in a consistent manner
how is the HPI written - answerin paragraph format with short phrases
while going over the Review of Systems with the patient you should always include -
answertwo to three questions from the general category b/c this is broad and can rule
out many things (ask about fever, chills, weight loss, weight gain)
when performing your physical exam you should always include information about -
answerthe general survey statement, respiratory, cardiac, and GI
what does a general survey begin with - answerevaluation of possible constitutional
symptoms
what are consitutional symptoms - answersymptoms that are vague and attributable to
many causes (fatigue, weakness, chills, fever, weight loss, weight gain)
somatic pain - answermusculoskeletal pain; dull, aching, throbbing
neuropathic pain - answerrelated to the nervous system; burning, stabbing, "pins and
needles"
adults should be screened for - answerexcessive alcohol use, tobacco use, illicit drug
use, high risk sexual activity that increase risk for STI
diagnostic manual used by mental health specialists - answerDSM-5
mental disorder - answerany condition or syndrome with clinical manifestations
characterized by significant impairment in cognition, emotion regulation, or behavior
measured in terms of deviation from normal and leading to significant distress or
disability in social, occupational, or other important activities of daily life
4 key neurotransmitters involved in mental disorders - answerserotonin, norepi,
dopamine, acetylcholine
most common symptoms of mental health disorders - answeranxiety or excessive
worry, depressed mood, memory problems, medically unexplained symptoms
Steps of the clinical encounter - answer initiating the session, gathering information,
performing a physical exam, explaining and planning, closing the session
a trusting relationship - answer what sets the groundwork for a successful clinical
encounter
the first step - answer when are trust and good rapport established
when gathering information, it is helpful to - answer let the patient tell their story
what is important to the success of the plan - answer shared decision making
social determinant of health - answer conditions in which people are born, grow, work,
live, and age, and the wider set of forces shaping the conditions of daily life
subjective data - answerwhat the patient says
objective data - answerwhat you observe
health history - answerformat for organizing the data you collect from the patient into a
logical order that summarizes their story
comprehensive health history - answerused for new patients or those who are
hospitalized
focused health history - answerused for a more specific or problem oriented visit (like
urgent care)
components of comprehensive health history - answerchief complaint, history of present
illness, past medical history, family history, social history, review of systems
components of HPI - answerOnset, Location, Duration, Characteristics,
Aggravating/Alleviating factors, Radiation, Timing, Setting (OLDCARTS)
when conducting a focused exam, include - answerone body system above and below
the area of concern and a basic cardiovascular and respiratory exam
Four standard techniques for physical exam - answerInspection, palpation, percussion,
auscultation
Techniques for abdominal exam - answerInspection, auscultation, palpation, percussion
, clinical reasoning - answerthe process by which you use the data you gathered to
formulate a hypothesis or a differential diagnosis
To come up with a differential diagnosis, what areas do you think about -
answerVascular Infectious Neoplastic Drug related Inflammatory Congenital Allergic
Traumatic Endocrine (VINDICATE)
What is a SOAP note - answerSubjective, objective assessment and plan; method for
health care professionals to write notes in a patient's chart in a consistent manner
how is the HPI written - answerin paragraph format with short phrases
while going over the Review of Systems with the patient you should always include -
answertwo to three questions from the general category b/c this is broad and can rule
out many things (ask about fever, chills, weight loss, weight gain)
when performing your physical exam you should always include information about -
answerthe general survey statement, respiratory, cardiac, and GI
what does a general survey begin with - answerevaluation of possible constitutional
symptoms
what are consitutional symptoms - answersymptoms that are vague and attributable to
many causes (fatigue, weakness, chills, fever, weight loss, weight gain)
somatic pain - answermusculoskeletal pain; dull, aching, throbbing
neuropathic pain - answerrelated to the nervous system; burning, stabbing, "pins and
needles"
adults should be screened for - answerexcessive alcohol use, tobacco use, illicit drug
use, high risk sexual activity that increase risk for STI
diagnostic manual used by mental health specialists - answerDSM-5
mental disorder - answerany condition or syndrome with clinical manifestations
characterized by significant impairment in cognition, emotion regulation, or behavior
measured in terms of deviation from normal and leading to significant distress or
disability in social, occupational, or other important activities of daily life
4 key neurotransmitters involved in mental disorders - answerserotonin, norepi,
dopamine, acetylcholine
most common symptoms of mental health disorders - answeranxiety or excessive
worry, depressed mood, memory problems, medically unexplained symptoms
