NR509 Midterm Review -Bates Guide to Physical Examination 13th edition Chapters 1-17 (Answered)

NR509 Midterm Review -Bates Guide to Physical Examination 13th edition Chapters 1-17 (Answered) Patient and clinician-centered The approach to a clinical encounter Echolalia repetition of the words and phrases of others Occurs in manic and schizophrenia Clinicians Experts have defined patient-centered interviewing as "following the patient's lead to understand their thoughts, ideas, concerns and requests, without adding additional information from the ________ perspective." F-I-F-E Feelings Ideas Functional effect Expectations Guided questioning Moves from open-ended to focused questions Offers multiple choices for answers Using echoing Clarifies what the patient is saying Asking a series of questions one at a time What are some types of challenging patients? Silent, talkative, aggressive, argumentative, discriminatory, flirtatious, nonadherent, confusing narrative Comprehensive Assessment Used for patients you are seeing for the 1st time. Includes all elements. Focused Assessment Used for patients you know well returning for routine care, or specific "urgent care" Components of the health history ALL SUBJECTIVE" Initial information (age, gender, source of info), CC, HPI, OLDCART, PMH, FH, SH, ROS What should be listed under adult illnesses in health history? Medical illnesses (DM, HTN, astham etc) Surgical (dates, indication, type) OBGYN (menstrual hx, obs hx, contraception) Psychiatric (dx, hospitalizations, treatments) Problem list Summarizes all related problems that support a differential diagnosis. Most active listed 1st. Differential diagnosis with pertinent + and - social determinants of health economic stability, education, neighborhood and built environment, health and health care, social and community context. Explain how the examination will proceed. A 23-year-old physician assistant (PA) student found that she felt nervous when called upon to examine men in her age group. On one occasion, she encountered a young male patient who appeared embarrassed to see her walk into the room. What should the PA do to minimize their mutual discomfort? Follow the patient's lead to understand their thoughts, feeling, and ideas. A 34-year-old male with a history of complex social and medical needs (including current substance abuse) presents to a PC clinic. The patient has experienced a number of adversarial relationships with prior clinicians, including voluntarily leaving two practices within the previous year and being asked to leave care at a third clinic due to misbehavior. The attending physician desires to utilize the approaches to this patient that are most likely lead to comprehensive care and patient compliance. Which of the following is the most appropriate interview style for the attending physician to use? Using nonverbal communication to encourage the patient to expand their narrative A 17-year-old male presents to a sexually transmitted disease clinic at the behest of his brother, who convinced the patient to attend the clinic after he disclosed that he prefers homosexual partners but is afraid that his last partner may have given him an infection. The patient expresses to the intake nurse that he is unashamed of his sexual orientation and will not stay through the visit if he feels that he is dismissed or discriminated against because of it. The nurse practitioner receives this communication prior to entering the examination room and decides to employ active listening to best connect with the patient at this critical juncture in his care with the clinic. Which of the following is an example of an active listening technique? Feelings, ideas, function, expectations A 42-year-old female mathematician presents for follow-up care regarding a new diagnosis of systemic lupus erythematosus 6 months ago after a lengthy diagnostic process during which she was debilitated with fatigue and joint pain. Since her diagnosis, she has been minimally compliant with medications and has switched her rheumatology provider twice. She continues to feel ill, and, in explanation for her lack of adherence to the prescribed treatment, she simply says, “I don’t like it.” At this initial visit with her third rheumatology provider, the clinician elects to explore the issues behind her noncompliance before engaging in diagnostics and treatment using the FIFE model. Which of the following best defines the elements of the FIFE model? The 5 P's of the Social History Partners Practices Protection from STI's Past history of STI Pregnancy plans Review of Systems (ROS) Constitutional HEENT Neck Breasts Respiratory Cardiovascular Gastrointestinal Peripheral Vascular Genitourinary Musculoskeletal Integumentary Neurological Psychiatric Endocrine Hematological Allergy/Immunological Obtain a more complete description of problems. A 39-year-old nurse who is a well-established patient complains of irregular menstrual periods and pelvic pain. She says that she is having trouble sleeping and asks whether she could be given a “sleeping pill.” The patient also says she is thinking of leaving her job. What is the best “next step” in caring for this patient? Validating and empathetic with open-ended questions A 29-year-old female professional athlete presents to a new primary care provider with chronic menstrual complaints. She remarks to the nursing staff that, in the past, she has experienced a dismissal of her complaints because of her high level of physical fitness and conditioning. She is seeking a care provider who will explore the issue in more detail and work with her particular concerns. Which of the following is the description of the patient-centered care this individual seeks? Recognizing the patient’s emotions by asking or confirming how she feels about the event A 36-year-old female air traffic controller presents to her primary care provider for a routine visit 3 months after losing her spouse to a lengthy battle with a neurodegenerative disease. The patient denies any psychiatric symptoms on review of systems and, in fact, states that she has slept better in the last month than she had in the previous years. She endorses a healthy support system, including the extended family of her deceased spouse, with whom she is still close. She becomes wistful and briefly tearful when speaking of the plans that they had when they first married that were never fulfilled; she then changes the subject rapidly to whether her Pap smear is due. Which of the following is an example of an empathetic response to this patient? Moving from open-ended to focused questions A 63-year-old male presents to establish care at a new primary care clinic to discuss issues with pain and fatigue. The clinician conducting the visit begins with general historical questions but quickly becomes suspicious that the patient is suffering from decompensated heart failure. When the patient mentions that he has had vague chest pain since last night, the clinician feels that the focus must be redirected to this potentially emergent condition. Which of the following interview techniques is the most appropriate to effectively manage this visit? Echoing A 59-year-old patient presents to his primary care provider with a history of several episodes of sharp epigastric pain. His father died of pancreatic cancer at age 52 years, and the patient recalls to the clinician that, “His pain was just like mine is now …” The patient then pauses several seconds. The clinician replies, “Just like?” after which the patient restarts his narrative. Which of the following is an example of the interviewing techniques employed by the clinician? “That sounds like a frightening experience that you are recovering well from.” A 14-year-old male presents to a new primary care provider after his family relocates to a state. The patient underwent treatment for sarcoma when he was age 11 years, including an above-the-knee amputation. He has learned to successfully navigate with a prosthetic leg and even engage in competitive athletics at school. He does not like to speak of his experience with cancer and often makes up humorous stories to tell new acquaintances about his amputation (such as, “I got bit by a squirrel and they had to amputate.”). Although he is very well engaged in most of the visit with the new clinician, when the topic of cancer arises, he demurs to his father, who accompanies him to this appointment. Which of the following statements is most likely to be helpful in cementing the patient’s trust in the new provider? Cut over eye from shaving A 54-year-old diplomat working at the United Nations reports occasional chest pain and a sense of tightness in his chest when particularly stressed over work deadlines. The patient is 6 feet 4 inches tall. He has a temperature of 98.6ºF and blood pressure of 140/78. He has a cut over one eye that he says is “from shaving.” Which of the following represents subjective information about this patient? Accelerated heart rate A 32-year-old office worker reports excessive stress at work and pain in the right lower quadrant. She states that last night she vomited twice. Her blood pressure is 120/75, heart rate 93 bpm. The patient looks pale and is sweating lightly. Which of the following is an objective finding? Determine the number of pack-years the patient smokes. A 29-year-old electrician complains of persistent cough and wheezing, particularly when he exercises. He says he smokes “occasionally” but rarely so much that he needs to purchase cigarettes: “Mostly, I bum them,” he says, chuckling. Upon hearing this information, what is the best next step on the part of the clinician? Obtain a menstrual history for the previous 6 months. A 47-year-old fitness trainer visits the physician assistant (PA) because of skin dryness, night sweats, and irregular menstrual periods. It is the PA’s first contact with this patient. The patient notes that “My sex life has really gone downhill lately” and says that she is considering divorcing her husband of 20 years, stating that “He’s not a bad guy. I just think that I can do better.” In which of the following ways should the clinician proceed? A comprehensive health history A 26-year-old homeless male presents for a new-patient evaluation at a community health center. He has a history of intravenous drug use, from which he contracted hepatitis C. He also suffers from uncontrolled asthma that he has had since childhood, with treatment including frequent doses of oral steroids when he cannot keep inhalers in his possession. Two years ago, he was diagnosed with bipolar disorder. On today’s visit, his main concern is a small abscess in his right antecubital fossa at a heroin injection site. Which of the following is the best approach to the health history for this patient at his first visit? Sensitivity Likelihood of a true positive for a disease Specificity Likelihood of a true negative to not have a disease Bias in research age, gender, race, sample size, selection, performance, detection, attrition Constitutional Symptoms SUBJECTIVE (ROS) fatigue, weakness, fever/chills, night sweats, weight loss/weight gain, pain, orientation General Survery OBJECTIVE (Physical Exam) Vital signs, height, weight, BMI, General appearance, LOC, skin color/consistency with ethnicity, dress, grooming, hygiene, gait and posture, mood Reasons for a BP reading falsely high brachial artery below the heart level cuff is too small (narrow) White coat syndrome BP abnormally elevated at the Dr. Office They will need to check at home and make a journal Masked HTN BP that is 140/90 while at the Dr. Office they will need a 2 week daily recording from home HTN Diagnosis Normal 120/80 Elevated 120-129/80 Stage I 130-139/80-89 Stage 2 140/90 must be elevated on 2 separate occasions (not the same visit) Orthostatic HTN SBP drop20 DBP drop 10 within 3 minutes of standing Causes include drugs, blood loss, prolonged bedrest, ANS disease Respiratory rate 12 bradypnea 25 tachypnea Hallucinations no external stimuli Occurs in schizophrenia, alcohol withdrawal, and systemic toxicity. Hallucinations may occur in delirium, dementia (less commonly), posttraumatic stress disorder, schizophrenia, and substance use. Illusions misinterprets external stimuli