Exam 1 Flashcards
(27 cards)
Note order
- introduction
- CC
- HPI
- PMH
- FH
- Personal-social history
- ROS
- PE
- lab/diagnostic studies
- assessment/plan
- problem list w/ differential diagnosis
Note introduction
- date and time of exam
- identifying information
- source of info and reliability
- provider name
CC
“in patient words”
HPI
- topic sentence
- 7 attributes of symptoms
- pertinent positives and negatives
- check for completeness and chronological order
PMH
- childhood illness
- adult illness: medial, surgical, ob/gyn, psychiatric
- medications
- allergies
- tobacco
- alcohol/drugs
- health screenings and immunizations
FH
- age and health of living
- age and cause of death for deceased
- important family medical history (CAD, cancer, DM, etc)
- family history related to CC
Personal-social history
- occupation
- education / health literacy
- personal relationships
- sexual history
- other pertinent (housing, religion, finances)
- health maintenance (stress, exercise, sleep habits, eating, etc)
- tobacco
- alcohol and drugs
ROS
- general
- skin
- HEENT
- Neck
- breast
- respiratory
- cardiovascular
- GI
- genitourinary
- musculoskeletal
- psychiatric
- neurological
- hematologic
- endocrine
- functional status
PE
- general description
- vital signs
- skin
- HEENT
- neck
- lymph nodes
- thorax and lungs
- cardiovascular
- peripheral vascular
- breast
- abd
- genitalia
- rectal
- extremities
- musculoskeletal
- neurological
- reflexes
Assessment/plan
- discuss problem providing a rational for diagnosis and tx
- plan: diagnostic, therapeutic, patient education, follow up/referral, management
7 attributes of symptoms
- location
- quality
- quantity or severity
- timing
- setting
- aggravating or relieving factors
- associated mainfestations
CAGE questions
- cutting down
- annoyance when criticized
- guilty feelings
- eye-openers
- screening tool for alcohol/drugs
Differential diagnosis
I VINDICATE AID
- idiopathic
- vascular
- infectious
- neoplastic
- degenerative
- inflammatory
- congenital
- autoimmune
- trauma
- endocrine and metabolic
- allergic
- iatrogenic
- drugs
Sensitivity
- identifies the proportion of people who test positive in a group of people known to have the disease (true positives)
- high sensitivity have a small number of false negatives
- Rule out disease (leaves just positive -both true and false)
- 90% or more makes good test
True positives
have disease and test positive
False negatives
have disease, but test negative
Specificity
- identifies proportion of people who test negative in a group of people know to be without the disease (true negatives)
- high specificity rarely have false positives
- rule in disease (leaves just the pts that have the disease and test positive)
- 90% or more is a good test
True negatives
do not have disease and test negative
False positive
do not have disease, but test positive
Predictive value
-indicates how well a given symptom, sign, or test result (neg or pos) predicts the presence or absence of disease
Positive predictive value
the probability of disease in a pt with a positive (abnormal) test
-proportion of true positives
Negative predictive value
the probability of not having the disease when the test is negative or normal
-proportion of true negatives
Gold standard sensitivity
a/a +c = total TP
of true positives / total with disease x100 = %
Gold standard specificity
d/b + d = total TN
of true negatives / total with disease x100 = %
