Week 1

Question 1

What are the two types of visits we conduct as FNPs? When would you conduct each? What are the components of each?

Answer 1

A comprehensive patient assessment: an assessment of new patients or an annual well visit exam
Focused patient assessment: an appropriate assessment for patients who are already established. Can be used during routine or UC visits

Question 2

What is the difference between subjective and objective data? What are some examples of each?

Answer 2

Subjective data is what the patient is telling you IE. symptoms
My head hurts, i have chest pain, my knee hurts when i stand on it
Objective data is measurable data
Data collected when palpating, auscultating, taking vital signs, lab/diagnostic values

Question 3

What is a differential diagnosis and how is one formulated?

Answer 3

List of potential causes/diagnoses for the patient’s problems. DDX is formulated by using the data from a patient’s assessment using objective and subjective data.
1. Always consider the worst possible scenario as part of your DDx, but “when you hear hoofbeats, think horses, not zebras”

Question 4

4. What is the HPI? How would the FNP obtain one?

Answer 4

HPI=History of present Illness
Concise, clear, chronological description of the problems prompting the patients visit.
• Summary: Onset, setting, manifestations and treatments to date
• Seven attributes of a symptom (will discuss later)
• Relevant risk factors
• Each symptoms needs its own history
• All medications including name, dose, route and frequency
• Allergies
• Tobacco use (in pack years)
• One pack = 20 cigarettes
• Number PPD x Number of years smoking = Pack years
• Or included date the patient quit
Alcohol use

Question 5

What are the seven attributes of a symptom? How do you define each? What is the difference between onset and timing?

Answer 5

1. Location: Where is it? Does it radiate?
2. Quality: What is it like?
3. Quantity or severity: How bad is it? (For pain, ask for a rating on a scale of 1 to 10.)
4. Timing: When did (does) it start? How long does it last? How often does it come?
   - Onset: setting in which symptom occurs
   - Duration: how long it has been present/lasts
   - Frequency: how often it occurs
5. Remitting or exacerbating factors: Is there anything that makes it better or worse?
6. Associated manifestations: Have you noticed anything else that accompanies it

Question 6

6. What does OLDCART stand for? How is onset in OLDCART different from the onset in the seven attributes of a symptom?

Answer 6

Onset
Location
Duration
Character
aggravating/alleviating
Radiation
Timing
Onset of OLDCART refers to WHEN the pain started. The attributes of a symptom refers to the SETTING of when the symptom occurs

Question 7

What is a leading question? Should these be used when obtaining a history from a patient?

Answer 7

A yes or no question. No- we should use open ended questions.

Question 8

How should the FNP quantify tobacco use?

Answer 8

Tobacco use (in pack years)
1.	One pack = 20 cigarettes
2.	Number PPD x Number of years smoking = Pack years 
Or included date the patient quit

Question 9

How would you approach the silent patient?

Answer 9

• Try not to feel uncomfortable with silence
• Patients may use periods of silence to collect their thoughts, remember details, or decide if they can trust you with certain information
• Watch the patient closely for nonverbal cues, such as difficulty controlling emotions
• Being comfortable with periods of silence may be therapeutic, prompting the patient to reveal deeper feelings
• Silence may indicate depression or dementia-can try guided questioning, direct inquiry about depression or mental status examination
• Depressed patients may have slow, monotone speech with long pauses
You seem very quiet. Have I done something to upset you?”

Question 10

How would you approach the confusing patient?

Answer 10

• Some patient stories may be confusing, vague or hard to follow
• Mental status change: psychosis
• Mental illness: schizophrenia, or a neurologic disorder
• Delirium: acutely ill or intoxicated patients and dementia in the elderly
In these patients gathering a detailed history can tire and frustrate both you and the patient. Shift to the mental status examination, focusing on level of consciousness, orientation, memory, and capacity to understand.

Question 11

How would you approach the talkative patient?

Answer 11

• No perfect solution
• Give them free rein to talk for a certain amount of time
• Focus on what seems important to the patient
• Avoid interrupting or showing impatience
Be honest about your time restrictions

Question 12

How would you approach the patient with a language barrier? What would you look for in the ideal interpreter?

Answer 12

• Spanish is the primary non-English language, spoken by 37 million Americans
• These individuals are less likely to have regular primary or preventive care and more likely to experience dissatisfaction and adverse outcomes from clinical errors
• If your patient speaks a different language, make every effort to find a trained interpreter
• The ideal interpreter is a “cultural navigator” who is neutral and trained in both languages and cultures
• Don’t rely on family and friends

Question 13

How would you approach the patient with a low literacy or low health literacy?

Answer 13

• More than 14% of Americans, or 30 million people, are unable to read basic documents
• Assess patient’s ability to read
• You may ask: “How is your reading?” or “How comfortable are you with filling out health forms?”
This can be a challenge as many forms are handed to patients by the office staff upon check-in

Question 14

How would you approach the patient with hearing loss?

Answer 14

• Find out the patient’s preferred method of communication
• Find out whether the patient uses American Sign Language (ASL)
• If the patient has a hearing aid, find out if the patient is using it; make sure it is working
• For patients with unilateral hearing loss, sit on the hearing side
• Hard of hearing may not be aware of the problem, a situation you will have to address tactfully
Eliminate background noise; face patients directly; have patients put on their glasses to see cues that help them understand you; speak at a normal volume and rate; avoid letting your voice trail off at the ends of sentences, covering your mouth, or looking down at papers/computer while speaking

Question 15

How should you approach the history of the patient with an altered mental status?

Answer 15

• Some patient stories may be confusing, vague or hard to follow
• Mental status change: psychosis
• Mental illness: schizophrenia, or a neurologic disorder
• Delirium: acutely ill or intoxicated patients and dementia in the elderly
In these patients gathering a detailed history can tire and frustrate both you and the patient. Shift to the mental status examination, focusing on level of consciousness, orientation, memory, and capacity to understand.

Question 16

What are some questions you should ask the depressed patient?

Answer 16

• Sadness, anger frustration
• Usually crying is therapeutic, as is your quiet acceptance of the patient’s distress
The clinician response will be different for everyone: learn how to accept displays of emotion so you can support patients at these moving and significant times

Question 17

What are some strategies you can use and questions that you might as when taking a sexual history?

Answer 17

• Determine risks for pregnancy, STIs, and human immunodeficiency virus (HIV)
• Most patients express their concerns relating to sexual health more freely when asked directly by the provider
• Do not forget to cover the sexual history in adolescents, older patients and patients with disability or chronic illness
• Refer to genitalia with explicit words such as penis or vagina and avoid phrases like “private parts”
Also ask about satisfaction with sexual activity
“When was the last time you had intimate physical contact with someone?”
• “Did that contact include sexual intercourse?”
• “Do you have sex with men, women, or both?”
• “How many sexual partners have you had in the last 6 months? In the last 5 years? In your lifetime?”
• “Have you had any new partners in the past 6 months?”
• “How often do you use condoms?”
“Do you have any concerns about HIV infection or AIDS?”

Question 18

What are some questions that you might ask when taking a mental health history?

Answer 18

• Ask open-ended questions initially:
• “Have you ever had any problem with emotional or mental illnesses?”
• Move to more specific:
• “Have you ever seen a counselor or psychotherapist?”
• “Have you ever taken medication for a mental health condition?”
• “Have you ever been hospitalized for an emotional or mental health problem?”
• “What about members of your family?
• Two validated screening tests for depression:
• “Over the past 2 weeks, have you felt down, depressed, or hopeless?”
• “Over the past 2 weeks, have you felt little interest or pleasure in doing things?”
• If s/s of depression, always ask about suicide

Question 19

1When considering alcohol and illicit drug use, what are some screening strategies that the FNP might use?

Answer 19

Tolerance: A state of adaptation in which exposure to a drug induces changes that result in a diminution of one or more of the drug’s effects over time
Physical Dependence: A state of adaptation that is manifested by a drug class-specific withdrawal syndrome that can be produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug, and/or administration of an antagonist
Addiction: A primary, chronic, neurobiologic disease, with genetic, psychosocial, and environmental factors influencing its development and manifestations. It is characterized by behaviors that include one or more of the following: impaired control over drug use, compulsive use, continued use despite harm, and craving

Question 20

Who should be screened for IPV

Answer 20

everyone, make it as comfortable as possible. maka parter leave the room. offer resources if they are not ready

Question 21

What is the difference between weakness and fatigue?

Answer 21

Weakness is a lack of physical or muscle strength and the feeling that extra effort is required to move
Fatigue is a feeling of tiredness or exhaustion or a need to rest because of lack of energy or strength

Question 22

What determines the validity of a test

Answer 22

Validity: Does the test accurately identify whether a patient has a disease?

Question 23

What is the difference between sensitivity and specificity?

Answer 23

Sensitivity: the probability that a person with disease has a positive test.
Sensitivity is also known as the true positive rate
Specificity: the probability that a non-diseased person has a negative test, Specificity is also known as the true negative rate

Question 24

What type of routine screening do older adults need?

Answer 24

individualized screening decisions should be based on each older adult’s health and functional status, including presence of comorbidity, rather than age alone
• Exercise is one of the most effective ways to promote healthy aging
• Fall prevention
• Immunizations: influenza; pneumonia, both PPSV23 and PCV13; herpes zoster (shingles); and tetanus/diphtheria and pertussis (Tdap and Td)
In 2015, the American Geriatrics Society stated: “Don’t recommend screening for breast, colorectal, prostate or lung cancer without considering life expectancy and the risks of testing, overdiagnosis and overtreatment

Question 25

What geriatric syndromes should the FNP assess for in the older adult?

Answer 25

quickly identify frail elderly patients
Look for common geriatric syndromes, including falls, delirium/cognitive impairment, functional dependence, and urinary incontinence in every patient.
Learn about efficient assessment tools for geriatrics and geriatric syndromes
Be familiar with community resources, such as fall prevention programs, PACE programs, and senior centers.
Take into account a patient’s goals, life expectancy, and functional status before considering any test or procedure.
Review advanced directives and goals of care periodically.
Be knowledgeable about the Beers Criteria (see p. 972)
Adopt an evidence-based approach to health screening

Question 26

What environmental changes should we consider in the office to make a history and examination as comfortable as possible for the older adult?

Answer 26

Adjust the office environment 
1.	Bright light
2.	Warm temperature 
3.	Face patient directly 
4.	Eliminate background noise
5.	Pocket talker - small portable microphone 
6.	Make sure the patient is using glasses, hearing aids, and dentures to assist with communication
7.	High chairs, handrails 
Content and Pace of the Visit

Question 27

How and why would you approach a pediatric or adolescent history/exam differently than an adult?

Answer 27

Younger children
1. Stranger anxiety (9-15 months)
2. Have the child remain on parent’s lap
3. Use distraction, toys, whatever it takes!
4. Age appropriate questions about their interests
5. Move from least distressing to most distressing part of exam
Older children
6. May be modest
7. Parent should stay with them up until the age of 11
Adolescent
8. Comfortable, confidential environment
9. Focus on adolescent, not their problems
10. Behavior is based upon their developmental stage, not their chronological age
11. Always consider confidentiality but never make confidentiality unlimited, particularly relating to safety
12. Topics: Puberty, growth, development, family and peer relationships, sexuality, healthy decision making, and high-risk behaviors
Encourage adolescents to discuss sensitive issues with their parents; offer to guide these discussions

Question 28

When observing the parent-child interaction during an exam, what would the FNP be looking for

Answer 28

Observe the parent-child interaction during the visit
1. Assess the “goodness of fit” between parents and child
Observe unstructured play in the exam room
2. Abnormalities in physical, cognitive, and social development or issues with parent–child relationship
Direct questions to child first if possible
When appropriate, review with the child the purpose of the visit
Examine child on parents lap
Distract, play, patience
Engage child with questions about their interests
Move from least invasive to most invasive (save ears, mouth, abdomen for last)