OLDCARTS
Onset,Location, Duration, Characteristics, Aggravating factors, Relieving factors, Temporal factors,
... [Show More] Severity
PQRST
provocative/palliative, quality, region/radiation, severity, and timing
COLDPA
characteristic, onset, location, duration, pattern, and associated factors
PMH
General health, childhood illnesses, adult illnesses or chronic diseases, Immunizations, surgeries, serious injuries resulting in disability, medications, ability to complete ADLs, allergies and reactions, transfusions, recent screening tests, emotional status,
FM
Investigate blood relatives in the immediate family with features similar to the patient's. If a disease "runs in the family", ask about everyone from grandparents to cousins. Ask about heart disease, hypertension, cancer, TB, stroke, sickle cell, CF, kidney disease, thyroid disease, blood diseases, Ascertain whether cancers are multiple, bilateral, and occurring more than once in the family, or at a young age.
SH
birthplace, home environment, cultural and ethnic background, education, occupation, marital status,hobbies or interests, sources of stress, habits of self-care (self breast exams, etc), habits regarding smoking, alcohol and drug use, and sexual history. Five Ps of sexual history-partners, practices, protection, past history of STIs, pregnancy prevention.
ROS
general, skin hair and nails, head and neck, eyes, ears, nose, throat and mouth, lymph nodes, chest and lungs, breasts, heart and blood vessels, peripheral vasculature, hematologic, GI, diet, endocrine, GU, musculoskeletal, neurologic, psychiatric.
concepts of developing a relationship with the patient
A primary objective is to discover the details about a patient's concern, explore expectations for the encounter and display interest, curiosity and partnership. Identifying underlying worries, believing them, and trying to deal with them optimizes your ability to be of help
effective communication strategies
Communication built on courtesy, comfort, connection, and confirmation.
patient-centered care
respecting and responding to patients wants and needs so they can make choices that best fit their circumstances
potential barriers of patient and provider communication
moments of tension this includes: patient curiosity about you, anxiety, silence, depression, seduction, anger, crying, financial issues, and avoidance.
Chief Concern
a brief statement about why the patient is seeking care. Many interviewers include duration in the CC
Females-
start and character of meneses, LMP, last PAP smear, pregnancies
Males
puberty onset, difficulty with erections, emissions, testicular pain and libido.
objective
direct observation, what you see, hear, smell and touch
Subjective
information patients offer about their condition or feelings. This includes chief complaint, past medical history, history or present illness, family history, and review of symptoms.
Sensitive issues
Provide privacy
Do not waffle be, direct and firm. Avoid asking, leading questions; open-ended
Do not apologize for asking a question
Do not preach. Avoid confrontation. You are not there to pass judgement
Use language that is understandable to the patient, yet not patronizing
Do not push too hard
Document carefully, using the pts own words
culturally aware and culturally competent
sensitive to heritage, sexual orientation, economic situation, and background. It requires acquiring knowledge and developing skills
components of a cultural response
communication (appropriate speech, eye contact, and body language), understanding of health beliefs and practices, understanding of diet and nutritional practices, and nature of family practices
test cranial nerve II
visual acuity test
3 types of visual acuity
distance vision, near vision and peripheral vision.
glaucoma or a retrobulbar tumor
A very firm eye that resists palpation
conjunctiva
clear and have no erythema, exudates, hemorrhage or abnormal growths (e.g. a pterygium)
pterygium
abnormal growth of conjunctiva that extends over the cornea from the limbus
Argyll Robertson pupuil
irregularly shaped pupils that fail to constrict light but retain constriction with convergence
Oculomotor nerve CN III damage
pupil dilated and fixed, eye deviated laterally and downward; ptosis
Adie pupil
The affected pupil dilated and reacts slowly or fails to react to light; responds to convergence
Yellow or green sclera
may signal liver disease
lacrimal glands
may become enlarged in some conditions such as tumors, lymphoid infiltration, sarcoid disease, and Sjogren syndrome
Eye movement
controlled by 6 extraocular muscles and 3 cranial nerves, III, IV, and VI.
cover-uncover test
stares at a fixed point nearby, cover one eye and observe the uncovered eye. Then remove the cover and observe that eye as it focuses on the object. Note any eye movement
corneal light reflex
patient looking at a nearby object, shine a light on the nasal bridge. The eyes should converge and reflect the light symmetrically
the fundus
retina
retina (fundus)
yellow or reddish pink, depending on the patient's pigmentation. It should have no light or dark areas except for crescents or dots at the disc margin
Lipemia Retinalis
Peripheral fundus changes in early stages. Initially the vessels appear salmon pink, as the triglyceride levels rise, the vessels turn whitish
Glaucoma
Optic nerve damage can clearly be seen during a dilated eye exam and produces a characteristic appearance of the optic nerve
(increased cupping). Visual field tests may show decreased peripheral vision.
Retinitis Pigmentosa
Optic atrophy with a waxy pallor, narrowing of the arterioles, and peripheral "bone spicule" pigmentation are hallmarks of advanced disease.
Chorioretinitis
sharply defined lesion: generally whitish yellow and becomes stippled with dark pigment in later stages ending with chorioretinal scar.
Episcleritis
inflammation of the superficial layers of the sclera anterior to the insertion of the rectus muscles
Episcleritis: subjective
acute mild to moderate discomfort or photophobia, painless redness and/or watery discharge without crusting
Episcleritis: objective
diffuse or localized injection of the bulbar conjunctiva, purplish elevation of a few millimeters, watery discharge
Band Keratopathy: patho
chronic corneal disease is most common, hypercalcemia, hyperparathyroidism, renal failure, syphilis
Band Keratopathy: subjective
decrease in vision, foreign body sensation and irritation
Band Keratopathy
deposition of calcium in the superficial cornea
Band Keratopathy: objective
line just below the pupil (passes over the cornea rather than around the iris), horizontal grayish bands interspersed with dark areas that look like holes
Corneal Ulcer
disruption of the corneal epithelium and stroma
Corneal Ulcer: patho
rheumatologic disorder - connective tissue disease such as RA, sjogren syndrome, vasculitic disorder; viral infections such as herpes simplex virus; bacterial infection; extreme dryness - incomplete lid closure or poor lacrimal gland function
Corneal Ulcer: subjective
pain, photophobia, hx wearing contact lens, blurry vision, feeling that something is in the eye
Corneal Ulcer: objective
visual acuity affected, inflammation and erythema of lid and conjunctiva, purulent exudates, round or oval ulcer (base is gray, border sharply demarcated)
strabismus
both eyes do not focus on an object simultaneously, but can focus with either eye [Show Less]