Complete H& P components
- Hx
- ROS
- PE
- Documentation (SOAP)
In a complete H&P, waht extra things should you ask in a history?
- Preventative health
- Hospitailizations
- Reproductive/sexual
- Blood transfusions
- Accidents
- Childhood diseases
- Cardiac risks
- Advanced directives
In a women, what should you always do a PE on in a complete H&P?
Breasts
Cardinal techniques
Inspect
palpate
percuss
auscultate
What is the purpose for a cmoplete H&P?
- Interval Assessment (q3years)
- Pre-Op
- Consult
- Age-related topics
- Patient Expectations
- Establish Care
appropriate components of h&p
Interview
exam
disposition: findings and plan
in making accurate diagnosis, what is the process you should follow?
fusion of analytical and non-analytical
- Pattern recognition
- Illness script
- Apply science
How do you make a accurate dianogsis?
- ID ABNL findings
- Localize findings anatomically
- Cluster the findings
- Look for cause
- make a hypothesis about presentation
- cluster clinical data
- test hypothesis and establish a working diagnosis
when making a dianogsis, what is one rule of thumb?
Include “WORST CASE SCENARIO” in DDx and make sure you rule it out based in findings and assessment of patient
how do you document findings in complete h&p?
document as you go
clinica reasoning starts at the FIRST of the encounter
develop meaning and impact of findings
Diagnosis should be supported by fingings
conside and succent
where do we indicate our impression and describe our reasoning?
Assessment = make a dx, do NOT list signs or symptoms
