NR 569 Week 4 Midterm Exam - Comprehensive Patient Assessment, Diagnosis

A. Using words or brief phrases instead of whole sentences is common, but abbreviations and symbols should be used only if they are readily understood. Omit unnecessary words. Describe what you observed, not what you did. ● Are clear descriptions or images included whenever possible? A. To ensure accurate evaluations and future comparisons, describe findings fully. Use measurements in centimeters, not fruits, nuts or vegetables. ● Is the tone of the write up neutral and professional? A. It is important to be objective. Hostile or disapproving comments have no place in the patient's record. Never use inflammatory or demeaning words or punctuation. 9. Components of the medical history I. Initial information (Identifying patient information/source/reliability) II. Chief Complaint(s) III. History of Present Illness IV. Past Medical History V. Family History VI. Personal/Social History VII. Review of Systems (ROS) 10. Evaluation and management (E/M) codes ● Codings ranging from 99202-99499 that represent a service by a provider in which the provider is evaluating or managing patients health 11. Evidence-based practice ● Conscientious, judicious and reasonable use of modern, evidence in making decisions on an individual's care 12. PICOT question ● Patient, intervention, comparison, outcome and time. 13. Application of sensitivity & specificity principles ● Sensitivity refers to a test's ability to designate an individual with a disease as positive ● Specificity refers to the ability of testing to recognize patients who do not have the disease. 14. Likelihood ratios in clinical practice ● Positive: The likelihood the patient with the disease tests positive, compared to the likelihood that a patient without the disease tests positive ● Negative: The likelihood the patient with the disease tests negative, compared to the likelihood that a patient without the disease tests negative 15. Diagnostic utility of radiology testing and categories of radiographic densities ● Air- blackest on radiograph ● Fat-darkest shade of grey ● Soft tissues/fluid-light grey ● Minerals-lightest shade of grey (absorbs most of x ray) ● Metal- white (most dense & absorbs all x ray) 16. USPSTF guideline rating: United States preventive service task force. ● Grade A- recommends this service, high certainty at the net benefits is substantial A. Offer or provide service ● The type of T cell response determines the type of rash that presents: Type 2 helper cells response causes a classic morbilliform with both macules and papules while cytotoxic t cells response will present more vesicular and pustular. 19. Causes and clinical presentation of types of urticaria ● Urticaria: Cutaneous disorder characterized by the presence of transient, pruritic, erythematous, irregular shape, slightly edematous plaques (hives) ❖ Physical stimuli, medications, infections, autoimmune disease ● Acute urticaria: hives lasting less than 6 weeks, evaluate for recent streptococcal infection or virus ❖ Ask patient about changes in mediations or diet, as well as recent infections (viral or strep) ● Chronic urticaria: last longer than 6 weeks without an identifiable external trigger ● Physical urticarias I. cholinergic urticaria: Sweating or changes in body temperature ➢ lesions appear as small urticarial papules on an