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Clinical Applications I > CLNAP Questions > Flashcards

CLNAP Questions Flashcards

1
Q

If it wasn’t documented it wasn’t…………

A

Done

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2
Q

What percent of medical diagnoses can be made based on the patient history alone?

A

80%

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3
Q

What are the top 4 reasons for documentation?

A
  1. Communication with the healthcare team allows for continuity of care 2. Legal compliance ensures standard of care was provided, all recall is on the record, standardization 3. Reimbursement purposes (pts and provider) 4. Quality improvement and initiatives (data collection)
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4
Q

What is the least important reason for clinical documentation?

A

Medical research

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5
Q

Describe the clinician centered interview approach

A
  1. Used in the previous century 2. focuses on the disease process 3. Ignore patient feelings or factors 4. Limited relationship with patient and psychosocial sources 5. Parental approach
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6
Q

Describe the patient centered interview approach

A

Emphasis on what is important to the patient (values) and their perceptions of illness

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7
Q

What approach do we use to interview patients

A

Integrated approach (using both techniques)

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8
Q

Give reasons for using the patient centered approach for interviewing patients

A
  1. Patients often seek healthcare for reasons other than a symptom 2. Hearing the full story from the pt is important diagnostically and therapeutically 3. Helps sort out the needs of patients who bring more than one concern 4. Gives a voice to our care and compassion as clinicians 5. Quality improvement
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9
Q

What competencies are important for the physician in using the patient centered approach to interviewing

A

Genuineness Respect empathy Professionalism Time management

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10
Q

What is the average time it takes for a physician to interrupt the patient while telling their story?

A

18 seconds

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11
Q

What model should we use for empathy?

A

N ame U nderstand R espect S upport

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12
Q

What steps are involved in setting the agenda for the patient?

A
  1. Elicit the chief concern 2. Indicate the time available 3. Review with the patient what you foresee discussing 4. Summarize the final agenda
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13
Q

How long should physicians give the patient to speak about their chief complaint?

A

2 minutes

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14
Q

List some potential communication barriers while interviewing the patient

A
  • HOH - Poor lighting - Cognitive disturbances - Patient distrust - Noisy setting - Visual impairments - Language barriers - Technology
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15
Q

What are the four types of questions we’ve discussed and indicate when it is appropriate to use them

A

Open ended: eliciting the CC Closed ended: ROS Focused: getting more information about the CC Leading: NEVER!

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16
Q

How many components of LOCATES are required to bill at the highest level?

A

4

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17
Q

What does LOCATES stand for?

A

Location, Other sxs, Sharacter, Aggravating/Alleviating, Timing, Environmental factors, Severity

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18
Q

What should you always do after your collected the HPI and move into the PMH?

A

SUMMARIZE

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19
Q

Explain sensitivity

A

Probability of a positive test given you have the disease - Good at ruling out - Few false negatives - ex: photophobia is a sensitive for migraines (fairly predictive of migraines)

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20
Q

Explain specificity

A

Probability of a negative test given you do not have the disease - Good at ruling in - Few false positives - Ex: chest pain for less than 1 minute is less likely to be a heart attack (specific indicator)

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21
Q

If a strep test is 99% specific, out of 100 patients who don’t have strep, how many will have a negative test?

A

99 (few false positives)

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22
Q

If a strep test is 80% sensitive, out of 100 pts with strep how many will have a positive test?

A

80, 20 will have a false negative test

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23
Q

What is the proper order for the complete H&P?

A

Date Time CC HPI PMH SH FH ROS PE A P Sign - PA-S1

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24
Q

If a patient says they are dizzy, what should you distinguish this from?

A

Light headedness

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25
Q

True or false: it is not appropriate to interpret data while collecting it in the HPI

A

True

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26
Q

What is CMS and what did they develop?

A

Centers for Medicare/Medicaid Services developed E/M (Evaluation/Management) coding to standardize levels of service

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27
Q

What are CPT codes?

A

procedure codes based on the level of service. Can be based on new or established patients and the time spent reviewing the chart or counseling

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28
Q

What are ICD-9 codes?

A

explain the reason for service (17,000 possible codes)

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29
Q

What is the newest version of ICD-9? When will it be released? How many codes are possible?

A

ICD-10, October 2013, 155,000 codes

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30
Q

What should never be used as a dx?

A

“rule out…” use suspected instead

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31
Q

True or false: coding for URI and coding for cough in the same pat for the same exam is acceptable

A

False: no double coding

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32
Q

True or false: it is not important to code for chronic illnesses if they contribute to the CC

A

False: you can code for them as long as they are pertinent to the CC

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33
Q

What is the purpose of EMR?

A
  • Process data - reminder tools - descision making tools - preventative health charts - drug interaction systems - easier E/M coding
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34
Q

A good EMR should be able to perform…

A
  • Health information data - Results and order management - decision support - e-communication and connectivity - patient support - Reporting - Administrative processes
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35
Q

What are the benefits of EMR?

A
  • immediate access to key information - quick access to new and old information - legibility - reduced duplication and fragmentation - regular screenings - continuity - epidemiologic surveillance - quality management
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36
Q

What are downfalls of EMR?

A
  • Computer literacy - Cost of implementation - Confidentiality - Technical issues - Systems adaptable to diverse environments (ED, OPD) - Lack of interoperability (different systems communicating with each other)
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37
Q

What mnemonic is used to gather PMH?

A

A adult illness/allergies H Hospitalizations I Immunizations S Surgeries T Trauma O Oral medications R Reproductive Y Youth illnesses

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38
Q

A remote hospital stay means what?

A

it was years in the past

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39
Q

What should be included when inquiring about immunizations?

A

What, When, up to date? Reactions?

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40
Q

What immunizations cannot be given to immunocompromised pts?

A

MMR Varicella Live flu

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41
Q

The influenza vaccine is contraindicated in pts with this allergy

A

Egg

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42
Q

What should be included when inquiring about surgeries?

A

Reason, what it was, when it occurred, complications, residual debilities

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43
Q

What “rights of medications” should be indicated under oral medications?

A

Drug Dose Root of administration Frequency Duration Side effects Allergies

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44
Q

What should be included when inquiring about reproductive history?

A
  • LMP - Menopause and year - Gravida (time pregnant)/ Parity (viable births) - First menses - Contraceptives - IPV - STD - Fertility - Intimate partner violence
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45
Q

What question is asked to screen for intimate partner violence?

A

Do you feel safe in your home?

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46
Q

What types of youth illnesses should be documented in the PMH?

A

Chronic, major conditions with long term sequela - Ex: rheumatic fever, leukemia, measles

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47
Q

When should you include spouse information int he FH?

A

fertility issues and genetic counseling

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48
Q

When mnemonic is used to collect SH?

A

F Family/food/faith L living arrangements A activity M marital status E education/economic/exposures (pets, travel) S screenings/sexual history/substance abuse/safety

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49
Q

What are the “P”s of sexual history?

A

Partners Practices Protection Prevention of pregnancy Past STD

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50
Q

How many systems are identified by CMS guidelines?

A

14

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51
Q

How many systems are required for the highest level of billing?

A

12

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52
Q

What are the 14 systems identified by CMS?

A

Constitutional Eyes ENT CV Respiratory GI GU MSK Neurologic Psychiatric Endocrine Hematologic/lymph Allergic/immunologic Integumentary

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53
Q

What setting usually uses MDM in their documentation?

A

ED

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54
Q

What fraction of ambulatory care are well visits?

A

1/5

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55
Q

What is considered primary prevention?

A

complete prevention of illness: vaccines, hand washing, safer sex

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56
Q

What is considered secondary prevention?

A

Aim to detect disease in earliest asymptomatic stages: mammography, HIV screening, PSA testing

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57
Q

What is considered tertiary prevention?

A

Aim at eliminating consequences of disease: most health care measures (DM II)

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58
Q

Define health maintenance

A

holistic approach to minimize illness and death

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59
Q

Define screening

A

Any test used to detect disease in those at risk

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60
Q

Identify common modifiable risk factors

A

exercise diet/nutrition BMI tobacco use EtOH/Drug use Sexual practices Partner violence Safety measures occupational history oral health blood product transfusions

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61
Q

What is the recommended exercise for healthy adults?

A

30min/day X 5 days weekly combined cardio and weight training

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62
Q

What other related conditions should be screened for when discussing exercise?

A

Anorexia, over-exertional syndromes (dehydration, osteoporosis)

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63
Q

What BMI is considered over weight? Which is considered obese?

A

Overweight: > 24.9 Obese: > 30

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64
Q

For a 1,800 calorie per day what percent should come from carb, protein and lipids?

A

50% carb 30% protein 20% lipid

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65
Q

How is BMI calculated?

A

(weight in lbs /height in inches(squared)) X 703

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66
Q

What fraction of Americans still smoke?

A

1/5

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67
Q

What percent of all deaths is directly or indirectly related to smoking?

A

20%

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68
Q

What has shown to improve outcomes of smokers quitting?

A

2 minutes of education about health benefits, support systems, meds, or psychodynamic factors

69
Q

What is the number of pack-years for a pt who smoked 1 ppd/40 years?

A

40 pack-years

70
Q

What is the number of pack-years for a pt who smoked 2 ppd/40 years?

A

80 pack-years

71
Q

What mnemonic is used for alcohol abuse?

A

C cut down A annoyed G guilty E eye opener Those with 2+ responses have a 7 fold risk of dependence above the general population 75% sensitivity

72
Q

What questionnaire was developed by WHO for alcohol abuse?

A

AUDIT 94% sensitive

73
Q

What surveys are used to determine drug abuse?

A

DAST-10 NIDA modified assist

74
Q

Explain DAST-10

A

10 item self report yes/no intended for >18

75
Q

What is the female prevalence for intimate partner violence?

A

50% in a lifetime

76
Q

What type of women are at higher risk for intimate partner violence?

A

Pregnant women Those with FH

77
Q

When do children need a carseat?

A

4 years old or 40 lbs

78
Q

What group of people are at higher risk for developing oral cancer?

A

>55 in smokers/drinkers or those with HPV

79
Q

What is gum disease linked to?

A

Increased risk for CVD

80
Q

What complications can occur from blood transfusions?

A

anaphylaxis iron overload TRALI Hemolytic reactions

81
Q

What are red flags in the FH that indicate hereditary risks?

A
  • early age of onset - two or more 1st degree relatives - two or more conditions in one relative - conditions that are refractory to prevention and treatment
82
Q

When is a colonoscopy indicated?

A

> 50

83
Q

When is FOBT indicated?

A

> 40

84
Q

When is mammogram indicated?

A

> 40 and annually

85
Q

When is a PAP indicated?

A

after 21 or sexual activity and 3 years after 2 normal results

86
Q

When is a DEXA indicated?

A

> 65

87
Q

When is HIV and Syphillis indicated?

A

> 18 and at risk

88
Q

When is a breast exam indicated?

A

> 20 and every 3 years to 40 then yearly

89
Q

When is PSA and prostate exam recommended?

A

> 40 and yearly

90
Q

When is hernia and testicular exam indicated?

A

18 and yearly

91
Q

What are the components of the WWE

A

GYN history Bimanual pelvic and PAP Clinical breast exam Mommogram if indicated Others as per USPSTF

92
Q

What are the components of the WME

A

Testicular, hernia, prostate, rectal, FOBT, PSA, sexual health exams

93
Q

What does a deferral of treatment imply?

A

It will be taken care of at a later date

94
Q

What age is baseline determined for geriatric pts?

A

65

95
Q

What index evaluates ADL?

A

Katz index bathing, dressing, continence, transferring, feeding

96
Q

What index evaluates IADLs?

A

Lawton index Shopping, driving, phone, cooking, housekeeping, laundry, finances

97
Q

When should you screen for glaucoma?

A

>60 or earlier with risk

98
Q

What is involved in the mini cognitive test?

A

3 item recall and clock drawing

99
Q

What assesses the mood and depression of geriatric pts?

A

GDS (geriatric depression scale)

100
Q

What evaluates the nutrition of geriatric pts?

A

MUST testing looks at wt loss, BMI, illness effect

101
Q

Pediatrics encompass until what age?

A

21 y/o

102
Q

What is the EPSDT program?

A

Medicaid mandate - growth (BMI, head, length, weight) - developmental (language, Denver developmental screening test) - Lab - Immunization - Anticipatory guidance - Risk factor ID

103
Q

When is lead screening performed?

A

1 and 2 years of age

104
Q

What labs are acquired on neonates?

A

PKU congenital hypothyroidism SSA Neonatal hyperbilirubinemia

105
Q

What topics should be discussed with neonate parents?

A

breastfeeding, sleep positioning

106
Q

What topics should be discussed with parents of 4 month olds?

A

teething, injury prevention

107
Q

What topics should be discussed with parents of 1 y/o?

A

baby proofing, dental hygiene

108
Q

What topics should be discussed with parents of 2 y/o?

A

decreased appetite, toilet training

109
Q

What topics should be discussed with 10-14 y/o?

A

safe sex, safety issues, peer issues, drugs

110
Q

When should a maternal history be documented for peds?

A

< 2 y/o - include pregnancy loss, medications, drugs, etoh, environmental risks, infections (TORCHs)

111
Q

What is HEEADSSS and when is it used?

A

Assessing pediatric pts H home E education/employment E eating A activities D drugs S sexuality S suicide/depression S safety

112
Q

What is the most common form of child abuse?

A

neglect

113
Q

What are typical coping mechanisms after learning bad news?

A

Denial Acting out Identification Intellectualization Reaction formation Regression Sublimation

114
Q

Explain identification

A

patterning behavior after someone else

115
Q

Explain intellectualization

A

explaining away the unreasonable in form of logic

116
Q

Explain reaction formation

A

setting aside unconscious feelings and express that exact opposite

117
Q

Explain regression

A

Resorting to child-like behavior

118
Q

Explain sublimation

A

Taking instinctual drives and funneling that energy into a socially acceptable action

119
Q

What are the stages of behavioral change? “Transtheoretical model”

A

Precontemplation Contemplation Preparation Action Maintenance

120
Q

What is the precontemplation stage?

A

Pt lacks appropriate awareness

121
Q

What stage of behavioral change requires the most help from the physician?

A

Preparation

122
Q

How should you end the interview?

A

Educate the pt using the teach back model Obtain a commitment Set goals Negotiate

123
Q

How should you approach the reticent patient?

A

Be candid about what you want to know Use emotion seeking skills Use focused, closed ended questions

124
Q

How should you approach the overly talkative patient?

A

Redirect them

125
Q

True or false: exams including interpreters are generally 3x as long as a normal visit

A

False: 2x

126
Q

Describe the pt with dependent personality

A

Fear abandonment Require much attention and care - Give more guidance and advice, f/u frequently - physician can become frustrated and reject the pt

127
Q

Describe the pt with obsessive compulsive style

A

Preoccupation with detail, isolate themselves from emotional intimacy - involve the pt, give lots of detail, compliment their detail - Battle for control with the physician

128
Q

Describe the pt with histrionic style

A

Requires attention of everyone, sexually and emotionally, seductive - respond with frequent compliments, respond calmly and firmly, reassurance - Physician distances themselves

129
Q

Describe the pt with self defeating style

A

Repeated failure, victimization - Give empathy, avoid reassurance, use a less upbeat style

130
Q

Describe the pt with narcissistic style

A

Overly entitled, smug, arrogant - make pt feel they are unique, don’t downplay their ego, engage on a medical level

131
Q

Describe the pt with paranoid style

A

Negative interpretation of other people’s work, actions, and intent, guarded, no delusional or perceptual disturbances - Provide full information, avoid becoming too close, do not reinforce or dispute their feelings

132
Q

Describe the pt with schizoid style

A

Socially withdrawn, introverted, no perceptual disturbances, illness triggers denial - avoid becoming too close

133
Q

Describe the pt with borderline personality disorder

A

Wildly emotional splitting self-destructive dissociate with negative experiences

134
Q

Describe the pt with avoidant personality disorder

A

extreme inadequacy avoids new things

135
Q

Describe the pt with antisocial disorder

A

law breakers violates rights of others seductive

136
Q

Describe the pt with schizotypical disorder

A

Magical thinking carvoyant isolated socially closest to schizophrenia in cluster A disorders

137
Q

What are the cluster A disorders?

A

The weird -paranoid, schizoid, schizotypical

138
Q

What are the cluster B disorders?

A

The aggressive (histrionic borderline, antisocial, narcissistic)

139
Q

What should be included in MDM in regards to patient personality?

A
  • difficulty or barrier to interaction - avoid making diagnoses of personality disorders - patient understanding and commitment
140
Q

What mnemonic is used to assess depression?

A

S sleep I interest G guilt/worthlessness E energy C concentration/cognition A appetite P psychomotor (agitation, slowing) S suicide

141
Q

What mnemonic is used to assess dementia?

A

D diabetes/dementia/drugs E epilepsy M migraine/multiple infarction dementia E ethanol (withdrawal/toxicity) N neurological deficit disease (BETA)/ nutritional deficiency) T TIA/trauma I insulin/infections A Alzheimer’s disease/abscess

142
Q

What mnemonic is used to assess neurological deficit disease?

A

B bleeds E encephalitis T tumors A abscess/meningitis

143
Q

What is the HbA1C used for?

A

evaluating 3 month BS levels >6% = BAD

144
Q

What information regarding the pt is included in demographic and billing?

A

Name DOB Address/phone Guardian Insurane Maital status Employer Avoid SSN

145
Q

What should the initial consult note include?

A
  • comprehensive H&P - assessment - recommendations (care, management, additional work-up) - periodic updates to PCP - Letter of request with clinical information - Letter sent back from consultant
146
Q

What does the living will express?

A

preferences in care - cardiopulmonary resuscitation, ventilation, artificial nutrition, hydration, DNR orders TRUMPS DPOA

147
Q

What is a DPOA?

A

Durabl power of attorney - patient named proxy to make decisions - covers a broader range of situations

148
Q

What is a DNR-cc?

A

Work to save the pt until you need to take extraordinary measures

149
Q

What is a DNR-arrest?

A

Work to save the pt until there is no pulse

150
Q

True or false: only document a phone call to a pt if they answer and speak to you

A

False: any attempts should be documented

151
Q

When presenting the PE what should be given first?

A

vitals

152
Q

When should shorter synopses of pts be given?

A

ED Focused complaints

153
Q

When should BP be checked in adults?

A

at 18 y/o and every 2 years after

154
Q

When should cholesterol levels be checked in adults?

A

Men: 35 - 65 y/o Women: 45 - 65 y/o

155
Q

When should Baby aspirin be considered to prevent heart attack in adults?

A

Men: 40 y/o Women: 50 y/o

156
Q

When should men be checked for abdominal aortic aneurysm?

A

Between 65-75 y/o if they have ever smoked

157
Q

When should women be checked for breast cancer?

A

40 y/o and every 1 to 2 years

158
Q

When should women be checked for cervical cancer?

A

21 y/o and 3 normal in a row then every 3 years after that

159
Q

When should adults be checked for colorectal cancer?

A

50 y/o yearly

160
Q

When should women be checked for chlamydia or gonorrhea?

A

18-25 y/o and then men and women at risk after that HIV and syphilis is only for those at risk)

161
Q

When should women be checked for osteoporosis

A

65 y/o and yearly

162
Q

When should adults be immunized for the flu?

A

65 y/o and annually

163
Q

When should adults be immunized for pneumonia?

A

65 y/o once

164
Q

What further testing does a positive FOBT call for?

A

colonoscopy

165
Q

How often should a colonoscopy be performed?

A

every 10 years

166
Q

When should a digital rectal exam be performed?

A

40 y/o and at the time of a flexible sigmoidoscopy or colonoscopy

167
Q

When should a flexible sigmoidoscopy be performed?

A

50 y/o with a negative FOBT

168
Q

What are the cluster C personality disorders

A

The nervous (avoidant, obsessive compulsive disorder, dependent)

Clinical Applications I (7 decks)

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