Dr. Kashefi's Lectures- Problem Focused History and Physical, Orientation Guide for SOAP Note

Question 1

which type of examination (comprehensive/focused) strengthens the clinician-patietn relationship?

Answer 1

the comprehensive examination

Question 2

what is conformation bias (aka. myside bias)?

Answer 2

the tendency to search for, interpret, or remember information in a way that confirms one’s beliefs or hypotheses

Question 3

how can you balance patient and provider-centered goals?

Answer 3

by establishing an agenda during the interview

Question 4

what are the techniques of skilled interviewing? (11)

Answer 4

• active listening
• guided questioning
• nonverbal communication
• empathic response
• validation
• reassurance
• partnering
• summarization
• transitions
• empowering the patient

Question 5

in HPI, what does OPQRST stand for?

Answer 5

O- onset
P- palliative, provoking, position
Q- quality
R- region, radiation
S- severity, symptoms
T- timing

Question 6

what is a question you can ask about the onset?

Answer 6

when did symptom begin?

Question 7

what is a question you can ask about palliative?

Answer 7

what makes the symptom better?

Question 8

what is a question you can ask about provoking?

Answer 8

what makes the symptom worse?

Question 9

what is a question you can ask about position?

Answer 9

does the symptom change with position?

Question 10

what is a question you can ask about quality?

Answer 10

describe the symtpom

Question 11

what is a question you can ask about region?

Answer 11

where is the symptom located?

Question 12

what is a question you can ask about radiation?

Answer 12

does the symptom radiate or travel?

Question 13

what is a question you can ask about severity?

Answer 13

on the scale of 1-10, 1 being no pain and 10 being the worst, how would you rate the pain?

Question 14

what is a question you can ask about symptoms?

Answer 14

are there any other symptoms associated with the chief complaint?

Question 15

what is a question you can ask about timing?

Answer 15

what is the timing of the symptom (constant, intermittent, progressing, time of day symptom occurs, duration, frequency)?

Question 16

in HPI, what does N of NLDOCAT stand for?

Answer 16

nature of presetting problem

Question 17

in HPI, what does L of NLDOCAT stand for?

Answer 17

location of problem

Question 18

in HPI, what does D of NLDOCAT stand for?

Answer 18

duration of problem

Question 19

in HPI, what does O of NLDOCAT stand for?

Answer 19

onset of problem

Question 20

in HPI, what does C of NLDOCAT stand for?

Answer 20

course, cause, of the problem

Question 21

in HPI, what does A of NLDOCAT stand for?

Answer 21

aggravating and alleviating factors

Question 22

in HPI, what does T of NLDOCAT stand for?

Answer 22

past treatment and its effects

Question 23

among the NLDOCAT, what is most important?

Answer 23

past treatment and its effects

Question 24

what are the steps to successful clinical reasoning?

Answer 24

1. gather data carefully
2. define the patient’s central problem
3. generate and prioritize the differential diagnosis
4. plan your work-up based on the differential diagnosis

Question 25

how do you state the central problem clearly and concisely?

Answer 25

[foreground] in a [patient-age, followed by gender] with [background]

Question 26

which patients should you NOT perform a rectal exam?

Answer 26

patients with neutropenia

Question 27

quinolone

Answer 27

any of a class of antibiotics used in treating a variety of mainly Gram-negative infections, and thought to be responsible for antibiotic resistance in some microbes