Dr. Kashefi's Lectures- Problem Focused History and Physical, Orientation Guide for SOAP Note Flashcards
which type of examination (comprehensive/focused) strengthens the clinician-patietn relationship?
the comprehensive examination
what is conformation bias (aka. myside bias)?
the tendency to search for, interpret, or remember information in a way that confirms one’s beliefs or hypotheses
how can you balance patient and provider-centered goals?
by establishing an agenda during the interview
what are the techniques of skilled interviewing? (11)
- active listening
- guided questioning
- nonverbal communication
- empathic response
- validation
- reassurance
- partnering
- summarization
- transitions
- empowering the patient
in HPI, what does OPQRST stand for?
O- onset P- palliative, provoking, position Q- quality R- region, radiation S- severity, symptoms T- timing
what is a question you can ask about the onset?
when did symptom begin?
what is a question you can ask about palliative?
what makes the symptom better?
what is a question you can ask about provoking?
what makes the symptom worse?
what is a question you can ask about position?
does the symptom change with position?
what is a question you can ask about quality?
describe the symtpom
what is a question you can ask about region?
where is the symptom located?
what is a question you can ask about radiation?
does the symptom radiate or travel?
what is a question you can ask about severity?
on the scale of 1-10, 1 being no pain and 10 being the worst, how would you rate the pain?
what is a question you can ask about symptoms?
are there any other symptoms associated with the chief complaint?
what is a question you can ask about timing?
what is the timing of the symptom (constant, intermittent, progressing, time of day symptom occurs, duration, frequency)?
in HPI, what does N of NLDOCAT stand for?
nature of presetting problem
in HPI, what does L of NLDOCAT stand for?
location of problem
in HPI, what does D of NLDOCAT stand for?
duration of problem
in HPI, what does O of NLDOCAT stand for?
onset of problem
in HPI, what does C of NLDOCAT stand for?
course, cause, of the problem
in HPI, what does A of NLDOCAT stand for?
aggravating and alleviating factors
in HPI, what does T of NLDOCAT stand for?
past treatment and its effects
among the NLDOCAT, what is most important?
past treatment and its effects
what are the steps to successful clinical reasoning?
- gather data carefully
- define the patient’s central problem
- generate and prioritize the differential diagnosis
- plan your work-up based on the differential diagnosis
how do you state the central problem clearly and concisely?
[foreground] in a [patient-age, followed by gender] with [background]
which patients should you NOT perform a rectal exam?
patients with neutropenia
quinolone
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
