exam 1 Flashcards
SOAP note
Subjective, Objective, Assessment Plan
Subjective
what the pt tells you. CC, HPI, PMH, meds, allergies, FMH, social hx- my throat hurts. I had a tonsillectomy
Objective
physical exam- inc VS, any diagnostics done before the assessment and plan. ex: PERRLA; tympanic membrane pearly, grey bilateral; mucosa pink’ pt appears in distress
Assessment
diagnosis; differentials, problems if unable to develop diagnosis or differentials. ex: otitis media
Plan
pharmacologic and non pharmacologic management, diagnostics ordered, education, referrals and fu
steps in evidence based practice
- begin with clinical problem. 2. pose clinical question focusing on pt problem and potential preventative service (Problem, intervention/Exposure Comparison Outcome). 3. select appropriate resources and conduct literature search of each key question discussing comparison of interventions and strategies to examine outcomes; appraise for validity and applicability. 4. apply knowledge to pts and their preferences
sources of evidence
- randomized control trials, meta-analysis, expert opinion, case reports, cohort studies and qualitative research provides less robust evidence
USPSTF grades
A- recommends this service. B- recommends service, benefit is moderate. C- recommends selectively based on professional judgement and pt preferences. D- recommends AGAINST this service. I- insufficient evidence
diagnostic reasoning
scientific process in which the practitioner suspects the case of the pts s/s based on previous knowledge. using diagnostic reasoning the practitioner is bale to determine what should be focused on, choose appropriate tests, cluster pertinent findings and develop diff Diagnosis
clinical reasoning
1- identify the problem, 2- frame the differentials, 3- organize diffs, 4- limit differentials, 5- explore diagnoses (use PE to further narrow)
coherence
are the physiological links, predisposing factors, and complications for this disease present in the pt?
parsimony
simplest explanation for the pts findings, important when finding a tx acceptable tot he pt. you are matching the pts CC with a disease and thus tx
system 1 reasoning
relatively rapid and intuitive. based on patter recognition and involves matching the pts presentation to an illness script, a prior example stored in memory. system 1 thinking predominates when an experienced clinician encounters a straightforward case
system 2 reasoning
slower process in which the clinician uses explicit analytic approach. system 2 predominates when the case is more complicated or the clinician is less experienced
heuristics
mental shortcut used to quicken the process of formulating differentials. can be productive in producing results quickly but can lead to biases
base rate neglect
pursuing a “zebra” type of bias where the clinician does not place enough weight on information in lieu of more appetizing information for an easy diagnosis
representativeness
ignoring atypical features that are inconsistent with the favored diagnosis
availability
considering easily remembered diagnoses more likely irrespective of prevalence
confirmation bias
seeking data to confirm rather than return the initial hypothesis
premature closure
stopping the diagnostic process too soon
sensitivity
the percentage of patients with the disease who have a true-positive test result. Can be used to rule in a disease.; ex) a test that’s 90% sensitive will correctly identify 90% of patients who have a disease and will show false negatives for 10%
specificity
the percentage of patients without the disease who have a true-negative test result. Can be used to rule out a disease Most tests are highly sensitive with low specificity meaning the test is good at identifying the disease but can come with a higher false positive rate. For example, mammograms can identify tumors very well but may not be specific to cancer. A highly specific test is a urine dipstick because it can rule out a UTI with no nitrites
primary prevention
activities directed at improving general well-being- counseling, preventative meds, vaccines
secondary prevention
identify or detect disease in its earliest stages before sxs appear- screenings (A1C, mammogram)
tertiary
improve quality of like for people with disease by limiting complications- improving asthma regimen to optimize sx control
leading hypothesis
most likely diagnosis based on prevalence, demographics, risk factors and signs
hypothesis
is generated during the assessment of the pts age, gender, race, appearance, and presenting problem
can a normal exam always EXCLUDE a diagnosis?
NO
steps of clinical reasoning model
identify the problem, frame the diff dx in a way that facilitates recall, organize diff dx into clinically useful subgroups that enable you to systematically work through the diff dx, limit differentials by using pivotal points to create a pt specific diff, explore the pt specific diff using hx and PE, rank the diff using the results of the exploration, test your hypothesis
fatigue hx taking questions
Fatigue vs. weakness; fatigue vs frailty Lifestyle habits – diet, exercise, stress, sleep pattern, alcohol and drug use Last normal menstrual period Exposure to STI Medications- HTN and cardiac meds, psychotropic meds, sedatives, antihistamines Change in appetite, weight loss, joint tenderness, increased urination Occupational exposure- heavy metals, pesticides Camping- Lyme disease Onset/pattern, severity, aggravating/alleviating factors, fever, bleeding, stress, anxiety, school performance
fatigue- common causes/diff diagnosis
Physiological - Poor sleep and rest, poor nutritional status Psychological- Depression or anxiety Organic causes for acute fatigue- infection, drugs/alcohol, anemia, hypothyroidism/hyperthyroidism Organic causes for chronic fatigue- sleep apnea, meds, heart failure, cancer, Mono, hepatitis, fibromyalgia, chronic fatigue syndrome
fatigue in women
Fatigue generally due to lifestyle factors or lack of sleep hours Consider fibromyalgia, more common in females Fatigue early sign of pregnancy
fatigue in men
sleep apnea more communion men >45yrs, interrupted sleep due to nocturne associated with BPH
fatigue in children
Fatigue uncommon in young children, the younger the child the more likely organic cause Depression in children will be expressed as sad/angry/irritable (crying) Children with joint tenderness and fatigue- Juvenile rheumatoid arthritis
fatigue in adolescents
generally d/t lifestyle factors or lack of sleep hours, consider mono based on age range
fever in neonates
Fever in children younger than 2 months of age is uncommon and must be viewed as serious. Neonates and young infants are less able to mount a febrile response: when they do, it is a significant finding. Neonates are more vulnerable to meningitis and other hematogenous complications. (Dains, pg 229) Fevers can be viral or bacterial. In a neonate may also indicate an underlying anatomical defect. UTI and bacteremia are often the first indications of a structural abnormality of the urinary tract. Infants with galactosemia may present in the first weeks to 1 month of life with gram-negative sepsis. All infants younger than 2 months with fever are considered to have sepsis or meningitis until proven otherwise (Dains, pg 224) The younger the child, the greater is the cause for concern in the presence of fever. Benign febrile seizure is uncommon in very young infants. Seizure in a febrile infant younger than 6 months old is suggestive of meningitis rather than a simple febrile seizure. (Dains, pg 232
fevers in children
3 categories. 1- short term fever: fever of short duration, readily diagnosed and resolves within 1 week. 2- fever without localizing signs: fever of brief duration (usually 10 days) that is not explained by findings on hx or PE. 3- fever of unknown origin, usually treated than 101.2, lasts longer than 2 weeks on more than 4 occasions
fever of unknown origin
UTI is the most common infection in girls younger than 2 years who present with high fever and inall infants younger than 90 days with fever. (Dains, pg 225) In infants and children, behavior changes may be the only indication that the child is ill. Responsiveness in children older than 2 months has been used to identify febrile children with serious illness. Yale Observation Scale often used to quantify observations for severity of illness in children. (Dains, pg 229) Temperature in infants and younger children- rectal or ear is more reliable
viral fever
accompanied by muscle aches, malaise, or resp sxs
bacterial fever
localized to site without general body manifestations
food poisoning fever
may occur up to 72hrs after ingestion of contaminated food
subjective fever
is assumed by the pt to be a fever, but not validated with thermometer. sxs such as flushing, chills, shaking chills, HA, malaise and muscle aches. many pts use touch to determine whether fever is present
components of mental health hx
Level of consciousness, memory, orientation, perception, thought process, thought content, insight, judgement, mood
level of consciousness
alertness or state of awareness of the environment
memory
process of registering or recording information, tested by asking for immediate repetition of material
orientation
awareness of personal identity, place and time, requires both memory and attention
perception
sensory awareness of objects in the environment and their interrelationships. also refers to dreams and hallucinations
thought process
logic, coherence, and relevance of the pts thought as it leads to selected goals. HOW PEOPLE THINK
thought content
what the pt thinks about
insight
awareness that sxs or disturbed behaviors are normal or abnormal. diff btwn daydreams and hallucinations
judgement
process comparing and evaluating alternatives when deciding on a course of action
mood
moire pervasive and sustained emotion that colors the person’s perception of the world. mood may be euthymic (in the normal range), elevated, dysphoric (unpleasant, possibly as sad, anxious or irritable)
multi-infarct dementia (vascular)
- Abrupt or gradual, gait disturbance during PE, urinary sym., personality changes
- Most common in pts with risk fxs for vascular disease or embolic stroke
- Step-like deterioration related to intermittent CVAs
- Focal neurologic exam, white matter changes or atrophy on imaging
- PE- exaggeration of deep tendon reflexes, extensor plantar response, pseudobulbar palsy(pathologic laughing, crying, grimacing; weak cranial ner: V, VII, IX, X, XI, XII) and focal neurologic signs
Mild cognitive impairment
older pts- memory loss, no functional impairment
dementia with lewy bodies
typically parkinson pts, fluctuating course and visual hallucinations, mil extrapyramidal sxs (rigidity, bradykineasia), most common dx after alzheimers
delirium
inattention/confusion, clues-acuity of onset and fluctuation, severe illness, drug toxicity, fluid/electrolyte (hyponatremia/azotemia), infections, hypo/hyperthermia
alzheimers disease
- Although present, memory loss may not be the presenting symptom in patients with AD; rather, behavioral or personality changes, functional impairments, social withdrawal, or language disturbances may be the initial symptoms.
- Be aware that AD should be on the differential diagnosis of subtle behavioral changes in older patients.
Alcohol withdrawal
- Minor-irritability, htn, tachycardia
- Alcoholic hallucinations (visual), have clear sensorium, good CAM
- Major- delirium tremens, confusion, disorientation, autonomic hyperactivity
- Wernicke Encephalopathy-caused by thiamine deficiency, may happen if pt receives IV glucose
- Triad of confusion, disorders of ocular movement, ataxia
- Usually presents with 1or 2 above symptoms
Delirium/Depression/Dementia/Parkinsonism
- Always get hx from another person- consistent contact with the patient & can report about usual behavioral patterns & conditions involved
- Confusion that is acute = delirium, CVA, subdural hematoma, neoplasm
- Hx of altered LOC + current confusion = immediate intervention
- Suicidal ideations = immediate intervention
delirium
caused by alterations in brain metabolism, abrupt onset, reduced level of acute consciousness & sleep-wake cycle disturbance. MEDICAL EMERGENCY!
persistent
< 30 days, symptoms can fluctuate over day, sleep cycle impaired= hallucinations/agitated
dementia
chronic generalized impairment of the brain function, affects thinking but not the LOC.
• Early compliant-forgetfulness with loss of concentration & loss of memory
• Causes of dementia can be classified as reversible (or partially reversible), modifiable, or irreversible
• Alert & aware, hallucinations late stage
• Visual hallucinations/cognitive impairment = Lewy body disease (clumsiness or falling)
alzheimer
memory loss
• Vascular causes of dementia = early loss of executive function
• Language disturbances-frontotemporal lobe dementia
• Fewer cognitive losses- severe negative thinking, guilt, remorse
reversible causes of dementia
drugs or medication, emotional illness or depression, metabolic or endocrine DO, eye or ear involvement or environmental, nutritional or neurologic, tumors or trauma, infection, alcoholism, anemia, or atherosclerosis
modifiable causes of dementia
normal-pressure hydrocephalus, hepatic encephalopathy, HIV encephalopathy (AIDS dementia complex)
irreversible causes of dementia
Alzheimers disease, multi-infarct dementia, dementia with lewy bodies, frontotemporal lobar degeneration
depression
cause of confusion in older adults- reversible cause of dementia, anxiety sxs= mild delirium
tremors
Parkinsonism, HIV, encephalopathy, liver disease
gait DO
Parkinsonism, medication reactions and head trauma
if pt presents with confusion + HA, N
think head trauma, stroke, tumor
if pt presents with confusion + fever
think HIV or other systemic infections or acute alcohol withdrawal
if pt presents with Change in wt/usual activities
depression = “vegetive symptoms-cessation of talking, eating, dressing, toileting, insomnia, wt +/-, -interest in activities) & feelings of worthlessness
