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Clinical Skills > Exam 1 > Flashcards

Exam 1 Flashcards

1
Q

Note order

A
  1. introduction
  2. CC
  3. HPI
  4. PMH
  5. FH
  6. Personal-social history
  7. ROS
  8. PE
  9. lab/diagnostic studies
  10. assessment/plan
  11. problem list w/ differential diagnosis
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2
Q

Note introduction

A
  • date and time of exam
  • identifying information
  • source of info and reliability
  • provider name
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3
Q

CC

A

“in patient words”

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4
Q

HPI

A
  • topic sentence
  • 7 attributes of symptoms
  • pertinent positives and negatives
  • check for completeness and chronological order
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5
Q

PMH

A
  • childhood illness
  • adult illness: medial, surgical, ob/gyn, psychiatric
  • medications
  • allergies
  • tobacco
  • alcohol/drugs
  • health screenings and immunizations
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6
Q

FH

A
  • age and health of living
  • age and cause of death for deceased
  • important family medical history (CAD, cancer, DM, etc)
  • family history related to CC
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7
Q

Personal-social history

A
  • occupation
  • education / health literacy
  • personal relationships
  • sexual history
  • other pertinent (housing, religion, finances)
  • health maintenance (stress, exercise, sleep habits, eating, etc)
  • tobacco
  • alcohol and drugs
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8
Q

ROS

A
  • general
  • skin
  • HEENT
  • Neck
  • breast
  • respiratory
  • cardiovascular
  • GI
  • genitourinary
  • musculoskeletal
  • psychiatric
  • neurological
  • hematologic
  • endocrine
  • functional status
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9
Q

PE

A
  • general description
  • vital signs
  • skin
  • HEENT
  • neck
  • lymph nodes
  • thorax and lungs
  • cardiovascular
  • peripheral vascular
  • breast
  • abd
  • genitalia
  • rectal
  • extremities
  • musculoskeletal
  • neurological
  • reflexes
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10
Q

Assessment/plan

A
  • discuss problem providing a rational for diagnosis and tx

- plan: diagnostic, therapeutic, patient education, follow up/referral, management

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11
Q

7 attributes of symptoms

A
  • location
  • quality
  • quantity or severity
  • timing
  • setting
  • aggravating or relieving factors
  • associated mainfestations
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12
Q

CAGE questions

A
  • cutting down
  • annoyance when criticized
  • guilty feelings
  • eye-openers
  • screening tool for alcohol/drugs
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13
Q

Differential diagnosis

A

I VINDICATE AID

  • idiopathic
  • vascular
  • infectious
  • neoplastic
  • degenerative
  • inflammatory
  • congenital
  • autoimmune
  • trauma
  • endocrine and metabolic
  • allergic
  • iatrogenic
  • drugs
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14
Q

Sensitivity

A
  • identifies the proportion of people who test positive in a group of people known to have the disease (true positives)
  • high sensitivity have a small number of false negatives
  • Rule out disease (leaves just positive -both true and false)
  • 90% or more makes good test
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15
Q

True positives

A

have disease and test positive

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16
Q

False negatives

A

have disease, but test negative

17
Q

Specificity

A
  • identifies proportion of people who test negative in a group of people know to be without the disease (true negatives)
  • high specificity rarely have false positives
  • rule in disease (leaves just the pts that have the disease and test positive)
  • 90% or more is a good test
18
Q

True negatives

A

do not have disease and test negative

19
Q

False positive

A

do not have disease, but test positive

20
Q

Predictive value

A

-indicates how well a given symptom, sign, or test result (neg or pos) predicts the presence or absence of disease

21
Q

Positive predictive value

A

the probability of disease in a pt with a positive (abnormal) test
-proportion of true positives

22
Q

Negative predictive value

A

the probability of not having the disease when the test is negative or normal
-proportion of true negatives

23
Q

Gold standard sensitivity

A

a/a +c = total TP

of true positives / total with disease x100 = %

24
Q

Gold standard specificity

A

d/b + d = total TN

of true negatives / total with disease x100 = %

25
Q

Gold standard positive predictive value

A

a/a + B = TP

of true positives / total positives x100 = %

26
Q

Gold standard negative predictive value

A

d/c + D = TN

of true negatives / total negatives x100 = %

27
Q

Prevalence

A
  • proportion of people in a specific population at any given time who have the disease in question
  • low prevalence = low positive predictive value
  • high prevalence = high sensitivity, specificity, positive predictive value; negative predictive value approaches 0

Clinical Skills (2 decks)

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