Exam I Flashcards
RASA stands for
Receive, Appreciate, Summarize, Ask
History and Physical is critical to providing a detailed picture of your patient and should include:
a. reason for encounter, relevant history, physical exam findings and prior diagnostic test results
b. assessment, clinical impression or diagnosis
c. medical plan of care
d. date and legible identity of observer
e. A and B
Answer: all of the above
True/False: Essential components of a History and Physical Exam include:
a. chief complaint
b. history of present illness
c. past medical history
d. past surgical history
e. family history
f. social history
g. allergies, medications
h. review of systems
i. physical exam
j. labs/imaging
k. assessment, plan
True
________ is a concise statement describing the reason for the encounter. It is stated in the patient’s words (point of view).
Ex: The patient complains of problems with breathing
Chief complaint
_______ is a chronological description of the development of the patient’s present illness from the first sign/symptom or from previous encounter to present
History of present illness
To Obtain A History of Present Illness (HPI), you can use OPQRSTA.
What does this stand for?
O: Onset P: palliatice/provocative Q: Quality R: Region/Radiation S: Severity (Scale 1-10) T: Timing/Treatment A: Associated Symptoms
Onset
When did it start?
Palliative/Provokes
What makes the problem better? What makes it worse?
Quality
Is it sharp, dull, stabbing, aching?
Region/Radiation
Where does it hurt? Does it radiate anywhere?
Severity
On a scale of 0-10, how severe is the problem?
Timing/Treatment
Is it constant or intermittent? How long does it last? What time of day? DOes it wake you at night? What medicines used?
Associated symptoms
Are there any other symptoms associated? Headache, nausea, vomiting, weight loss?
What are the Medical Histories that should be assessed?
- PMH
- - past illnesses/medical conditions - PSdiseaseH
- -operations/traumatic injuries and Tx - Family Hx: 1st degree relatives
- -hereditary; - Social History
- -age appropriate review of past and current use: alcohol, tobacco, illicit
- -diet, occupation, marital status, history of STI’s - Medications
- Allergies
An inventory of body systems obtained by asking a series of questions to identify signs/symptoms
List the systems
- Constitutional symptoms
- –fever, weight loss
- EENT
- CV
- Resp.
- GI
- GU
NOTE: can document pertinent systems and use “all other systems are reviewed and are negative”
- What fluids do NOT contain tansmissible infectious agents?
- What is the single most important means of preventing the spread of disease?
- Change coats and clean stethoscope
- sweat, non-intact and mucous membrane
- Hand washing
- -concern for well-being
EKG: True/False: It is possible to measure the amplitude (height) and duration (width) of the P wave, QRS complex, ST segment, and T-wave
True
EKG: The first downward deflection of the QRS movement
They are likely to be in inferior leads (II, III< AVF) in more than half of normal adults.
Q waves
- -duration and amplitude important for old heart attack
- -not more than 0.04 duration or 0.5 mV
EKG: ST segment can aid in identifying what pathological conditions?
Myocardial infarction
- ST elevation
- point of J (beginning of ST segment)
EKG: The T-wave represents part of ventricular repolarization. It is positive in all leads EXCEPT:
aVR (down deflection)
*normal T-wave (assymetric shape - peaks close to end of wave)
EKG: Calculate Heart rate by R-R intervales. What are the numbers?
300, 150, 100, 75, 60, 50, 43, 37
normal: 60-100 bpm
EKG: Sinus rhythm originates from the
SA node
- -upright P wave, followed by QRST
- -check lead AVR (negative) and lead II (upright)
EKG: List the
- Limb Leads
- Pre-cordial leads
- Limb
- -I, II, III
- -AVR, AVL, AVF - Pre-cordial
- -V1-V6
EKG: What is the systematic approach to reading an EKG?
- Rate
- Rhythm
- Intervals
- Ischemia (upside down T-wave)
- Old injury (Q-wave – too deep)
- Axis
- R-wave progression
EKG: To analyze rhythm, what 3 things must you look at?
- is it regular? (equal space between QRS spikes)
- are there normal P waves present?
- -sinus (P before every QRS); P within correct axis? - what is the relationship between the p-waves and QRS complexes?
EKG: What is the most common NON-sinus rhythm?
atrial fibrillation (quivering)
- irregularly irregular
- -no P waves, no organization
EKG: The P-wave represents atrial depolarization. It is a small deflection before the QRS complexes. Typical assessment looks at the amplitude, width and deflection (neg vs. pos)
What are pathologies of the P-waves?
- focus rhythm initiation
- conduction blocks
- chamber enlargements
EKG: Interval that is measure from the beginning of the P-wave to the beginning of the QRS complex. It includes the P-wave
P-R interval
- time taken for stimulus to spread through atria and pass through AV junction
- delayed to allow ventricles to fill
EKG: What is the normal PR interval? What causes PR prolongation?
NOrmal: 0.12 - 0.2
(3-5 small boxes)
Prolongation: >0.2
–1st degree heart block
EKG: In a QRS complex:
- The initial deflection that is negative is a _____ wave
- The first positive deflection is an _____ wave
- A negative deflection after the R-wave is an ___ wave
- Q
- R
- S
*normal QRS: <3 small boxes
EKG: THe interval that is measured from the beginning of the QRS complex to the end of the T-wave.
It represents the return of stimulated ventricules to resting state (vent. repol.)
QT interval
*values depend on heart rate
EKG: What are influencers of QT prolongation?
- long QT syndromes
- electrolyte abnormalities
- drug effects
580ms = prolongation
*more than half of R-R
EKG: To determine axis, find the limb lead in which the QRS has equal positive and negative movement.
THe QRS axis will be perpendicular to this lead.
OR you can determine axis by looking at what leads?
Lead I and AVF
- if QRS is positive: normal axis (two thumbs up or 1 thumb up and 1 thumb sideways)
- normal = -30 to +90
NOTE: Whichever thumb is up determines the axis. ***extreme axis: both thumbs down
EKG: __________ refers to the absence of the normal increase in size of the R wave in the precordial leads when advancing from lead V1 to V6.
In lead V1, the R wave should be small. The R wave becomes larger throughout the precordial leads, to the point where the R wave is larger than the S wave in lead V4.
Poor R wave progression
*goes from more negative to more positive (anti-clockwise to clockwise)
Causes:
- *Wolff Parkinson White
- *Prior anteroseptal MI
EKG: What is the zone of transition with regard to R-wave progression?
normal depol. of left ventricle
EKG: A wide QRS complex (>120ms; >0.12s) represents a ventricular rhythm (fibrillation or tachycardia). Generally the rate of ventricular rhythm is 20-40bpm.
What happens in a Left Bundle Branch block?
-wide QRS
-Leads V5, V6 and aVL = broad, notched, or slurred R waves
absent Q wave absent
-prolonged T peak time (>60ms in V5 and V6; normal in leads V1 and V2)
NOTE: affects ability to detect acute MI changes (different stress tests)
**fibrosis or scarring of the heart
EKG: A wide QRS complex (>120ms; >0.12s) represents a ventricular rhythm (fibrillation or tachycardia). Generally the rate of ventricular rhythm is 20-40bpm.
What happens in a Right Bundle Branch block?
- wide QRS
- rsr’ or rSR’ pattern: V1 or V2
- wide, notched R wave
- S wave longer than 40ms (or longer than R-wave) in V6
*can be normal or associated with cardiac pathology
EKG: Enlargement of this part of the heart is typically seen in lung disease.
It features are:
- > 2.5mm in lead II
- and/OR 1.5 mm in V1
**look to lead II
RIght atrial enlargement
EKG: THe following describes what disease patterns?
- P-wave duration >0.12 (leads I or II)
- biphasic P wave (V1) w/ terminal negative of 0.04
Left atrial enlargement, valve disease, HTN, cardiomyopathies
EKG: LVH is found in HTN, valvular heart disease, cardiomyopathies and congenital heart disease.
What is the voltage criteria for LVH?
> 35 mm
*large S wave (V1 or V2) + large R wave (V5 or V6)
What are the 3 main EKG stages of acute MI?
- T wave peaks, then inverts
- ST segment elevates in a distribution
- Q waves appear
List the Coronary arteries and the Leads that detect them
- LCx/diagonal branch of LAD: I, AVL, V5-V6
- LAD: V1-V4
- RCA or LCx: II, III, AVF
Hyper acute T wave is indicative of
acute myocardial infarction
The U wave is a small, rounded deflection sometimes seen after the T-wave. It represents the last phase of ventricular repolarization.
Prominent U waves are characteristic of
hypOkalemia
Interviewing Skills: True/False: 75-95% of the info needed to make a correct diagnosis is thought to come from the patient reported medical history
True
Tasks in the patient encounter include Biomedical Tasks and Humanist/Communication tasks:
Which is a part of the biomedical tasks?
a. identify problem
b. fix problem
c. engage
d. empathize
Answer: A and B
COmmunication:
-engage, empathize, educate, enlist
Which of the following is a benefit of effective patient-centered medical interviewing skills?
a. inc. effectiveness of care
b. improved patient knowledge and satisfaction
c. inc. adherence to medical recommendations
d. decreased patient anxiety and distress
all of the above
- inc. pateint return
- inc. physician satisfaction
- dec. lawsuit
Which of the following is a relevant core competency for med students?
a. establish/maintain physician-patient relationship
b. listen actively (open body posture, etc.)
c. patient centered interview (identify/respond to emotional cues)
d. exhibit element of altruism and empathy (listen to respective views)
All of the above
Active listening involves
- Reflective listening (what they’re saying)
- Empathic listening (what they’re feeling)
What are methods of reflecting listening?
- paraphrasing
- -repeat portion of patient’s statements - summarizing
- -pertinent points - clarifying
- -determining meaning if unclear
Active listening involves
- Reflective listening (what they’re saying)
- Empathic listening (what they’re feeling)
Empathic listening is the most important skill for building the physician-patient relationship. It communicates your understanding of the patient’s emotions. What are the 2 types of verbal empathic responses?
- Reflection
- -tentative communication of your understanding:
“It sounds like you feel….”
“You seem…”
“Are you feeling”
- Validation
- -tell patient their feelings are understandable
- -name the emotion
“I can understand your irritation…”
“It makese sense..”
Which is an example of non-verbal empathic response?
- hand on patient’s shoulder
- facial expression/tone of voice
- box of tissues
- silent but attentive
What are the consequences of NOT responding to a patient’s emotions?
a. escalation of emotions
b. dec. accuracy in providing history
c. less able to listen and remember
d. less motivated to cooperate with physician
All
*caused by: physcian’s desire to fix problem, time pressure, distress
NOTE: Sequence: empathic listening then suggestions and actions to fix problem
True/False: try to make at least one verbal empathic response in every medical interview
True
- being yourself while staiying in the professional role
- -own emotional response - recognizing or giving positive feedback for a patient’s behavior
- explicit statement that physician wants to help
- statements to facilitate patient’s participation in his/her own treatment
- -we need to look at….
- -research shows…which would you prefer?
- Genuineness
- Praise
- Support
- Partnership
What are the steps for gather information in medical interviews?
- set the stage and open the interview
- obtain px’s agenda w/ general, unoppened questions
- facilitate patient telling own story
- ask focused, open ended questions
- ask close ended questions (clarification)
What are the steps for gather information in medical interviews?
- set the stage and open the interview
- obtain px’s agenda w/ general, unoppened questions
“what brings you in today?”
“what concerns you the most?” - facilitate patient telling own story
–general open ended
“tell me about your headaches” - ask focused, open ended questions
- -easier and faster than closed-ended - ask close ended questions (clarification)
“yes or no responses”
-does it get worse with rest? - Summarize pertinent points
FIFE (mnemonic for obtaining patient perspective)
- Feelings
- -related to illness (fears, concerns) - Ideas
–explain cause of symptom
“do you have any ideas about what caused this?” - Functioning
- -impact of illness on daily life - Expectations
–of the doctor
“what do you hope i can do for you?”
- use layman’s language
- avoid why questions
- avoid yes/no about sensitive issues
Neonatal: What should be included in newborn history?
- Maternal history
- -1st post-natal
- -blood type, labs, medications, lactation - Birth history:
- -where, complications, weight, length of stay - Delivery history
* *Apgar score - Delivery history
- -meconium: stool (mucosal cells; bilirubin)
- -passage prior to delivery = intrautine stress - Nursery Hx and Social Hx
- -feedings (breast/formula; amount)
- -voiding and stooling patterns
- -home life - Family Medical History w/ Pediatric emphasis
Neonatal: List the developmental milestones associated with the neonate at birth with regard to:
- Gross motor
- Language
- Fine motor
- Personal-Social
- Gross -motor
- -equal movements
- -lift head
- -head up to 45deg. - Language:
- -respond to bell
- -vocalizes - Fine motor
- -follow to midline - personal: regard face, smile
Neonatal: THe apgar score is a standardized way to communicate the clinical status of a newborn infant. It should not guid efforts of neonatal care, or be used to predict neurologic outcomes.
What are the components of the apgar score?
- Appearance (skin color)
- Posture (muscle tone)
- Grimace (reflex irritability, heart rate)
- Resipirations (respiratory effort)
*1 and 5 min of age
Describe the scoring on the Apgar score
- Score = 0
- absent heart rate
- absent resp.
- flaccid muscle
- no reflex
- blue/pale - Score = 1
- <100 bpm
- weak cry; hypoventilation
- some flexion
- grimace (reflex)
- acrocyanotic - Score = 2
- ->100bpm
- -good cry
- -active motion/well flexed
- -cry/cough/sneeze
- -completely pink
Neonateal: True/False: During Physcial exam, one should be on the same level with the patient and complete as much of the exam with the child in the parent’s lap. Also, save invasive items for last.
True
Neonatal: During pediatric physical exam, observation is very important as it helps to determine state of wellness of patient.
What are some things to look for?
- well vs. ill
- -acute vs. chronic
- -alert vs. lethargic
- -nutrition
- -face, skin color, rashes
- -behavior (combative)
During observation of the newborn, what are the 3 key things to ask? What are key observations?
- crying?
- pink or blue?
- flexed or flaccid?
- -character of cry
- -character of resp.
- -position
- -odor?
- -unusual musc. movements
How do you check temperature in younger childern?
What is important about pulse?
- temperature:
- -rectal (younger)
- -infants may have normal temps even if sick - pulse more sensitive to illness, exercise and emotions
What are the important growth parameters of a child?
-weight (weight infants naked or dry diaper)
- Length
- Head circumference (cm) [>2y/o BMI]
- Development
Describe normal growth parameters in a baby?
- weight
- length
- Weight:
- -2 weeks: birth weight
- -6 months: double weight (most growth)
- -1 year: triple
* 30g/day (0-3 mos)
* 20g/day (3-6) - Length (cm)
- -2 cm/mo (1st year)
- -5-6cm/year - Head circumference
- -1cm/mo (1st year)
- -greatest in 1st year
Newborn Exam: The Ballard Assessment of Gestational age is a subjective measure of newborn materuity. It is useful for evaluating infants with unsure dates.
It may be affected b intrauterine drug exposure or stress.
When is it the most accurate? What are some important things it looks at?
Most accurate: 12-24 hours after delivery
Important things:
–neuromuscular activity (flexed — term; extended – premature)
–physical maturity and appearance
NOTE: 40 weeks gestation ~ mature (wrinkles on foot, areolar development, joints, cartilage)
Compare premature and mature babies in the context of:
- Arm recoil and scarf sign
- posture and square window
- heel to ear and popliteal window
- Skin
- Genital development
- Arm Recoil/Scarf:
- -mature: scarf
- -premature: extended - Posture and square window:
- -term baby: flexed - Heel to ear
- -term baby: 90 degrees
- -preterm: hyperflexed - skin
- -preterm: translucent; vessels visible
mature: peeling skin, inc. lanugo (fine hair) - Cartilage
- -premature: ears: less recoil and floppy - Genital
- -mature: prominant labia minora; rugae boys - Feet
- -mature: transverse creases: toes to heel
