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Clinical Med > Foundations > Flashcards

Foundations Flashcards

1
Q

Goals of an interview

A
  1. Understand the patient’s Environment
  2. Understand their Illness
  3. Develop a problem List
  4. Develop a Plan
  5. Developed a Contract for care

(EPIC-L, environment, plan, illness, contract, list)

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2
Q

CAGE

A

concern
annoyed
guilt
eye opener

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3
Q

TACE

A

Take to get buzzed
annoyed with drinking
cut back want?
Eye opener

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4
Q

CRAFFT

A 
Car - been in car with driver drunk
Relax - drink to relax
Alone - drink alone?
Forget what you did
Family/friend want you to cut back
Trouble - have you gotten into trouble while drinking?
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5
Q

HITS

A

Hurt you?
Insult you?
Threaten you?
Scream at you?>

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6
Q

Four Cs

A

courtesy
comfort
connection
confirmation

Call - what do you call your probem
Cause - what do you think caused it
Concern - what is yours
Cope - how do you cope with this

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7
Q

Facilitation

A

interview technique involving head nodding, expressing understanding and encourage them to keep going

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8
Q

Reflection

A

Repeat what they’re saying and clarify to show that you are listening

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9
Q

Clarification

A

What do you mean? Clarify terms with multiple meanings

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10
Q

Reassurance

A

Duh + do not give false hope

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11
Q

Empathy

A

Duh

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12
Q

Confrontation

A

Use for disturbing behavior

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13
Q

Interpretation

A

Restate and confirm

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14
Q

Validation

A

acknowledge and legitimize

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15
Q

Ask me three

A

What - is problem
How - should I do?
Why - should I do it?

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16
Q

SIGE CAPS

A 
Sleep
Interest lost
Guilt
Energy
Concentration
Appetite
Psychomotor (anxiety
Suicidal thoughts
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17
Q

What is the range of drinks one can have to be considered “low risk” for developing alcoholism?

A

Men: less than or equal to 14 drinks/week, and less than or equal to 4 on one occasion

Women: Less than 7 drinks/week, and less than 3 on one occasion.

18
Q

What is the range of drinks one can have to be considered “high risk” for developing alcoholism?

A

Consuming more than the “low risk” ranges

19
Q

Define binge drinking

A

Drinking so much in 2 hours to reach a BAC of 0.08 g/dL

20
Q

What is the one part of the note that is okay to document, even though you did not personally do it?

A

Vital signs

21
Q

What type of words should you avoid when writing a note?

A

Normal, poor, good.

22
Q

If a patient defers or if you choose to omit something from your note, how should you document this?

A

State reason or that the patient declined.

23
Q

What is the correct order of information in the note?

A 
CC
HPI
Meds
Allergies
PMHx
Surgical hx
FMHx
SHx
ROS
PE
A&P
24
Q

What are the six items needed to properly document medications?

A 
Name
Dose
Frequency
Number of tablets
Route
Frequency
Last dose taken.
25
Q

What are items in a SHx?

A

ORT AIDS METH

Occupation
Relationship
Tobacco
Alcohol
Illicit drugs
Diet
STDs
Military
Exercise
Travel
Hobbies
26
Q

What are THE CHADS

A 
Thyroid
HTN
Emphysema
Cancer
Heart disease (CAD)
Asthma
DM
Stroke
27
Q

What goes on the left side of a note, must be present when writing a hand-written note?

A

Patient name/DOB

Headings

28
Q

True or false: it is acceptable to skip a line so that it makes your note easier to read.

A

False

29
Q

What type of writing utensil should notes be written in

?

A

Blue or black ink pen

30
Q

How do you make an error correction in a hand written note?

A

Cross it out (never erase), and date and initial next to it.

31
Q

What do you have to do at the bottom of each page

A

Print and sign name

32
Q

True or false, it is okay to summarize a section if it deals with chief complaints

A

False.

33
Q

What does PPE stand for?

A

Personal protective equipment

34
Q

True or false: it is okay to recap a needle if using a one handed technique.

A

True, but generally, never recap needles–put them in the sharps container.

35
Q

When is it required to wash your hands?

A

After contact with fluids, immediately after removing gloves, and between patients.

36
Q

When is respiratory hygiene necessary? When is it necessary?

A

For any patient that has a cough.

At point of contact.

37
Q

When are standard precautions necessary?

A

FOR EVERYONE.

38
Q

What bodily secretion is not considered dangerous?

A

Sweat

39
Q

True or false, you should take precautions when touching mucus membranes.

A

True.

40
Q

What part of your hand should be used when palpating?

A

The palmar side of your fingers/hand

41
Q

What is the correct order of examination?

A

Inspect
Palpate
Percussion
Auscultation

42
Q

What are the four Cs?

A

Courtesy
Comfort
Connection
Confirmation

Clinical Med (30 decks)

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