HAPE exam 1 Flashcards
what does the clinical interview need to incorporate?
both the clinican and patients views of reality, disease, and illness
describe the general structure and sequence of the clinical encounter
- Initiating the encounter
-setting the stage/preparation
-greeting the patient and establishing initial report - gathering information
-initiate information gathering
-exploring patients perspective of illness
-exploring biomedical perspective of disease including relevant background and context - performing the physical examination
- explaining and planning
-provide correct amount and type of info
-negotiate plan of action
-shared decision making
5.closing the encounter
if this is your first time seeing a patient what should you explain?
your role, your status as a student, and how you will be involved in their care
what kind of language should you use when referring to patients with disabilities?
“people first” language
what is a good way to establish the agenda for the patient ecounter?
begin with open ended questions that allow full freedom of response: ex; “what are your special concerns today”
how should you invite the patients story?
encourage patients to tell their stories in their own words, using an open ended approach
train yourself to follow the patients lead
what is a mnemonic that explores the patients perspective of disease?
FIFE
f- the patients feelings
i-the patients ideas about the nature and cause of the problem
f-the effect of the problem on the patients function
e-the patients expectations of the disease
what percentage of patients in primary care practice have anxiety and depression?
30-40%
responding to emotional cues using nurse statments
N-name “that sounds like a scary experience”
U- understand “its understandable that you feel that way”
R- respect “youve done better than most people would do with this”
S- support “I will continue to work with you on this”
E- explore “how else were you feeling on this”
what is teach back?
it is NOT a test of the patients knowledge, but rather a test of how well you explained things in a manner your patient understands
steps of the teach back method/ how to use it and get comfortable with it
-plan your approach
-chunk and check (dont wait until end of visit)
-clarify and check again
-start slowly and use consistently
-practice
-use the show me method
-use handouts along with teach back
what is the pinnacle of patient centered care? what is the 3 step process
shared decision making;
1- introducing choices and describing options
2-exploring patient preferences
3- moving to a decision or giving pt more time if needed
why should you do self reflection after closing the encounter with a patient?
self reflection is a continual part of professional development in clinical work. it brings a deepening personal awareness to our work with patients.
what are the disparities in health care?
social determinants of health, racism and bias, cultural humility
what are the social determinants of health?
neighborhood and built environment, health and health care, economic stability, education, social and community context
skills and practices to migrate bias in your clinical encounters
- reflect on patterns of emotion and behavior
- pause before starting an encounter and prepare for potential triggers of bias
- generate alternative hypotheses for bias anchored in behavior
- practice universal communication and interpersonal skills
- explore your patients identities
- explore your patients experiences of bias
what are the 3 dimensions of cultural humility?
1- self awareness
2- respectful communication
3- collaborative partnerships
what are the 5 Rs of cultural humility
Reflection
Respect
Regard
Relevance
Resiliency
guiding questions in assessing the role of spirituality in your patient
-what values guide your patients healthcare decisions?
-how do patient spiritual beliefs and practices influence how they cope with their illness and care for themselves?
-does your patient have spiritual struggle or distress and need a referral to a chaplain?
what are the core values of medical ethics?
1-nonmaleficence
2-beneficence
3-respect for autonomy
4-decisional capacity
5-confidentiality
6-informed consent
7-truth telling
8-justic
what are the elements of decisional capacity?
Patients must have the ability to:
1-understand info about diagnosis or treatment
2-appreciate their situation
3-use reason to make a decision
4-communicate their choice
skilled interviewing technique
active or attentive listening, guided questioning, empathetic responses, summarization, transitions, partnering, validation, empowering the patient, reassurance, appropriate verbal communication, appropriate nonverbal communication
how do you express empathy?
you must first recognize the patients feelings, then actively move toward and elicit emotional content
what are techniques for empowering the patient?
1 evoke the pt persepctive
2convey interest in the person
3 follow the pt lead
4 elicit and validate emotional content
5 share info with the pt
6 be transparent with clinical reasoning
7 reveal limits of ur knowledge
what does appropriate verbal communication include?
using understandable and nonstigmatizing language
what are examples of nonverbal communication
body orientation, gaze orientation, head nodding, posture, tone of voice, use of silence, use of touch
guidelines for broaching sensitive topics
be nonjudgmental, explain why you need to know, find opening questions, conciously acknowledge whatever discomfort you are feeling
SPIKES (6 step protocol for delivering bad news)
S- setting up the interview
P-assessing pt perception
I-obtaining the patients invitation
K-giving knowledge to pt
E-emotions and empathetic responses
S-strategy and summary
SBAR (a tool to facilitate interprofessional communication)
S-situation
B-background
A-assessment
R-reccomendation
when treating a deaf patient it is important to:
learn whether they belonged to the deaf culture or the hearing culture when the hearing loss occured
what factors should you keep in mind when adjusting the scope of your history and physical examination?
magnitude and severity of pt problems, the need for thoroughness, clinical setting, primary or specialty care, and time
subjective vs objective info
subjective- symptoms the pt tells you
objective- info from the physical examination that you detect
what should you do when documenting the chief complaint?
make every attempt to quote the pt own words especially if unusal or unique
what is the hpi?
most basic story of pt problem and task of oral and written organization is yours
oldcarts
onset, location, duration, character, aggravating or alleviating factors, radiation, timing, setting
pertinent negatives vs pertinent positives
negatives-expected symptoms or signs that are not present
positives-symptoms or signs that you would expect to find if a possible cause for patients problem were true
what are two validating questions for depression?
1- over the past two weeks have you felt down, depressed, or hopeless?
2- over the past two weeks have felt little interest or pleasure doing things?
gravida and parity
G- number of pregnancies
P-number of delivers (term, preterm, abortions)
allergy vs side effect
allergy-adverse drug reaction mediated by an immune response
side effect- expected and known effect of a drug that in not the intended theraputic outcome
what should be included when documenting medications?
name, dose, route, frequency of use
basic ADLS
ambulating, feeding, dressing, toileting, bathing, transferring
instrumental ADLS
using the phone, shopping, preparing food, housekeeping, doing laundry, using transportation, taking medicine, managing money
sample questions to ask about pt sexual orientation or gender identity
-how would you describe ur sexual orientation
-how would you describe your gender identity
-what is the sex on your original birth certificate
what is the CAGE questionarre used for?
used to detect alcohol abuse
cuttting down
annoyance when criticized
guilty feelings
eye openers
2 or more is positive
pack years
calculated by multiplying the number of packs of cigarettes smoked per day by the number of years the pt has smoked
the five Ps of sexual history
1-partners
2-practices
3-protection from STIs
4-past hx of stis
5-pregnancy plans
FICA spiritual tool
faith or beliefs, importance and influence, community, address (how to address these issues in your healthcare)
what are the steps in beginning the physical examination
1- reflect on your approach to the patient
2- adjust the lighting and environment
3-check your equipment
4-make the patient comfortable
5-observe standard and universal precautions
6-choose the sequence, scope, and positioning of examination
the following fluids are considered potentially infectious
blood, semen, vaginal secretions, csf, synovial, pleural, peritoneal, pericardial, and amniotic fluids
what are the 4 classic techniques the physical examination relies on?
inspection, palpation, percussion, and ausculation
what part of the exam should the room be darkened for?
the ophthalmoscopic exam bc it promotes pupillary dilation and improved visibility of the fundi
when does close observation being during a head to toe physical exam?
begins at the outset of the patient encounter and continues throughout the exam
how should you exam the neck?
move behind the sitting pt to feel the thyroid gland and to examine the back, posterior thorax, and lungs
is the pt sitting or standing when inspecting the breasts and axillae?
sitting
what position is the female pt in when palpating the breasts?
supine and you are on the right side of the pt bed
what is the position of the pt and exam table for the cardiovascular examination?
pt is supine and ELEVATE HEAD OF EXAM TABLE TO -30 degrees adjusting as necessary to see the jugular venous pulsations
what is the position of pt and exam table for abdominal exam?
pt supine and lower bed to flat position
what position is pt in when palpating femoral pulses as well as lower extremity exam
supine
how should the pt be positioned when examing the musculoskeletal system?
standing to look at aligment of spine, legs, rom
basic structure of clinical reasoning process
gathering initial info, organizing and interpreting info, testing hypothesis, planning diagnositc and treatment stragety
what is a problem representation?
a clinicians evolving sense of the clinical picture
what do the elements of an illness script include?
diseases pathophysiology, epidemiology, time course, salient symptoms and signs, diagnostics, and treatment
what should you always include in your differential diagnosis?
worst case scenario to make sure things have been ruled out based on your finding and patient assessment
what is evidence based medicine?
exists at the intersection of the best available evidence, clinician judgement, and patient values
common types of clinical cognitive errors
anchoring bias, availability heuristic, confirmation bias, diagnostic momentum, framing effect, representation error, visceral bias
suggested rules for good decision making
slow down, be aware of base rates for ur differentials, consider what data is truly relevant, actively seek alternative diagnosis, ask questions to disprove not approve your hypothesis, remember you are often wrong
examples of semantic qualifiers
acute, chronic, constant, diffuse, localized, sharp, dull, young, old, mild, severe
what is a summary statement?
chief complaint placed in context of patients overall health status, includes pertinent party of hx, physical, and labs, no more than 2-3 sentences, demonstrates clinical reasoning, should make a case for a diagnosis, distillation of ur understanding of the case
patient problem list
documented pt problems, list the most active and serious problems first. This helps you individualize a pt care
what are the guidelines for an oral presentation?
opening statement, source (if no comment pt assumed to be reliable), present illness, other history, physical examination, labs/data, synthesis, enumerated problem list
constitutional symptoms
patient concerns that accompany many disease processes
what symptoms should you ask your pt about when doing the ‘general’ portion of the review of symptoms
ask about fatigue and weakness, fevers, chills, night sweats, weight change, pain
what is fatigue a common symptom of?
depression and anxiety but also infections, endocrine disorders, heart failure, chronic disease of lungs, kidneys, or liver, electrolyte imbalance, anemia, medications
what does weakness suggest?
especially if a neuroanatomical pattern, suggest possible neuropathy or myopathy
what does recurrent shaking chill suggest?
suggests more extreme swings in temperature and systemic bacteremia
- hot and sweating can also accompany menopause
*night sweats occur in tuberculosis and malignancy
what can be possible causes of weight gain?
changes in body fluid, edema in pt with heart failure, nephrotic syndrome, liver failure, and venous stasis, medications
what can be possible causes of weight loss
GI diseases, endocrine disorders, chronic infections, malignancy, chronic cardiac, pulmonary or renal failure, depression, anorexia
what can cause weight loss with high food intake suggest?
diabetes, hyperthyroidism, malabsorption
how do you perform a general survey?
notate pt appearance, apparent state of health, skin colorm dress, odors, grooming
what is a stadiometer?
device specifically designed for accurate measure of height
how do you calculate bmi
weight in kg/ height in m2
what happens to pt bp if the cuff is too small and too narrow
too small- bp will read high
too large- bp will read low
orthostatic hypotension
sustained reduction in SBP of at least 20 mm Hg or in DBP of atleast 10 mm Hg within 3 min of standing
what should you notate about pulse?
rate, rythym, strength (weak or strong)
what should be notated about respiration?
rate, rythym, depth, and effort
what are causes of fever
infection, malignancy, drug reactions, immune disorders
define pain
unpleasant sensory and emotional experience
somatic pain
linked to tissue damange, can be acute or chronic, dull pressing pulling throbbing
neuropathic pain
direct consequence of a lesion or disease affecting the somatosensory system, ex cns or spinal chord injury
what are things that can have significant effect son patients experience of pain?
arthritis, hiv, substance abuse, sickle cell, psychiatric disorders
use consistent methods to assess pain (there are 3 common tools)
visual analog scale, numeric rating scale, wong backer faces
list important topics for health promotion and counseling
screening for hypertension, blood pressure and dietary sodium, optimal weight, nutrition and diet, exercise and physical activity
what are the regulatory functions of serotonin and norepinephrine?
helps regulate mood, arousal, and cognition
*low serotonin w high norepinephrine= anxiety
what are the regulatory functions of dopamine?
helps regulate mood, arousal, cognition, and motor control
*too much dopamine w low serotonin- psychosis and mania
what are the regulatory functions of acetylcholine?
regulate sleep, arousal, and attention (low concentration levels can cause dementia)
what are common or concerning mental health symptoms?
anxiety or excessive worrying, depressed mood, memory problems, medically unexplained symptoms
list common risk factors in patients with anxiety
fam hx of anxiety, personal hx of anxiety or mood disorder, being female, chronic illness, behavioral inhibition
screening questions for anxiety
1- over the past two weeks have you been feeling nervous, anxious, or on edge?
2- over the past 2 weeks have you been unable to stop or control worry?
3- over the past 4 weeks have you had an anxiety attack?
what are common comorbid conditions that accompany excessive or uncontrollable anxiety?
hyperthyroidism, cardiopulmonary disorders, and TBI
what diseases would you consider in an older pt with one sided hand tremor and difficulty starting mvmts? what about a young pt?
parkinsons and huntingtons
lewy body dementia vs frontotemporal dementia
lewy body- visual hallucinations
frontotemporal- personality changes
list the key components of the mental status exam
assess appearance and behavior, assess speech and language, assess mood, assess thoughts, assess insight and judgement, assess cognition
what are the levels of conciousness?
alertness, lethargy, obtundation, stupor, coma
obtundation vs stupor
obtundation- opens eyes when tactile stimulus is applied and looks at you but responds slowly and is confused
stupor- arouses only after a painful stimuli, verbal responses are slow or absent and pt lapses into an unresponsive state when the sitmulus ceases
what characteristics should you look at when observing speech in a mental status exam?
quantity, rate and volume, articulation of words, fluency
broca aphasia vs wernicke apashia
broca- pt can comprehend but not form fluent speech
wernicke- pt can speak but not comprehend
what are some variations and abnormalities in thought processes?
blocking, circumstantiality, clanging (ex rhyming), confabulation (making things up), derailment, echolalia (repitition of words), flight of ideas, incoherence, neologisms, perservation
abnormalities of thought CONTENT
anxieties, compulsions, delusions, depersonalization, derealization, obsessions, phobias
abnormalities of perception
hallucinations and illusions
mental health important topics for health promotion and counseling
screening for depression, assessing for suicide risk, screening for dementia and delirium, screening for substance abuse disorders
when neurologic disease is suspected? what two complimentary questions should guide your assessment?
- what is the localization of the responsible lesion in the nervous system?
- what is the underlying pathophysiology that explains the pt symptoms and neurological findings?
what are concerning neurological symptoms?
headache, dizziness, weakness, numbness, fainting, seizures, tremors
migraine is present if 3/5 POUND features are present
Pulsatile or throbbing
One day duration
Unilateral
Nausea or vomitting
Disabling
headache warning signs
frequent or severe over 3 month period, head trauma, cancer or hiv, change in pattern, over 50 years old, aggravated or relieved by change in position, weight loss, night sweats, neck stiffness
