Lecture 1 unit 1.1: Pt encounter

Question 1

What type of approach to patient encounters will we learn? What is it designed to do?

Answer 1

A “one size fits all patients” approach to structuring the patient encounter; designed to reveal the unique clinical and personal picture each patient

Question 2

1) When is a comprehensive assessment appropriate?
2) When is a focused assessment appropriate?

Answer 2

1) Comprehensive: new patients
2) Focused: established patients, especially during routine or urgent visits

Question 3

1) What is the main goal of comprehensive assessments?
2) What is the main goal of focused assessments?

Answer 3

1) Provides fundamental and personalized knowledge about the pt.
2) Address focused concerns or symptoms

Question 4

What type of assessment strengthens the pt-provider relationship?

Answer 4

Comprehensive

Question 5

1) What is the goal of focused assessments?
2) What type of assessment creates a platform for health promotion?

Answer 5

1) Assesses symptoms restricted to a specific body system; applies examination methods relevant to assessing the concern as thoroughly and carefully as possible
2) Comprehensive

Question 6

What are SOAP notes?

Answer 6

Subjective
Objective
Assessment
Plan

Question 7

What’s the difference between subjective and objective info?

Answer 7

Subjective is what the patient tells us, objective is what we observe

Question 8

If a patient says it hurts when an examiner presses on their chest, is that subjective or objective?

Answer 8

Objective

Question 9

If a patient’s mother and father have history of early MI, is that subjective or objective?

Answer 9

Subjective

Question 10

If a patient says it hurts when they press on their chest, is that subjective or objective?

Answer 10

Subjective

Question 11

List 6 types of subjective information

Answer 11

1) Chief Complaint “CC”
2) History of present illness “HPI”
3) Review of systems “ROS”
4) Past medical history “PMH”
5) Family history
6) Social history

Question 12

True or false: the chief complaint is one data point

Answer 12

True

Question 13

What are two ways to handle the chief complaint? Give examples of each

Answer 13

1) Separate from the HPI
Ex: CC: “shortness of breath”
2) Embedded in the HPI. Ex: CC/HPI: John Doe is a 55 yo male who presents with “shortness of breath.”

Question 14

What is the most nuanced element of the subjective section?

Answer 14

HPI

Question 15

1) What does every thorough HPI include?
2) What do good providers do with this section?

Answer 15

1) Every thorough HPI includes the 7 attributes of a symptom.
2) GOOD providers, the ones who perform a meaningful work-up, chase the right diagnosis, and write good notes DO THIS SECTION COMPLETELY, regardless of the scenario. Don’t skimp here.

Question 16

What are 7 elements of HPI?

Answer 16

1) Location
2) Quality
3) Quantity or severity
4) Timing: onset, duration, frequency
5) Setting
6) Aggravating or alleviating factors
7) Associated symptoms
& key information

Question 17

What does HPI stand for?

Answer 17

History of present illness

Question 18

What does ROS stand for?

Answer 18

Review of systems

Question 19

What does PMH stand for?

Answer 19

Past medical history

Question 20

What are the 7 parts of HPI? Describe each

Answer 20

1) Location: literally where is the symptom: chest, head, belly, etc. Does it move from one place to another?
2) Quality: what is it like? Aching, stabbing, squeezing, burning, pressure, cramping, something else?
3) Quantity or severity: how bad is it? How extensive is it?
Is it unbearable chest pain? Is the rash everywhere?
4) Timing: when does it occur, and how often, how long does it last?
Careful, some CCs are intermittent
5) Setting: this is the literal setting in which it occurs, or the circumstances surrounding the onset
6) Aggravating or alleviating factors: what makes it better or worse?
7) Associated symptoms

Question 21

What is Morgan’s made up mnemonic to remember the 7 aspects of HPI?

Answer 21

Look, Queer Queens Talk Shit About Kings

Question 22

Give examples of considerations to take when deciding if something is key information about HPI

Answer 22

1) Is it a person with chest pain who has a history of heart attack? That’s relevant.
2) Is it a person with high blood pressure who is taking medicine already?
3) Did they already seek medical care for this?
4) If the person with MS is treated at a local neurology office, you should mention it.
5) Are they presenting to your ER, family practice, urgent care, specialty clinic?
6) Are they ALLERGIC TO ANY MEDICINES!??
7) Does the person with shortness of breath and weightloss also have a 40 year pack history? Worth mentioning.
8) Is their chief complaint high risk for certain diseases with classic symptoms? Ask about these and document the positives or negatives.
9) Recent exposures to anyone sick?

Question 23

What is the proper mnemonic to remember HPI?

Answer 23

OLD CARTS

Question 24

How do you get good at interviews? (7 things)

Answer 24

1) Ask open-ended questions
2) Use active listening
3) Demonstrate empathy
4) Keep an open mind toward the patient
5) Use the “worst case scenario” in your list of causes and ask the appropriate questions to screen for these
6) Check yourself for mistakes
7) Confer with colleagues to expand your approach

Question 25

For EVERY body system, you need to have at least how many questions memorized that help you to further investigate any symptoms they may have?

Answer 25

3

Question 26

What are ALL the ROS questions?

Answer 26

Any fever, chills, sweats, shakes, lightheadedness, dizziness, headache, head injury, double vision, blurry vision, changes in your vision, ringing in the hears, ear pain, loss of hearing, runny nose, stuffy nose, bloody nose, bleeding teeth or gums, sore throat hoarseness, difficulty swallowing, lumps or bumps in the neck, stiff neck change in range of motion of the neck, lumps or bumps in the breast tissue (do you check?), shortness of breath, wheezing, cough, chest pain, heart racing, skipping a beat, nausea, vomiting, diarrhea, loose stool, bloody stool, abdominal pain, burning when you pee, having to pee more often, change in smell or color of your urine, any itching-redness-swelling-pain on your genitals, any itching redness or rashes anywhere else?, (when was your last period?), any new low back pain, aching swollen joints, change in range of motion of your joints, any calf pain redness or swelling, any easy bruising or bleeding, ever had a blood clot, ever had a blood transfusion, ever been anemic, any change in hair or nails, extra hot extra cold extra thirsty, any numbness, tingling, tremors, loss of consciousness, have you had any anxiety or depression, changes in your memory, thoughts of hurting yourself or others?

Question 27

1) How could you preface an ROS? 2) If a patient answers "Yes" to any questions, what do you need to do? 3) When an ROS question is positive, where else does it need to go in the chart? What's the exception?

Answer 27

1) By saying, “I’m going to ask you a ton of yes or no questions now—were going to try to be extra thorough” 2) Drill down and get the 7 attributes for this positive finding 3) Positive ROS question also goes into your HPI as a second paragraph. Exception to this is a positive ROS that is not medically significant, or already a part of the HPI as an “associated symptom”

Question 28

What PMH questions should you ask children?

Answer 28

1) Major acute or chronic diseases: Measles, rubella, mumps, congenital heart disease, asthma, diabetes, ALL 2) Vaccinations received

Question 29

What PMH questions should you ask adults?

Answer 29

1) Medications (don’t forget supplements, natural remedies!) and allergies 2) Medical illnesses: hypertension, diabetes, high cholesterol 3) Surgeries/ hospitalizations: with dates, even if approximate 4) Health maintenance: annual physicals, PAP smears, mammograms, colonoscopies—routine tests and screenings and vaccinations 5) OB/GYN: births, pregnancies, menstrual history (if not already asked)

Question 30

1) When should you ask about allergies? 2) What specific questions should you ask?

Answer 30

1) A good place to ask about allergies  2) Make sure to ask about allergies to medicine, food, and environment And when you ask about allergies, ask “what happens when you’re exposed!”

Question 31

1) During family history what info do you need to gather? 2) What family members should you ask about?

Answer 31

1) You need to trace through pertinent diseases, along with the age of onset (and death or resolution) in patient’s immediate relatives 2) Immediate: Parents, siblings, children

Question 32

1) What primary questions should you ask about family history? 2) What else should you ask about family history?

Answer 32

1) Ask about cancer (including type if positive), heart disease, stroke, hypertension, cholesterol, diabetes, thyroid disease, mental illness 2) You can also consider clotting disorders, headaches, allergies, addiction, seizure disorders, etc

Question 33

How could you preface social history questions?

Answer 33

“These next few questions are kind of personal, but it’s just to get a complete picture so that we can take good care of you.”

Question 34

What are the 6 subjects you need to ask about during social history?

Answer 34

1) Tobacco use, alcohol use, illicit drug use, caffeine intake 2) Eating habits: diets or lack there of 3) Exercise: any regimens in place 4) Occupation, military history 5) Exposures: do you do anything at work that exposes you to illness 6) Homelife: do you feel safe in your home 7) Sexual history: current partners, preferences, contraception use (prophylaxis)

Question 35

Are physical exams subjective or objective?

Answer 35

Objective

Question 36

What considerations need to be made during physical exam to ensure they're comfortable and you have all the data?

Answer 36

1) Lighting: is your migraine patient wincing at the overhead light? And do you have enough light in the room to sew this laceration? 2) Position: do you need to adjust the bed to help the patient breath better, or just relax? Is the bed high enough for you do a knee exam? 3) Privacy: are you in the hallway? Do you need to pull out a divider to help protect their privacy? 4) Draping: does the patient need more exposure? Do you need them in a gown? Are you done examining the part of them that you had to expose – if so, cover them back up! 5) Advance notice of what you are doing: Let them know what you plan to do!

Question 37

1) What should you do before a physical exam? 2) When does PPE need to be especially considered?

Answer 37

1) Do you have all your medical equipment on you? 2) During physical exam

Question 38

What is a good order of evaluation for physical exams? What considerations should be taken for each?

Answer 38

1) Eyes: Visual inspection first. Simply look at whatever you are examining. -If the patient has belly pain, look at the belly! -Wrist pain? Make a deliberate step out of visual inspection! 2) Hands: Palpation is also often skipped. Don’t be afraid to touch your patients! -If the knee hurts, feel the knee! You will become much more acquainted with your patients and with anatomy if you always feel the affected part of their body, even if you’re not doing a special exam maneuver. -That said, percussion, specific maneuvers and tests are also done here. 3) Instruments: Often this means listening, auscultation. But also, use of scopes, tuning forks, visual acuity charts, rulers, ultrasound, etc.

Question 39

In developing your physical exam routine, it is often helpful to go in what order? What else is done in this order?

Answer 39

“Head to toe” just as you have done with ROS.

Question 40

When should you look at the vital signs (usually on laptop for you)?

Answer 40

Right before physical exam

Question 41

What are the vital signs you should look at? (5)

Answer 41

1) Blood pressure 2) Pulse 3) Respiratory Rate + Oxygen saturation 4) Temperature 5) Ht/wt

Question 42

What should be observed during the general survey step of physical exam?

Answer 42

-Patient’s overall appearance: well-appearing, ill appearing, toxic, in acute distress, in NO acute distress, calm, pleasant, agitated -Posture, motor activity, orientation -Dress, grooming, hygiene, odor (if pertinent) -Weight, sexual development, appearance vs. stated age

Question 43

1) What should you do when your general survey overlaps the body systems? 2) When does the general survey begin?

Answer 43

1) Consider this the prelude 2) At first sight of the pt

Question 44

1) What should you look for when you're visually inspecting the skin? What should you note about those things? 2) What else do you need to inspect? 3) What should you feel for when you're physically examining the skin? 4) When should you examine the skin, besides during its individual assessment?

Answer 44

1) Pallor, jaundice, cyanosis, lesions; noting location, distribution, arrangement, type, color 2) Hair and nails 3) Moisture, dryness, temperature 4) Continue as you move through the rest of your exam, i.e. when you are checking peripheral vascular you can assess the skin on the legs at that time

Question 45

What should be observed during the HEENT part of the physical exam?

Answer 45

Head Eyes Ears Nose Throat

Question 46

What should you look at when you're visually inspecting the head?

Answer 46

Hair, scalp, skull and face

Question 47

1) What should you look at when you're visually inspecting the eyes? 2) What should you use your hands to inspect? 3) What else should you look for? What will you need for this?

Answer 47

1) Eyelids, sclera and conjunctiva 2) Extraocular movements and visual fields 3) Ophthalmic examination: visual acuity, pupils, lenses -You need a fundoscope and a penlight for this

Question 48

1) What should you look at when you're inspecting the ears? 2) What will you need for this?

Answer 48

1) Auricles, canals, tragus, drums, & acuity 2) An otoscope and tuning for this

Question 49

1) What should you look at when you're inspecting the nose? 2) What should you use your hands to inspect? 3) What else should you look for? What will you need for this?

Answer 49

1) External nose, rhinorrhea, congestion, 2) Sinus pain, patency of the nares 3) Nasal mucosa, septum, turbinates -You’ll need otoscope again for this part -You will also use scented materials to check the olfactory nerve

Question 50

1) What should you look at when you're inspecting the throat? What will you need for this? 2) What should you palpate when inspecting the throat?

Answer 50

1) Lips, oral mucosa, gums, teeth, tongue, palate -You need your eyeballs and a pen light 2) The teeth, gums, and floor of the mouth

Question 51

1) What should visually inspect on the neck? 2) What should you palpate on the neck?

Answer 51

1) Neck, trachea, thyroid 2) Cervical lymph nodes, musculature and other soft tissue, trachea deviation, thyroid

Question 52

1) What should you look at when you're inspecting the thorax and lungs? 2) What should you use your hands to inspect? 3) What else should you look for? What will you need for this?

Answer 52

1) AP diameter, symmetry, bony structures, breathing 2) Palpate the chest wall, intercostal muscles, percuss, and perform tests 3) Listen to breath sounds, adventitious sounds, transmitted sounds with a stethoscope

Question 53

1) What should you look at when you're inspecting the upper extremities? 2) What should you use your hands to inspect?

Answer 53

1) Inspect the extremity, its parts, and the condition of the skin and muscles 2) Palpate boney structures, assessing neurological status as well, perform special tests

Question 54

1) What should you look at when you're inspecting the breasts and axillae (female)? 2) What should you use your hands to inspect?

Answer 54

1) Inspect breasts for dimpling, masses, lesion or rash 2) Palpate for lymphadenopathy or masses

Question 55

1) What should you visually inspect when you're inspecting the cardiovascular system? What do you need for this? 2) What should you use your hands to inspect? 3) What else should you look for? What will you need for this?

Answer 55

1) Observe jugular venous pulsations (penlight, straight edge) 2) Palpate thrills heaves, check apical pulse, check pulses 3) Listen for heart sounds: S3, S4, murmur, gallops, rubs, with a stethoscope

Question 56

1) What 5 things should you inspect the abdomen for? 2) What 2 things should be listened for? With what tool? 3) What 3 things should you palpate for?

Answer 56

1) Body habitus, bruising, mass, distension, surgical scars 2) Bruits, bowel sounds with a stethoscope 3) For tenderness or masses, organomegaly, percuss

Question 57

What are the 3 systems that are a part of the lower extremities portion of the physical exam?

Answer 57

1) Peripheral vascular system 2) Musculoskeletal 3) Complete nervous system

Question 58

1) What 5 things need to be inspected for during the peripheral vascular system part of the exam? 2) What needs to be palpated?

Answer 58

1) Look for rubor, pallor, unhealed lesions, varicose veins, skin 2) Peripheral pulses, lymph nodes, muscular and bony structures

Question 59

1) What 4 things need to be noted during the musculoskeletal part of the exam? 2) What needs to be palpated?

Answer 59

1) Joint deformity, erythema, effusion, observe gait 2) Palpate bony structures

Question 60

What 5 things need to be observed during the complete nervous system part of the exam?

Answer 60

1) Mental status 2) Cranial nerves 3) Motor system 4) Sensory system 5) Reflexes

Question 61

What 3 things should be observed when looking at the mental part of the exam?

Answer 61

Orientation, mood, and thought process

Question 62

1) What should be observed during the cranial nerve part of exam? 2) What 3 things should be observed during the motor system part of exam?

Answer 62

1) Nerves I-XII 2) Muscle bulk tone, strength, and cerebellar function

Question 63

1) What senses should be observed during the sensory system part of exam? 2) What is needed for this?

Answer 63

1) Pain, temperature, light touch, vibration, discrimination 2) Various additional instruments

Question 64

What reflexes should be observed during the reflex part of exam?

Answer 64

Biceps, triceps, brachioradialis, patellar, Achilles DTR, Babinski

Question 65

What should be examined and palpated during a genital/ rectal exam (men)?

Answer 65

-Inspect sacrococcygeal and perianal areas -Palpate anal canal, rectum, and prostate -Examine shaft of penis and testicles for deformity, mass, lesions, discharge

Question 66

What should be examined and palpated during a genital/ rectal exam (women)?

Answer 66

-Same rectal exam as men without prostate palpation -Examine external genitalia, vagina, cervix -Palpate uterus and adnexa bimanually

Question 67

What is the suggested sequence of 4 patient positions during a physical exam? What should be observed during each?

Answer 67

1) Seated: general, skin, lung, (abbreviated heart) skin, HEENT, optional neuro 2) Half reclined: Optional full cardiovascular 3) Supine: abdomen, optional breasts/axillae 4) Seated/standing: musculoskeletal, neuro where gait or balance is needed

Question 68

What goes first in the assessment and plan section?

Answer 68

Most important and new to least important and old

Question 69

Describe what "finding a match" means in terms of the assessment portion of a patient exam

Answer 69

In medicine you learn techniques to mine data from the patient, using history and physical and advanced testing – you learn a wide body of information about disease presentations and you try to “find a match” between them

Question 70

What are the 7 steps of diagnosis?

Answer 70

1) Identify abnormal findings 2) Localize findings 3) Cluster the clinical findings 4) Search for the probable cause 5) Cluster the clinical data 6) Generate hypotheses 7) Test those hypotheses

Question 71

i.e1) What does identifying abnormal findings involve? 2) What does localizing these findings anatomically mean?

Answer 71

1) Make a list of the symptoms and the signs you observed, and integrate lab data or imaging 2) See if you can pin down the true culprit to a particular anatomical location (i.e. pinpoint to a body location, system, or structure)

Question 72

Give an example of localizing findings (part of assessment step)

Answer 72

Chest > musculoskeletal > left pectoral muscle

Question 73

1) What do you do when the list of symptoms and the list of explanations are both a mile long? 2) What should you consider when doing this?

Answer 73

1) Cluster symptoms 2) Patient age, timing of symptoms, involvement of different body systems, multisystem conditions, key questions

Question 74

1) Describe what "search for the probable cause" means in terms of the assessment step of a patient exam 2) Give examples

Answer 74

1) This doesn’t mean cinch the diagnosis, it means consider the nature of the underlying cause 2) Ex: Congenital, infectious, immunologic, neoplastic, metabolic, nutritional, degenerative, vascular, traumatic, toxic

Question 75

What are the 5 steps of generating a hypothesis?

Answer 75

1) Select the most specific and critical findings to support your hypothesis 2) Filter out the noise 3) Match your findings against all conditions that cause them -Know your stuff 4) Eliminate the diagnostic possibilities that fail to explain what you’ve found -Start ruling things out 5) Weigh the competing possibilities and chose the most likely diagnosis -Put your money down! 5) Give special attention to life-threatening conditions -HAVE A BIAS TOWARD THE WORST-CASE SCENARIO

Question 76

How should you test your hypothesis?

Answer 76

1) Get any additional tests if needed -However, you may already have the data you need from your initial gathering of information (i.e. you may have already done the tests and now you are weighing conclusions)

Question 77

Describe what establishing a working diagnosis looks like

Answer 77

-Sometimes you are able to be very specific i.e. “bacterial meningitis, pneumococcal” -Sometimes you cannot move beyond mere description i.e. “fatigue”

Question 78

List and describe the 7 types of cognitive errors

Answer 78

1) Anchoring bias: locking onto salient features of illness to early on 2) Availability heuristic – likelihood: what comes to mind 3) Confirmation bias: seeking information that confirms initial suspicion 4) Diagnostic momentum: going with a prior diagnosis from a previous visit 5) Framing effect: interpretation of information is influenced heavily by the way it is initially presented Ex. “med noncompliance” 6) Representation error: disregarding prevalence in patient demographic 7) Visceral bias: negative or positive feelings about the patient cloud judgment

Question 79

A SOAP note is the same as what?

Answer 79

A patient encounter

Question 80

What do you need to check your SOAP note for?

Answer 80

1) Did you make headings clear? 2) Did you keep subjective/objective findings in the appropriate sections? 3) Do dates included help to narrow the diagnosis? Were you specific or general? 4) Did you write “normal” or did you give the evidence of a normal finding? 5) Are pertinent negatives given? 6) Is there too much detail? (ex: saying "cervix is pink and smooth" instead of "cervix shows no redness, ulcers, etc, etc, etc, etc")

Question 81

If it isn’t documented ______________

Answer 81

it didn't happen