Unit 1 DOCS Flashcards
Justify the value of gathering medical history.
Gathering medical history allows you to have a conversation with the pt to build a foundation of trust and rapport while obtaining data framing chief complaint and allowing pt to be heard
Define pt-centered approach
An approach to care that respects and values the individual pt’s preferences, needs, and values. It involves giving a voice to the pt and including the pt in their care and treatment decisions.
Outline the steps for setting the stage of an interview.
Greet pt, introduce yourself, obtain permission - “Good morning Mr/Mrs. ______, I’m Student Doctor ___________. I’m part of Dr. _________’s team today and I’ll be getting some information from you if that’s okay with you.”
Ensure pt readiness and privacy - ask if they want family to stay in the room, close door/curtain
Address barriers to communication, ensure comfort - sit down, get interpreter, make small talk
Indicate time availability and set agenda - “Well I’ve got about ___ mins with you today, can you tell me what’s brought you in?”
Summarize and prioritize - “So we’ve got A, B, C, D, E, and F written down here. So we don’t risk the quality of care you receive, let’s focus on A, B, and C today, and we’ll get you scheduled to come back so we have more time to take care of D, E, and F.”
What are the elements of a comprehensive medical exam?
Identifying Information
Chief Complaint (CC)
History of Present Illness (HPI)
Medications and Allergies
Past Medical History (PMH)
Family Hx (FMH)
Social Hx (SH)
Review of Systems (ROS)
Identify and give examples of subjective vs objective information on exams
Subjective - what the patient tells you, symptoms
“My chest hurts” “It’s been going on for one week” “I feel depressed”
Objective - what can be measured, signs
Tests, labs, weekly logs, physical exam
Explain the value in using open-ended questions, describe the different tactics, and give an example.
Encourage the patient to continue giving information, makes pt feel heard
“What brought you in today?”, “Can you tell me more about that?”
Silence: staying silent after a pause to see if pt will continue
Nonverbal encouragement: silence with body language (sympathetic facial expression)
Continuers: brief, noncommittal statements (“uh-huh” “Go on”)
Explain the value in using open-ended focused questions, describe the different tactics, and give an example.
Helps pt develop their narrative, expands on what’s been put on the table
“Can you describe that?” “How did that make you feel?” “Tell me more about…”
Echoing: provides encouragement to focus by repeating words or phrases
Open-ended requests: asking for more information
Summarizing: shows pt that clinician was listening, following story and is ready for more info
Explain the value in using closed-ended questions, describe the different tactics, and give an example.
Useful for clarifying information toward the middle/end of the interview
“So you mentioned you fell, did you break skin?” “Did you fall on your right knee or left?”
Yes/no questions
Brief answer
Multiple choice
Explain the value in using leading questions and give an example.
No value. Do not use.
“You don’t smoke, right?” “I’m sure you don’t but I have to ask…”
Define palpation
The application of variable manual pressure to the surface of the body for the purpose of determining the shape, size, consistency, position, inherent motility, and health of the tissues beneath
Light placement of the hands or fingers on the pt’s body to discover abnormal changes of the soft tissue, bones, organs, or skin
What are the layers of palpation?
Observation - lesions, wounds, etc
Temperature - felt with wrist or back of hand
Skin topography/texture - feeling drag, moisture, turgor, etc
Superficial fascia - gentle pressing; should slide with ease
Muscle - moderate pressing; more difficult to slide, more dense
Tendons - traced in periphery to bony attachments
Ligaments -
Bone - deep palpation; should once again slide with ease
Explain FIFE and it’s use in exploring the patient’s perspective of their illness
Feelings - asking the pt how they are perceiving what’s happening
Ideas - what do they think may have caused it?
Effect on Function - how it is affecting their daily lives?
Expectations - what do they expect from the physician, the appointment, the illness, etc
Explain NURSE and it’s use in building empathy during a medical interview
Name - give a name to what they’re experiencing “That sounds scary” “I see you’re upset”
Understand - validate their concerns/feelings
Respect - “You’re brave/strong to admit this”
Support - Collaborate with pt, ensure you’ll work together
Explore - “How else are you feeling about it?”
What are the four qualities of empathy?
Perspective-taking
Staying out of judgement
Recognizing emotion in other people
Communicating
Describe the elements of a SOAP note
_________ guides the __________ -> __________ and __________ give rise to the __________ -> __________ leads to the __________.
Subjective information (what the pt says)
Objective information (what you observe, examine, etc)
Assessment (what you think it is)
Plan (next steps)
Subjective guides the Objective -> Subjective and Objective give rise to the Assessment -> Assessment leads to the Plan
OPPQQRRST
Onset
Position
Precipitating factors
Quality
Quantification
Radiation
Related symptoms
Setting
Transformation
Describe the anatomic position
Standing upright
Head, gaze and toes pointed anteriorly
Arms adjacent to sides w/ palms facing anteriorly
Lower limbs together w/ feet parallel
What are the 5 places to listen to the heart?
URSB - Upper right sternal border
ULSB - upper left sternal border
LMSB - lower medial sternal border
LLSB - lower left sternal border
Apex
OLDCARTS
Onset: When did CC begin?
Location: Where is the CC located?
Duration: How long has the CC been going on for?
Characterization: How does the patient describe the CC?
Alleviating/Aggravating factors: What makes the CC better? Worse?
Radiation: Does the CC move or stay in one location?
Temporal factor: Is the CC worse (or better) at a certain time of day?
Severity: On a scale of 1-10, 10 being the worst, how does the patient rate the CC?
OPQRST
Onset
Precipitating factors
Quality
Radiation
Severity
Timing
TART examination sequence
Observation
Temperature
Skin topography/texture
Fascia
Muscle
Tendons/ligaments
Erythema friction rub
General Spinal Examination Sequence
Inspection
Palpation
Range of Motion
Active testing does/does not involve the patient moving themselves
Passive testing does/does not involve the patient moving themselves
does - the patient is active
does not - the patient is not actively moving
Normal ROM for thoracic spine
Flexion - 45 degrees
Extension - 0 degrees
Side bending - 45 degrees
Rotation - 30 degrees
Normal ROM for lumbar spine
Flexion - 40-60 degrees
Extension - 20-35 degrees
Side bending - 15-30 degrees
Rotation - 3-18 degrees
You are performing a hip drop test on a patient. When the pt drops the right hip (puts all their weight on their left leg), you notice limited movement and a lack of sacral curve. What does that mean?
The pt has a restriction on the right side of the lumbar spine.
Myotomes of the Lumbar and Sacral spines used for strength testing
L2: Hip flexion
L3: Knee extension
L4: Ankle dorsiflexion
L5: Great toe extension
S1: Ankle plantarflexion, eversion, hip extension
S2: Knee flexion
Dermatomes of Lumbar and Sacral spines used for sensation testing
L1: groin
L2: inner thigh
L3: medial knee
L4: medial ankle
L5: top of foot
S1: lateral ankle
S2: lateral knee
Reflexes of Lumbar and Sacral Spine (L3-L4, and S1-S2)
L3-4: Patellar
S1-2: Achilles
Movement in a transverse plane about a vertical axis
Rotation
Movement in a coronal plane about an anterior-posterior axis
Sidebending
Anterior movement in a sagittal plane about a transverse axis
Flexion
Posterior movement in a sagittal plane about a transverse axis
Extension
Landmarks for scoliosis screening
Occipital plane
Shoulder plane
Scapular planer
Iliac crest plane
PSIS plane
Greater trochanter plane
Soft tissue treatment is only considered a(n) ________ technique
direct
3 categories of lower back pain
with radiculopathy
without radiculopathy
associated with systemic disease, organ system or other cause (referred pain)
The hallmark “Grocery Cart Sign” associated with lower back pain typically leads to what diagnosis?
Lumbar stenosis
Lower back pain with bowel/bladder dysfunction and “Saddle Anesthesia” is typically…
Cauda Equina Syndrome
Lower back pain associated with stiffness, gets better with movement, does not respond to treatment, symptoms gradually getting worse. Sacroiliitis seen on Xray later on in disease progression
Axial spondyloarthropathy - type of inflammatory arthritis
Spinal Landmarks
C7 - C7 prominins
T3 - spine of scapula
T7SP/T8TP - inferior border of scapula
L4 - superior border of iliac crest
S2 - most inferior PSIS
Sacral apex - upper greater trochanter
PO
by mouth
BID/TID/QID
twice/thrice/four times daily
qhs/qAM
at bedtime/ in the morning
PRN
as needed
What to ask for medication hx
Formulation - pill, liquid, tablet?
Dose - strength and amount
Route of admin - oral, nasal, IM?
Frequency of dosing - how often are you supposed to take it?
Adherence - how often do you actually take it?
Duration of treatment - how long have you taken it?
Adverse effects - any noticed?
Indication - why are you taking it?
You (as a physician) call child protective services in the case of suspected child abuse. What type of advocacy is this? Why?
Clinical Advocacy - providing care that integrates the full spectrum of the patient’s needs.
You (as a physician) meet with hospital leadership to discuss starting a student-run free clinic for patients with limited funds. What type of advocacy is this? Why?
Institutional advocacy - making changes in your institution
You (as a physician) vote to expand state Medicaid coverage. What type of advocacy is this? Why?
Health Care Advocacy - targeting health care policies or laws
You (as a physician) write a letter to your congressman supporting prison reform. What type of advocacy is this? Why?
Community-based Advocacy - affecting the broader population beyond the patients seen in a typical healthcare setting
What goes into a PMHx?
Active medical problems (not CC)
Childhood illnesses
Adult illnesses
Preventative Health
Allergies
What does into a PSHx?
Surgeries, procedures
When, why, complications, anesthesia type
What does into a FHx?
Common familial illnesses
Illnesses specific to one generation up/down
Relationship-age-disease
How is somatic dysfunction disgnosed?
Screening exams - posture, gait
Regional exams - inspection, AROM/PROM, TART
Segmental exams - palpation, motion testing, Fryette’s principles
List the classification, indications and contraindications of soft tissue technique.
Classification: Direct, Passive
Indication: Myofascial soft tissue disorder
Absolute contraindications: consent, no SD
Relative contraindications: Open wounds, fractured vertebrae, pain, contagious skin rash/disorder
List the classification, indications and contraindications of muscle energy technique.
Classification: Direct, Active
Indication: Arthrodial, myofascial SD
Absolute contraindications: consent, no SD
Relative contraindications: Open wounds, fractured vertebrae, pain, contagious skin rash/disorder, neurological or vascular compromise, malignancy, muscle strain
Give an example of an external motivator of Self-Determination Theory
Some type of reward
-Doing it because they want something out of it
Give an example of an introjected motivator of Self-Determination Theory
Self-critical, shaming, pressure to impress
-Doing it because they want to avoid guilt
Give an example of an identified motivator of Self-Determination Theory
Understanding the feeling of needing to perform/accomplish
- Doing it because they value the goal
Give an example of an integrated motivator of Self-Determination Theory
Congruence, awareness, synthesis with self and core love
- Doing it because it’s important to their self-worth
Give an example of an intrinsic motivator of Self-Determination Theory
Interest, enjoyment, satisfaction
- Doing it because they really want to.
What are the stages of change?
Precontemplation
Contemplation
Preparation
Maintainence
Relapse
Differentiate between Deontology, Utilitarianism, and Virtue Ethics.
Deontology is rule-based; the right/moral thing to do is that which honors the rule.
Utilitarianism is outcome-based; the right/moral thing to do is that which maximizes collective goodness.
Virtue Ethics identifies a virtuous role model; the right/moral thing to do is emulate what our virtuous model would do in this situation.
What are the Four Quadrants approach to Clinical Ethics?
Medical Indications
Patients Preferences
Quality of Life
Contextual features
