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PAS 765 (Clinical Assessment I) > Unit I > Flashcards

Unit I Flashcards

1
Q

what are the seven attributes of a symptom

A
  1. location
  2. quality
  3. quantity/severity
  4. timing
  5. onset
  6. remitting/exacerbating factors
  7. associated manifestations
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2
Q

what are the seven components of the medical interview

A
  1. chief concern
  2. HPI
  3. medications
  4. past medical history
  5. family history
  6. social history
  7. review of systems
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3
Q

signs

A

object observable phenomena associated with a disease

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4
Q

symptoms

A

subjective patient reported phenomena associated with disease

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5
Q

what are at least four ways that providers interact nonverbally with a patient

A
  1. eye contact
  2. facial expression
  3. posture
  4. head position and movement
  5. interpersonal distance
  6. placement of arms and legs
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6
Q

open ended questions

A

questions that allow the patient to tell a story

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7
Q

closed ended questions

A

questions that are focused on trying to find a particular piece of information

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8
Q

leading questions

A

questions that suggest a particular answer

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9
Q

what are ten techniques of skilled medical interviewing

A
  1. active listening
  2. empathic responses
  3. guided questioning
  4. nonverbal communication
  5. validation
  6. reassurance
  7. partnering
  8. summerization
  9. transitions
  10. empowering the patient
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10
Q

three aspects of active listening

A
  1. being closely attentive to the patient
  2. taking into consideration the patients emotional state
  3. using verbal and non verball cues
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11
Q

what are three examples of empathic responses

A
  1. how do you feel about that
  2. that sounds upsetting
  3. you must be feeling sad
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12
Q

what is the goal of guided questioning

A

allowing the patient to communcate their story in their own words without interruption

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13
Q

what are three examples of guided questions

A
  1. moving from open to focused questions
  2. asking questions that need a guided response
  3. asking a series of questions one at a time
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14
Q

paralanguage

A

pacing, tone, and volume of speech

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15
Q

validation

A

affirm the legitimacy of the patients experiences

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16
Q

why is reassurance different for a provider than a casual person? what is a good starting point when reassuring the patient

A

because the instinctual response is telling someone everything will be ok when as a provider that might be premature

identifying and acknowledging patient concerns

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17
Q

partnering

A

building rapport with patients

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18
Q

rapport

A

trust between the patient and the provider

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19
Q

what are two reasons why summarization an example of skilled interviewing

A
  1. it proves to the patient that you were listening
  2. it gives you a chance to pick on something you missed
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20
Q

why are transitions considered a sign of being a skilled interview

A

it can put the patient at ease when you change from one part of the interview to the other

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21
Q

what is empowering the patient and why is it a sign of skilled interviewing

A

giving the patients a feeling of control over their illness

allowing them to ask questions and take part in their treatment plan

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22
Q

empathy

A

the capacity to identify with the patient and feel their pain as your own

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23
Q

what is an example of an empathic repsonse

A

i cannot imagine what you are going through

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24
Q

what are 6 of the 11 indications that a mental health screening should be done

A
  1. Medically unexplained physical symptoms—more than half have depression
  2. or anxiety disorder
  3. Multiple physical or somatic symptoms or “high symptom count”
  4. High severity of the presenting somatic symptom
  5. Chronic pain
  6. Symptoms for more than 6 weeks
  7. Physician rating as a “difficult encounter”
  8. Recent stress
  9. Low self-rating of overall health
  10. Frequent use of health care
  11. substance abuse
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25
Q

what are the five most common mental disorders encountered in practice

A
  1. anxiety
  2. depression
  3. alcohol
  4. somatoform
  5. eating disorders
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26
Q

what are two high yield questions to idenift depression

A
  1. Over the past 2 weeks, have you felt down, depressed, or hopeless?22,28,29
  2. Over the past 2 weeks, have you felt little interest or pleasure in doing things (anhedonia)?
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27
Q

what are three high yield questions to identify anxiety

A
  1. Over the past 2 weeks, have you been feeling nervous, anxious, or on edge?
  2. Over the past 2 weeks, have you been unable to stop or control worrying?
  3. Over the past 4 weeks, have you had an anxiety attack—suddenly feeling fear or panic?
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28
Q

what are 12 terms related to the mental status exam

A
  1. attention
  2. thought process
  3. affect
  4. memory
  5. thought content
  6. mood
  7. orientation
  8. insight
  9. language
  10. perceptions
  11. judgement
  12. higher cognitive function
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29
Q

attention

A

The ability to focus or concentrate over time on a
particular stimulus or activity—an inattentive
person is easily distractible and may have
difficulty giving a history or responding to
questions.

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30
Q

thought process

A

The process of registering or recording information,
tested by asking for immediate repetition of
material, followed by storage or retention of
information.

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31
Q

orientation

A

Awareness of personal identity, place, and time;
requires both memory and attention

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32
Q

perception

A

Sensory awareness of objects in the environment
and their interrelationships (external stimuli);
also refers to internal stimuli such as dreams or
hallucinations.

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33
Q

thought processes

A

The logic, coherence, and relevance of the patient’s
thought as it leads to selected goals; how people
think

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34
Q

insight

A

Awareness that symptoms or disturbed behaviors
are normal or abnormal; for example, distinguishing
between daydreams and hallucinations that
seem real.

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35
Q

judgement

A

Process of comparing and evaluating alternatives
when deciding on a course of action; reflects values
that may or may not be based on reality and social
conventions or norms

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36
Q

affect

A

A fluctuating pattern of observable behaviors that
expresses subjective feelings or emotions through
tone of voice, facial expression, and demeanor

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37
Q

mood

A

A more pervasive and sustained emotion that colors
the person’s perception of the world.

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38
Q

language

A

A complex symbolic system for expressing, receiving,
and comprehending words

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39
Q

higher congnitive function

A

Assessed by vocabulary, fund of information, abstract
thinking, calculations, construction of objects that
have two or three dimensions

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40
Q

what are five strategies to facilitate effective communication

A
  1. active listening
  2. empathic responses
  3. guided questioning
  4. nonverbal communication
  5. validation
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41
Q

five questions for general review of symptoms

A
  1. Usual weight
  2. recent weight change
  3. clothing that fits more tightly or
  4. loosely than before
  5. weakness, fatigue, or fever.
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42
Q

name 7 of the 13 questions for the skin ROS

A
  1. When did it first appear? Other symptoms that started along with this?
  2. Any changes over time? Fever?
  3. Any new areas involved? Any joint pain?
  4. Ever had anything like this before? Fatigue?
  5. Does it itch? (pruritis) Burn? Hurt? Numbness?
  6. Any new medications?
  7. What makes it better? Worse?
  8. Tried any new foods?
  9. Does sun exposure affect it?
  10. Any changes in skin color or texture? Localized?
  11. What treatments have you tried?
  12. Changes in dryness or sweating?
  13. Anyone else have a similar skin problem?
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43
Q

4 questions for head ROS

A
  1. Headache,
  2. head injury,
  3. dizziness,
  4. lightheadedness.
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44
Q

11 ROS questions for eyes

A
  1. Vision,
  2. glasses or contact lenses,
  3. last examination,
  4. pain,
  5. redness,
  6. excessive tearing,
  7. double or blurred vision,
  8. spots,
  9. specks,
  10. flashing lights,
  11. glaucoma, cataracts
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45
Q

7 ROS Questions for ears

A
  1. Hearing,
  2. tinnitus,
  3. vertigo,
  4. earaches,
  5. infection,
  6. discharge.
  7. If hearing is decreased, use or nonuse of hearing aids
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46
Q

5 ROS questions for nose ROS

A
  1. Frequent colds,
  2. nasal stuffiness, discharge, itching,
  3. hay fever,
  4. nosebleeds,
  5. sinus trouble
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47
Q

8 questions for mouth ROS

A
  1. ​Condition of teeth and gums,
  2. bleeding gums,
  3. dentures, if any, and how they fit,
  4. last dental examination,
  5. sore tongue,
  6. dry mouth,
  7. frequent sore throats,
  8. hoarseness
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48
Q

6 questions for neck ROS

A
  1. “Swollen glands”
  2. Goiter
  3. Lumps
  4. Pain
  5. Stiffness in neck
  6. Reduced motion in the neck
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49
Q

5 questions for breast ROS

A
  1. Lumps
  2. Pain
  3. Discomfort
  4. Nipple discharge
  5. Does the pt. do self-breast exams?
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50
Q

seven questions for respiratory ROS

A
  1. Cough
  2. Sputum (color, quantity)
  3. Hemoptysis
  4. Shortness of breath (SOB)/dyspnea
  5. Wheezing
  6. Pain with a deep breath pleurisy
  7. Last CXR
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51
Q

nine questions for cardiovascular ROS

A
  1. Heart trouble”
  2. High blood pressure
  3. Chest pain or discomfort
  4. Palpitations
  5. Shortness of breath
  6. Need to use pillows at night to ease breathing (orthopnea)
  7. Need to sit up at night to ease breathing (Paroxysmal nocturnal dyspnea)
  8. Swelling in the hands, ankles, or feet (edema)
  9. Results of past electrocardiograms or other cardiovascular tests
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52
Q

15 questions for the gastrointestinal ROS

A
  1. Appetite
  2. Trouble swallowing
  3. Heartburn
  4. Nausea
  5. Bowel movements (stool color and size, change in bowel habits)
  6. Pain with defacation
  7. Rectal bleeding or black or tarry stools
  8. Hemorrhoids
  9. Constipation
  10. Diarrhea
  11. Abdominal pain
  12. Food intolerance
  13. Excessive belching or flatulence
  14. Jaundice
  15. Liver or gallbladder trouble
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53
Q

7 questions for the peripheral vascular ROS

A
  1. Intermittent leg pain with exertion (claudication)
  2. Leg cramps
  3. Varicose veins
  4. Previous clots in the veins
  5. Swelling in the calves, legs, or feet
  6. Color change in the fingertips or toes during cold weather
  7. Swelling with redness or tenderness
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54
Q

15 questions for the urinary ROS

A
  1. Frequency of urination
  2. Polyuria (large quantities of urine)
  3. Nocturia
  4. Urgency
  5. Burning or pain during urination (dysuria)
  6. Blood in the urine (hematuria)
  7. Urinary infections ok to leave in ROS
  8. Kidney or flank pain
  9. Kidney stones
  10. Ureteral colic
  11. Suprapubic pain
  12. Incontinence
  13. Reduced caliber or force of urinary stream (males)
  14. Hesitancy
  15. Dribbling
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55
Q

8 questions for the male genital ROS

A
  1. Hernias
  2. Discharge from or sores on the penis
  3. Testicular pain or masses
  4. Scrotal pain or swelling
  5. History of sexually transmitted infections (STIs) and their treatments
  6. Sexual habits, interest, function, satisfaction,
  7. birth control methods, condom use, problems.
  8. Concerns about HIV infection
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56
Q

ten questions for the female genital ROS

A
  1. Age at menarche
  2. Regularity
  3. Frequency
  4. Duration of periods
  5. Amount of bleeding
  6. Bleeding between periods or after intercourse
  7. Last menstrual period (LMP)
  8. Dysmenorrhea
  9. Premenstrual tension
  10. Age at menopause, menopausal symptoms, postmenopausal bleeding
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57
Q

seven questions for the musculoskeletal ROS

A
  1. Muscle or joint pain
  2. Stiffness
  3. Arthritis
  4. Gout
  5. Backache
  6. Neck or low back pain
  7. Joint pain with systemic symptoms
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58
Q

if there are any positives on the musculoskeletal exam, what are eight follow up questions

A
  1. Location of affected joints or muscles
  2. Swelling
  3. Redness
  4. Pain
  5. Tenderness
  6. Stiffness
  7. Weakness
  8. Limitation of motion or activity
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59
Q

nine questions for the psychiatric ROS

A
  1. Nervousness
  2. Tension
  3. Mood
  4. Depression
  5. Behavior change-staying up all night, spending sprees, gambling, sexual promiscuity
  6. Memory change
  7. Suicidal ideation
  8. Suicide plans or attempts
  9. Past counseling, psychotherapy, or psychiatric admissions
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60
Q

four questions for the hematologic ROS

A
  1. Anemia
  2. Easy bruising or bleeding
  3. Past transfusions
  4. Transfusion reactions
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61
Q

6 questions for the endocrine ROS

A
  1. Thyroid trouble”
  2. Heat or cold intolerance
  3. Excessive sweating
  4. Excessive thirst or hunger
  5. Polyuria
  6. Change in glove or shoe size
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62
Q

why should providers be aware of personal biases during the patient interview

A

because biases can create tunnel vision that might exclude symptoms outside the providers bias

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63
Q

what is the DSM and what is its purpose

A

the diagnostic and statistical manual of mental disorders

to codify what the primary indications are for diagnosis of mental disorders

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64
Q

what are the 8 components of the general survery

A
  1. apparent state of health
  2. level of consciousness
  3. signs of distress
  4. skin color or obvious lesions
  5. dress/grooming/hygiene
  6. facial expression
  7. breath or body odor
  8. posture, gait, motor activity
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65
Q

what are three purposes of the physical exam

A
  1. to validate findings from the health history
  2. investigate problems
  3. screen for diseases
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66
Q

what are the limitations of the physical exam

A
  1. detection and measuring errors
  2. limited sensitivity to distinguish health from disease
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67
Q

what are four advantages to the physical exam

A
  1. objective
  2. sensity to certain signs of disease
  3. cheap
  4. laying on hands builds a relationship with patient
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68
Q

what are seven errors common to the physical exam

A
  1. technique
  2. errors of omission
  3. errors of detection
  4. errors of interpretation
  5. errors in documentation
  6. variability in clinical measurements
  7. legitimate disagreement
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69
Q

what are the four cardinal techniques of the physical exam and what is the order of these techniques

A
  1. inspect
  2. palpate
  3. percuss
  4. auscultate
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70
Q

what is the exception to the general sequence of the physical exam

A

the abdomen, where you inspect, auscultate, percuss, then palpate the abdomen first shallow then deeply

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71
Q

what is the suggested sequence to proceed through the physical exam

A
  1. general survey
  2. vital signs
  3. skin and nails
  4. head
  5. eyes
  6. ears
  7. nose
  8. mouth
  9. neck
  10. lymph nodes
  11. pulmonary
  12. breasts
  13. heart
  14. abdomen
  15. GU/rectal
  16. extremities
  17. musculoskeletal
  18. neurological
  19. psychological
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72
Q

what is normal BMI

A

18.5 to 24.9

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73
Q

what is a normal BP

A

120/80

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74
Q

what is a normal pulse

A

60-100 bpm

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75
Q

what is a normal respiratory rate

A

20 breaths per minute

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76
Q

what is normal temp

A

98.6 degrees F

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77
Q
A
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78
Q

jaundice

A

a yellowing of the skin, eyes, lips, tongue, and TM caused by excess bilirubin related to liver disease or hemolysis

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79
Q

carotenemia

A

yellow color on the palms, soles, and face caused by high levels of carotene in the diet

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80
Q

when is carotenemia common

A

when babies are starting on solid food

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81
Q

where is central cyanosis best seen

A

lips, oral mucosa, tongue

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82
Q

where can peripheral cyanosis be seen

A

nails, hands, feet

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83
Q

what should be noted during inspection and palpation of the skin

A
  1. color
  2. temp
  3. moisture
  4. texture
  5. turgor
  6. mobility
  7. lesions
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84
Q

what are 6 ways to describe abnormal skin color

A
  1. jaundice
  2. carotenima
  3. erythema
  4. cyanosis
  5. pallor
  6. absence of pigment
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85
Q

what are three consideration to take into account when assessing skin moisture

A
  1. chronic vs acute dryness
  2. age
  3. oily skin
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86
Q

how is skin temp assesed

A

with the back of the hand

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87
Q

what are four reasons to expect increased skin temp

A
  1. exercise
  2. inflammation
  3. fever/infection
  4. hyperthyroid
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88
Q

what are three reasons to expect decreased skin temp

A
  1. poor circulation
  2. hypothyroid
  3. inadequate clothing
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89
Q

when would you expect rough skin? velvety skin?

A

rough from hypothyroid

smooth from hyperthyroid

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90
Q

what are two conditions that would result in loss of skin mobility

A
  1. edema
  2. scleroderma
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91
Q

what are 11 features to note about skin lesions

A
  1. size
  2. shape
  3. location
  4. generalized/localized
  5. patterned
  6. single/multiple
  7. type of lesion
  8. color of lesion
  9. painful
  10. associated warmth
  11. drainage
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92
Q

what are the ABCDEs of assessing a skin lesion for cancer risk

A

A) asymmetry

B) borders (irregular)

C) color

D) diameter

E) evolution

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93
Q

T/F a skin lesion that is smaller than 6mm does not fit the criteria for skin cancer

A

false, it may fit the criteria if it is significantly larger than other skin lesions

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94
Q

what percentage of skin cancer is basal cell carcinoma

A

80%

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95
Q

where is someone most likely to get skin cancer

A

on sun exposed areas

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96
Q

describe how a basal cell carcinoma looks

A

pearly erythmatous translucent papule

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97
Q

T/F basal cell and squamous cell carcinomas rarely metastize

A

false, squamous cell carcinomas metastize approx 1% of the time

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98
Q

how common are squamous cell carcinomas

A

16% of all skin cancers are squamous cell carcinomas

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99
Q

a patient presents with a dry, hyperkeratotic lesion on the face, what is a likely diagnosis

A

squamous cell carcinoma

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100
Q

how common is melanoma

A

4-5% of all skin cancer is melanoma

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101
Q

T/F melanoma is the least likely type of skin cancer reported in patients ages 25-29

A

false, it is the most

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102
Q

which of the three skin cancers is potentially most lethal? why

A

melanoma, because it is more likely to metastize

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103
Q

what is the HARMM acronym and what is it used for

A

H) hx of previous melanoma

A) age over 50

R) regular dermatologist absent

M) mole changing

M) male

used to delineate risk factors for melanoma

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104
Q

what are three other risk factors associated with melanoma

A
  1. red/light hair
  2. freckles
  3. severe blistered sunburns as a child
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105
Q

macule/patch

A

a flat, non-palpable lesion with changes in skin color

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106
Q

what is the difference in size between a macule and a patch

A

macules are up to 1cm

patches are larger than 1cm

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107
Q

papule (example)

A

a solid elevated lesion up to 1 cm (warts, moles)

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108
Q

plaque (example)

A

palpable, elevated lesion greater than 1cm, sometimes formed from plaques

psoriasis

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109
Q

nodule (example)

A

knot like lesion deeper and firmer than a papule, less than .5cm in size (dermatofibroma)

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110
Q

cyst (example)

A

nodule filled with expressible material (ganglion, sebaceous)

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111
Q

wheal (example)

A

somewhat irregular, reletively transient superficial area of localized skin edema (uticarial wheals/hives)

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112
Q

vesicle/bulla (example)

A

a palpable elevation filled with serous fluid (chicken pox blisters, herpes blisters)

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113
Q

what is the difference in size between a vesicle and a bulla

A

vesciles are up to 1cm

bulla are 1cm or greater

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114
Q

pustule (example)

A

a palpable elevation filled with pus (acne, insect bites)

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115
Q

burrow (example)

A

a small, slightly raised tunnel in the epidermis that looks like a short curved grey line with a small vesicle, papule, or crust (scabies)

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116
Q

where are burrows usually found

A

finger sides and webs

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117
Q

scale (example)

A

a thin flake of dead exfoliated epidermis (peeling sunburn)

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118
Q

crust (example)

A

a dried residue from exudate such as blood, pus, or serum (scab)

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119
Q

lichenification (example)

A

a visible and palpable thickening of the epidermis and roughening of the skin with increased visability of the normal skin furrows (atopic dermatitis)

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120
Q

what is usually the cause of lichenification

A

chronic rubbing and scratching

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121
Q

scar

A

an area with increased connective tissue that arises from injury or disease

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122
Q

keloid

A

a hypertrophic scar that extends beyond the borders of the original injury

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123
Q

atrophy (example)

A

an area of deceased skin or muscle growth (pit caused by chronic steroid injections

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124
Q

erosion (example)

A

nonscarring loss of superficial epidermis (aphthous stomatitis)

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125
Q

ulcer

A

a deep erosion that may cause a scar

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126
Q

excoriation (example)

A

linear or punctate erosions caused by scratching (atopic dermatitis)

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127
Q

fissure

A

a linear crack in the skin, often caused by dryness

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128
Q

induration (example)

A

hardening or sclerosis of skin (infection, scleroderma)

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129
Q

telangiectasia

A

chronic dilation of a group of capilaries

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130
Q

milia

A

superficial inclusion cysts filled with keritinaceous debris

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131
Q

where are milia often found

A

on the face of newborns

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132
Q

two types of hair

A

velus and terminal

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133
Q

velus hair

A

short fine hair found all over

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134
Q

terminal hair

A

hair the scalp, eyebrows

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135
Q

what are four qualities to note when inspecting the hair

A
  1. quantity
  2. texture
  3. distribution
  4. pattern of hair loss
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136
Q

alopecia

A

hair loss that can be diffuse, patchy, or total

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137
Q

would hair loss be expected in a patient with hyperthyroidism?

A

no, you would expect fine silky hair with hyperthyroid

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138
Q
A

A) nail plate

B) nail groove

C) lunula

D) eponychium

139
Q

what should noted when inspecting and palpating the finger and toe nails

A
  1. color
  2. shapes
  3. lesions
  4. infections
140
Q

paronychia (cause)

A

superficial infection of the proximal and lateral nail folds adjacent to the nail plate (staph infection)

141
Q

onychomycosis

A

fungal infection of the toenails

142
Q

what is the most common disease of the nails

A

onychomycosis

143
Q

clubbing

A

a bulbous swelling of the soft tissue at the nail base, with loss of the normal angle between the nail and proximal nail fold

144
Q

what causes clubbing

A

vasodilation in response to heart, lung, or metastatic malignancies causes increased blood flow to the digits

145
Q

onycholysis

A

a painless separation from distal to proximal of the nail plate from the nail bed

146
Q

what are three common causes of onycholysis

A
  1. trauma
  2. fungal infection
  3. allergic reations
147
Q

leukonychia

A

white spots that grow out with the nail caused by trauma

148
Q

mee’s lines

A

curving transverse white bands that cross the nail parallel to the lunula

149
Q

what are three causes of mees lines

A
  1. arsenic poisoning
  2. heart failure
  3. hodgkins disease
150
Q

beaus lines

A

transverse depressons of the nail plates resulting from disruption of proximal nail growth

151
Q

what are three causes of beaus lines

A
  1. illness
  2. trauma
  3. raunauds disease
152
Q

terrys nails

A

a condition where the nail plate turns white with a ground glass appearance

153
Q

what are three conditions associated with terrys nails

A
  1. liver disease
  2. heart failure
  3. DM
154
Q
A

actinic keratosis

155
Q
156
Q
A

basal cell carcinoma

157
Q
A

beaus lines

158
Q
159
Q

1cm in diameter or greater

160
Q
161
Q
162
Q
A

carotenema

163
Q
A

cherry angioma

164
Q

less than 1cm in diameter

A

chickenpox vesicle

165
Q
166
Q
167
Q
168
Q
169
Q
A

ecchymosis

170
Q
171
Q
172
Q
A

excoriation

173
Q
A

herpes zoster

174
Q
175
Q
176
Q
177
Q
A

leukonychia

178
Q
A

lichenification

179
Q

greater than 0.5cm in size, deep and firm on palpation

180
Q

greater than 0.5cm in size, deep and firm on palpation

181
Q
A

onycholysis

182
Q
A

onychomycosis

183
Q

solid, elevated, less than 1cm

184
Q
185
Q
A

paronychia

186
Q

greater than 1cm in size

187
Q
188
Q
189
Q

greater than 1cm

190
Q

larger than 1cm

191
Q
192
Q
193
Q
194
Q
195
Q
196
Q
A

seborrheic dermatitis

197
Q
A

seborrheic keratosis

198
Q
A

spider angioma

199
Q
A

squamous cell carcinoma

200
Q
A

squamous cell carcinoma

201
Q
A

telangiectasia

202
Q
A

terrys nails

203
Q
204
Q
205
Q
206
Q
207
Q
208
Q
209
Q

what is the differene between assessment and plan

A

assessment is what you think, plan is what you do

210
Q

what are some issues to take into consideration when developing a plan?

why?

A

financial status, patient goals, family structure

some people will not have the financial or social support for lab tests or adherence to medication

211
Q

three types of clincial reasoning

A
  1. pattern recognition
  2. development of schemas
  3. application of science
212
Q

how does pattern recognition play a role in clincial reasoning

A

through experience practitioners will come to understand disease processes and recongize their progression

213
Q

two examples of schemas

A

algorithms

mnemonic

214
Q

what is the VINDICATE mnemonic stand for

A

Vascular

Infection/inflammatory/autoimmune

Neoplasm

Drugs

Iatrogenic

Congenital/Development/inherited

Anatomic

Trauma

Environmental Exposure/Endocrine/Metabolic

215
Q

what is the purpose of the vindicate mnemonic

A

to brainstorm about what disease processes might be in play

216
Q

what is one way to narrow down problems when trying to diagnose

A

think about what structures are anatomically close to symptoms

217
Q

steps of clinical reasoning

A
  1. identify abnormal findings
  2. localize findings anatomically
  3. cluster clinical findings
  4. interpret the findings in terms of a probable disease process
  5. form a hypothesis
  6. confirm with tests
  7. establish a working diagnosis
218
Q

what are some considerations when clustering clinical findings

A
  1. there may be more than one cluster
  2. older patients have more chronic/systemic disease
  3. temporal relationship between problems
  4. localized vs systemic problems
  5. multisystemic issues
219
Q

three whys to interpret findings and translate them into a disease process

A
  1. Pathologic (diseases of body system or structure)
  2. Pathophysiologic (problems in biologic function
  3. psychopathologic
220
Q

what is especially important when developing a hypothesis

A

recognition and treatment for potentially lifethreatening situations

221
Q

T/F the plan is a finality and must take into consideration all aspects of care

A

false, each problem should have their own plan and will change for each visit

222
Q

what are five pitfalls of clinical reasoning

A
  1. Anchoring
  2. Search satisficing
  3. Diagnostic momentum
  4. psych-out error
  5. premature closing
223
Q

anchoring

A

being stuck on a particular diagnosis despite contrary evidence

224
Q

search satisficing

A

choosing the first diagnosis that fits all the symptoms

225
Q

premature closing

A

making a snap decision based on limited evidence

226
Q

diagnostic momentum

A

when a diagnosis becomes a matter of fact: treat all patients like they have no diagnosis

227
Q

psych out error

A

when somatic diagnoses are ignored in favor of psychological ones

228
Q

what is the problem list? what is it used for?

A

a running list of all problems

to keep a tab on all a patients problems, treatment, and duration of problem

229
Q

three attributes of well organized medical records

A
  1. clear
  2. concise
  3. comprehensive
230
Q

why is it important to be precise whend documenting findings

A
  1. things you don’t record aren;t part of the record and can’t be used in treatment going forward
  2. you cant record abnormalities you don’t observe
231
Q

validity

A

how closely a given observation is to the truth

232
Q

reliability

A

how well a measurement can be repeated

233
Q

sensitivity

A

a test that provides a reliable positive to people who have the disease

234
Q

what is a good indication that test is sensitive?

when will a sensitive test be most useful?

A

a 90% sensitivity

best to rule out diseases because there are few false positives for specific disease

235
Q

SnNout

A

when a sensitivity of a symptom or sign is high, a negative response rules out the disease in question

236
Q

a negative on a sensitive test means what

A

you can rule out a disease and be confident that the patient doesn;t really have it

237
Q

specificity

A

identifies the proportion of people who test negative in a group that don’t have a disease

238
Q

SpPin

A

when specificity is high, a positive test rules in the target disorder

239
Q

predictive value

A

indication of how well a given symptom, sign, or test predicts the presence or absence of a disease

240
Q

positive predictive value

A

the proportion of true positives out of the total population with the disease

241
Q

negative predictive value

A

the proportion of true negatives out of the total population without the disease

242
Q

LR

A

likelihood ratio, the odds that a finding occurs in a patient with the condition compared to a patient without the condition

243
Q

what LR value is most useful when trying to rule out a disease? when trying to rule in

A

to rule in, choose the test with the highest positive LR

to rule out, choose the test with the lowest negative LR

244
Q

negative LR

A

the odds that a negative finding will accurately rule out a disease

245
Q

positive LR

A

the odds that a positive test will accurately indicate the person has a disease

246
Q

what test would you choose to rule in an infection? which would you use to rule out?

A

to rule in, use the test with the highest positive LR, procalcitonin

to rule out, use the test with the lowest negative LR, CRP

247
Q

what does it mean to say that a test has a high level of certainty

A

the available evidence comes from well designed studies and the findings are representative of primary care populations

248
Q

what are the sections of the health history in order including the ROS (24)

A
  1. Identifying info
  2. CC
  3. HPI
  4. Medications
  5. Allergies
  6. Alcohol/Tobacco/Drugs
  7. PMI
  8. Family History
  9. Social History
  10. ROS (general)
  11. Skin
  12. HEENT
  13. Neck
  14. Breasts
  15. Respiratory
  16. Cardiovascular
  17. GI
  18. Peripheral Vascular
  19. Urinary
  20. Genital
  21. Musculoskeletal
  22. Pyschiatric
  23. Neurologic
  24. Hematologic
249
Q

what is the order of the physical exam (18)

A
  1. General
  2. MEntal
  3. Vitals
  4. Skin
  5. Hands/Nails
  6. Head
  7. Neck
  8. Eyes
  9. Nose
  10. Mouth and throat
  11. Ears
  12. Axillary and Epitrochlear nodes
  13. Chest
  14. Cardiovascular
  15. peripheral vascular
  16. Abdomen
  17. Musculoskeletal
  18. Neuro
250
Q

how will the patient be postioned during the physical exam

A
  • sitting for general, vitals, skin, head, neck, breasts
  • lay back for cardiovascular, then roll partly to the left, then sit up and lean forward
  • lay flat for the abdomen
  • stand if needed as needed for musculoskeletal, neuro, skin
  • women lay back for pelvic, men on their left side for prostate
251
Q

T/F Depression is the leading cause of disability world wide

252
Q

what are five physical symptoms of depression

A
  1. Fatigue
  2. Sleep disturbances
  3. musculoskeletal pain
  4. headache
  5. GI problems
253
Q

Approx what percent of unexplained symptoms are related to depression

254
Q

T/F Sleep disturbances happen when a patient wakes up frequently in the night

A

false, it can mean getting too much sleep as well as too little

255
Q

when should a mental health screen be performed

A

there are many possible key factors but the US preventative service task force reccommends one for all patients

256
Q

what are the five components of a mental health exam

A
  1. apperance and behavior
  2. speech and language
  3. mood
  4. thoughts and perceptions
  5. cognitive function
257
Q

what four patient qualities should be examined when assessing apperance and behavior

A
  1. level of consciousness
  2. posture and motor behavior
  3. dress/grooming/hygiene
  4. manner/affect/relationships
258
Q

what are five ways to describe level of consciousness

A
  1. alert
  2. lethargic
  3. obtunded
  4. stupor
  5. coma
259
Q

three indicators a person is alert

A
  1. responds to normal tone of voice
  2. good eye contact
  3. appropriate responses
260
Q

three indicators a person is lethargic

A
  1. drowsiness
  2. opens eyes only to look at you
  3. responds to questions then falls asleep
261
Q

five indicators that a patient is obtunded

A
  1. opens eyes to look at you
  2. responds slowly
  3. somewhat confused
  4. decreased alertness
  5. might need a shake awake
262
Q

three indicators a patient is stuporous

A
  1. arouses only with painful stimuli
  2. slow or absent verbal response
  3. minimal awareness of environment
263
Q

two indictors of a comatose patient

A
  1. unrousable with eyes closed
  2. no response to painful stimuli
264
Q

what are four ways to introduce painful stimuli

A
  1. trap squeeze
  2. sternal rub
  3. pencil on nail bed
  4. pinch
265
Q

what are four examples of abnormal posture and motor behavior

A
  1. pacing
  2. abnormal posture
  3. spastic movement
  4. complaining of a level of pain that doesn’t match presentation
266
Q

what are 4 examples of variation in affect

A
  1. labile
  2. blunt
  3. exaggerated
  4. pleasant
267
Q

labile affect

A

someone who expresses in appropriate or excessive displays of emotion

268
Q

when assessing manner/affect/relationships what are five factors to examine

A
  1. affect
  2. level of approachability
  3. appropriate reactions to others
  4. possible hallucinations
  5. euphoria
269
Q

what are five ways to evaluate speech and language in a mental health exam

A
  1. quantity
  2. rate
  3. volume
  4. articulation
  5. fluency
270
Q

pressured speech

A

an abnormal speech pattern where the patient continuously talks with no breaks

271
Q

what are two issues that might present with pressured speech

A
  1. mania
  2. substance abuse
272
Q

what are three issues that might present with slowed speech

A
  1. depression
  2. stroke
  3. sedation
273
Q

T/F slowed speech can involve speaking slowly or the inability to get words out

274
Q

four disorders of speech

A
  1. aphasia
  2. apraxia
  3. dysarthria
  4. dysphonia
275
Q

what is aphasia

A

a communcation disorder caused by damage to the language centers of the brain

276
Q

what is the defining characteristic of aphasia

A

difficulties communicating (speech, writiing, reading) with no decrease intelligence

277
Q

apraxia

A

a motor disorder in which the signal conduction from the brain to the mouth is interrupted, causing the person to be unable to move their mouth properly to speak

278
Q

dysarthria

A

a motor speech disorder resulting from impaired muscles used in speech

279
Q

what determines the type and severity of dysarthria

A

the area of the nervous system that is affected

280
Q

dysphonia

A

a voice disorder caused by impairment of the mouth, tongue, throat, or vocal cords resulting in hoarseness

281
Q

what is the goal of assessing a patients thoughts and persceptions during a mental health exam

A

the assess the logic, relevance, organization, and coherence of a patients thought process

282
Q

what are 5 examples of a derranged thought process

A
  1. circumstantial
  2. tangential
  3. flight of ideas
  4. incoherent
  5. echolalia
283
Q

what are circumstantial thoughts? what disorder might they indicate

A

speech with pointless, unnecessary detail

OCD

284
Q

what are tangential thoughts? what disorder might they indicate

A

shifting between unrelated topics

psychotic

285
Q

if a patient was described as having a flight of ideas, what kind of thought process would that describe? What might be the cause

A

non-stop, pressured speech with quickly changing topics

severe schizophrenia

286
Q

what is echolalia? what might it indicate

A

repetition of words and phrases of others

mania, schizophrenia, autism

287
Q

what is a good method to encourage a patient to describe there thought content

A

follow their lead, ask open ended questions

288
Q

what are five terms to describe the content of a patients thoughts

A
  1. complusions
  2. delusions
  3. phobias
  4. anxiety
  5. obessions
289
Q

compulsion

A

a repetitive response to a stimuli

290
Q

obession

A

recurrent, persistant thoughts, feelings, or urges

291
Q

phobias

A

persistent, irrational fears

292
Q

delusions

A

false, fixed beliefs

293
Q

three types of delusion

A
  1. persecutory
  2. grandiose
  3. erotomania
294
Q

persecutory delusion

A

the feeling someone is out to get them

295
Q

grandiose delusions

A

an inflated sense of importance

296
Q

erotomania

A

the delusion that another person is in love with the patient but has not reason to be

297
Q

what are six types of hallucinations

A
  1. auditory
  2. visual
  3. olfactory
  4. gustatory
  5. tactile
  6. somatic
298
Q

what is the most common form of hallucinations

299
Q

how might a patient behave tactile hallucinations

A

an exaggerated reaction to a imagined stimuli (somone touched my head)

300
Q

somatic hallucinations

A

believing your body is filled with parasites

301
Q

what are five ways to examine cognitive function

A
  1. orientation
  2. attention
  3. remote memory
  4. recent memory
  5. new learning ability
302
Q

what are three ways to test attention

A
  1. digital span
  2. serial 7s
  3. spelling backwards
303
Q

how to test remote memory

A

asking to recall past events

304
Q

how to test learning ability

A

give the patient three words to remember, have them repeat the words, then ask them again in 3-5 minutes

305
Q

what are four ways to test higher cognitive function

A
  1. knowledge and vocabulary
  2. calculating ability
  3. abstract thinking
  4. constructional ability
306
Q

what is one way to test abstract cognitive ability

A

ask the patient to define a common proverb

307
Q

what is one way to assess a patients constructional ability

A

ask them to draw a shape or a clock

308
Q

what is the most widely used cognitive test for dementia in the US

A

the mini-mental state exam

309
Q

what are the six factors tested on the mini-mental state exam

A
  1. orientation
  2. recall
  3. attention
  4. calculation
  5. language
  6. constuctional praxis
310
Q

what are two weaknesses of the mini-mental health exam

A
  1. not sensitive to severe or mild dementia
  2. maybe influenced by age, education, language, etc
311
Q

why should to room be dark for opthalmoscopic exam

A

because it promotes pupil dilation and visibility of the fundus

312
Q

G-P-M-L

A

gravida

parity

miscarriages

living

313
Q

gravida

A

the number of pregnancies

314
Q

parity

A

number of deliveries

315
Q

what is the national institute of alcohol abuse and alcoholism definiton of low risk drinking for men, women, and older individuals

A
  1. men no more than 4 drinks on a single day or 14 in a week
  2. women no more than 3 drinks a day or 7 in a week
  3. over the age of 65 with no medications no more than 3 drinks a day or 7 in a week
316
Q

why is fatigue a ambiguous diagnosis

A

because it can be a symptom of a mental disorder (depression, anxiety) but also can be a physical disorder (cancer, infection, diabetes)

317
Q

when would weakness be associated with myopathy or neuropathy

A

when it is localized to a specific neuroanatomical pattern

318
Q

recurrent fever and chills are indicative of what

A

systemic bacteremia

319
Q

what is the suspected cause of rapid weight loss over a few days

A

change in fluid retention, not tissue

320
Q

what are four possible causes of weight loss with relatively stable diet

A
  1. hyperthyroid
  2. DM
  3. malabsorption
  4. bulemia with vomitting
321
Q

what are three example of pathgnomonic faces

A
  1. hyperthyroid bulging staring
  2. immobile face parkinsons
  3. flat affect depression
322
Q

auscultory gap

A

a lag time where heart beats will be heard, stop briefly, then start again during blood pressure recordings

323
Q

what is the risk of an ausculatory gap

A

a very high systolic pressure or a very low diastolic pressure

324
Q

what condition is ausculatory gap associated with

A

atherosclerotic disease

325
Q

what is the benefit of treating isolated systolic hypertension in patients greater than 60 yrs

A

reduction of morbitity and complications from cardiovascular disease

326
Q

what happens if a blood pressure cuff is too small? too large?

A

too small = higher BP

too big = lower BP

327
Q

what are four ways to monitor patient outcomes

A
  1. analgesia
  2. ADLs
  3. adverse effects
  4. abberant drug related behaviors
328
Q

what are four sources of urticaria with no apparent rash

A
  1. dry skin
  2. pregnancy
  3. leukemia
  4. polycythemia vera
329
Q

what is the difference between a blanching and non-blanching lesion

A

blanching lesions are erythematous, non-blanching lesions are vascular bright red or violaceous

330
Q

what are three examples of a non-blanching lesion

A
  1. petechiea
  2. purpura
  3. cherry angioma
331
Q

what can local redness of the skin be indicative of in a bed bound patient

A

nercosis associated with bed sores

332
Q

what is the size division beween petechia and ecchymosis

A

petechia is 1-3mm, ecchymosis is larger than 1 cm

333
Q

annular skin lesion

A

ring shaped with a central clearing

334
Q

nummular

A

circular or coin shaped

335
Q

pendunuclated

A

attached to the skin by a narrow stalk

336
Q

confluent vs coalescing

A

confluent lessions run together

coalescing are distinct lesions that touch

337
Q

follicular lesions

A

involve the hair follice

338
Q

truncal

A

favors the trunk

339
Q

intertriginous

A

affecting the body folds

340
Q

what sort of lesion might be described as honey colored

341
Q

guttate

A

looks like it was dropped with an eye dropper

342
Q

serpiginous

A

snake like

343
Q

eschar

A

a hard darkened plaque usually covering areas of extensive tissue infarcts or gangrene

344
Q

umbilicated

A

lesions with a central indentation

PAS 765 (Clinical Assessment I) (5 decks)

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