Clinical Sciences 550 Fall 2010 Midterm

Front 1

SOAP format of medical documentation
S=
O=
A=
P=

Back 1

S= subjective (chief complaint, med Hx)
O= objective (all exam observations)
A= assessment (diagnosis)
P= plan (treatment, Px instructions)

Front 2

6 parts of ocular examination

Back 2

1. history
2. preliminary testing
3. refraction
4. binocular vision/NP testing
5. ocular health
6. assessment and plan

Front 3

6 parts of ocular history

Back 3

1. Chief Complaint (CC)
2. visual Hx and demands (POHx)
3. Personal medical Hx and ROS
4. Family visual and med Hx
5. social and vocational Hx (SHx)
6. summary

Front 4

Must answer 3 essential questions through history-taking

Back 4

1. Does the patient have a problem?
2. What is the specific problem?
3. What is/or will be the effect of the problem on the patient's activities?

Front 5

symptoms refer to the ________ subjective _________

Back 5

patient's
complaints

Front 6

signs describe _________ ___________

Back 6

objective observations

Front 7

walk _____ patient to the examination room

Back 7

with

Front 8

address older/elderly patients with ____

Back 8

formal names

Front 9

address children by___

Back 9

first name

Front 10

address teenagers/pre-teens

Back 10

with formal name

Front 11

with blind, and non-English-speaking patients...DO NOT
DO

Back 11

increase volume
slow down, check for understanding, ask if they need you to slow down

Front 12

KISS rule

Back 12

Keep It Short and Simple. most patients are at 5th to 8th grade level

Front 13

when recording info during exam...always ______ first, then ______

Back 13

listen first, then record

Front 14

Patient Type: openness
general description:

Back 14

inquistive facial expression
relaxed posture
"open" position of arms and legs

Front 15

Patient Type: closedness
general description

Back 15

crossed or "closed" legs
folded/"closed" arms
tightened muscles/posture
accusatory facial expression

Front 16

Patient Type: anxiety
general description

Back 16

head in fixed position
wide awake/alert appearance
gestures of self-protection, "guarding"
repetitive hand movements

Front 17

Patient Type: anger
general description

Back 17

flushed appearance
tightened, forward posture
directed stare at interviewer
increased respiratory rate
compressed/tightened lips

Front 18

with blind, and non-English-speaking patients...DO NOT
DO

Back 18

increase volume
slow down, check for understanding, ask if they need you to slow down

Front 19

KISS rule

Back 19

Keep It Short and Simple. most patients are at 5th to 8th grade level

Front 20

Patient Type: grief, sorrow, or flat
general description

Back 20

response to loss
slumped posture
half-closed, downcast eyes
downturned mouth, red eyes

Front 21

when recording info during exam...always ______ first, then ______

Back 21

listen first, then record

Front 22

Patient Type: openness
general description:

Back 22

inquistive facial expression
relaxed posture
"open" position of arms and legs

Front 23

Patient Type: closedness
general description

Back 23

crossed or "closed" legs
folded/"closed" arms
tightened muscles/posture
accusatory facial expression

Front 24

Patient Type: anxiety
general description

Back 24

head in fixed position
wide awake/alert appearance
gestures of self-protection, "guarding"
repetitive hand movements

Front 25

Patient Type: anger
general description

Back 25

flushed appearance
tightened, forward posture
directed stare at interviewer
increased respiratory rate
compressed/tightened lips

Front 26

Patient Type: grief, sorrow, or flat
general description

Back 26

response to loss
slumped posture
half-closed, downcast eyes
downturned mouth, red eyes

Front 27

raised eyebrow, pursed lips during examination of patient can be interpreted as

Back 27

being perplexed, as if "I don't understand you", "I can't follow you", "doesn't make sense"

Front 28

head shake generally interpreted by patient as

Back 28

disapproving, unbelievable

Front 29

this type of facilitation is used with more information is needed after patient has stopped...

Back 29

repeating/reflection
Pt "...and then I had this eye pain"
Doc "you had this eye pain?"

Front 30

this type of facilitation is used when a word is ambiguous or confusing

Back 30

clarification
Doc "tell me what you mean by..."

Front 31

type of facilitationg that involves recognizing and acknowledging a person's feelings..

Back 31

empathy
Doc "This must by very difficult for you"

Front 32

type of facilitation that involves observation or statement to show discrepanciese, especially in affect

Back 32

confrontation
Doc: "You smile when you tell me that your mother passed away"

Front 33

type of facilitation that is based not upon observation but rather upon inference, linking statements to imply cause

Back 33

interpretation
Doc "It seems that every time you wear your contact lenses, your eyes are crusted the next morning"

Front 34

type of facilitation that involves why a question is going to be asked or has been asked

Back 34

explanation
Doc "when the eyes are this red for this long, we need to ask questions about your activities and symptoms in other areas of the body"

Front 35

these types of questions are unstructured, undirected

Back 35

open-ended questions
i.e. start with "what, when, where, how"

Front 36

these types of questions are structured, directed "yes, no"

Back 36

closed questions
i.e. start with "do you... does anyone, are you?"

Front 37

this question-type focuses on specific information

Back 37

direct question (short answer)
direct open "what type of activities do you do at work?"
direct closed "are you currently working?"

Front 38

this question-type involves open-ended questions that do not sound like a question

Back 38

indirect question
i.e. your glasses are very heavy, that must cause you difficulty in school

Front 39

double barreled question type

Back 39

compound question

AVOID

Front 40

laundry list question type

Back 40

multiple choice questioning
use when patients need help narrowing down choices

Front 41

this question-type suggests the "correct answer"

Back 41

leading question

AVOID

Front 42

this question-type is asked in a way that information is given as to why a question was asked

Back 42

informing question

i.e. this medication is usually taken for _____ is that why you are taking it?

Front 43

question-type that is used to confirm meaning and accuracy. involves both observation and interpretation of cues

Back 43

validation question

i.e. you seem worried about those findings

Front 44

question-type that acknowledges your observation and asks "what would the Pt like?"

Back 44

acknowledging questions

i.e. "you are nervous about this test. anything i can to to make it more comfortable?

Front 45

Pt question-types for doctor (4 types)

Back 45

1. clarification (know basics behind conditions)
2. information (know reasons behind treatments/tests)
3. personal questions (avoid, get back on track)
4. manipulations (get back on track)

Front 46

10 Traps of Interviewing:
"Don't worry I'm sure it will be all right" is an example of

Back 46

providing assurance or reassurance

Front 47

10 Traps of Interviewing:
"If i were you, I'd do..." example of?

Back 47

giving advice

**this increases your liability

Front 48

10 Traps of Interviewing:
"Your doctor knows best" example of?

Back 48

using authority

**promotes feeling of Pt inferiority

Front 49

10 Traps of Interviewing:
"...passed on..."

Back 49

using euphemisms or language or avoidance

**avoids reality..use "died"

Front 50

10 Traps of Interviewing:
"We find..." or "We as doctors find that..." is an example of

Back 50

engaging and distancing

"we" implies the whole office

Front 51

10 Traps of Interviewing:
Using "myopic" instead of "nearsighted"

Back 51

use of professional jargon

**excludes patients, talking over their head

Front 52

definition of lenticular

Back 52

having to do with the lens

Front 53

10 Traps of Interviewing:
"You don't smoke, do you?" is an example of

Back 53

leading or biased questions

**AVOID, judgmental

Front 54

10 Traps of Interviewing:
When patient loses train of thought because of explanations from doc

Back 54

talking/teaching during history

Front 55

10 Traps of Interviewing:
Cutting patient off during history, chief complaint

Back 55

interrupting

**discourages elaboration, may miss vital information

Front 56

10 Traps of Interviewing:
implies blame, condemnation

Back 56

using "why" questions