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138 Cards in this Set
- Front
- Back
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History, Physical and Communication
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Aug 9
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How do you not the patients chief complaint?
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In the patients own words
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SOAP note
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-method of documenting patient visit
Subjective Objective Assesment Plan |
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Subjective
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1. Chief complaint
2. History of Present Illness (OLDCAARTS), Past medical history (MIIMASH), family history and social history (SHORES) 3. Get a full history of new patients and focused on returning patients |
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Histroy of Present Illness (HPI)
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OLDCAARTS
Onset Location Duration Charachter Associated and Aggravating factors Relieving factors Temporal Severity |
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Past Medical History
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MIIMASH
Medications Immunizations Injuries Medical illnesses Allergies Surgeries Hospitalizations |
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Social History
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SHORES
Safety at home Hobbies (smoking, drinking, ect) Occupation Religion Environment Sexual relationship |
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Objective
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vitals
physical exam physiological data x-rays lab results |
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Assesment
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differential diagnosis
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Plan
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therapy (meds and procedures)
Investigations referrals patient education |
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Cardinal Principles to Exam
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1. Inspection
- begins when you walk in room - most productive exam method - dependant on konwledge of physician 2. Palpatation - evaluate for tenderness, texture, temperature, tone, masses 3. Percussion - surface of the bdy is struc to emit sounds that vary in intensity according to the density of underlying tissue - tympanic, resonant, flat 4. Auscultation - heart sounds, vocal sounds, vessels sounds, lung/breath sounds, abdominal sounds |
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7 Essential elements to communication
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1. open discussion
2. build the relationship 3. gather information 4. understands the patients perspective 5. share information 6. reach agreement on problems and plans 7. provide closure |
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Process for arriving at a diagnosis
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1. recognize patterns
2. sampling the universe - testing 3. algorithms 4. hypothesis generation and testing |
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2 types of medical records
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1. Source oriented
2. Problem oriented |
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Source Oriented medical record
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- information filed as it comes in
- no table of contents - difficult to find information |
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Problem Oriented medical record
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- 4 elements
1. Data base - past and present history - review of systems - physical exam - physiological data and lab -consults 2. Problem list - a comprehensive list of the patient's past and present health - divided into acute and chronic 3. Progess Note - write each visit - contains SOAP note 4. Initial Plan - diagnostic test - therapeutic treatment - patient education |
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7 elements of communication
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1. open the discussion
2. build the relationship 3. gather information 4. understand the patients perspective 5. share information 6. reach agreement on problems and plans 7. provide closure |
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Acculturation
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process by which an individual accommodates to the traits and behaviors of another culture
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Culture
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a complex, integrated system reflecting the whole of human behavior and experience: a group's adoption of shared values, the attempt to make sense of their world
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Custom
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habitual activity of a group or subgroup: patterned responses to given occasions, generally passed on from one generation to the next
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Enculturation
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process by which an individual assumes the traits and behaviors of a given culture, adapting to it, adopting its values, and taking on that particular cultural identity
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Ethnocentrism
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belief in the superiority of one's own group and culture, combined with disdain for other groups and cultures. Any degree of enthnocentrism impairs effort to understand patients within the context of their individual cultures
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Ethnos (ethnic group)
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group of the same race or nationality, with a common culture and distinctive traits
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Minority
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group that is differnt from the majority of a population, as with regard to religion, race, or thnic origin. When the difference is deep-seated in historical relationships or is obvious, the minority group may be treated unjustly, sometimes obviously, sometimes subtly
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Norm
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prescribed standard of allowable behavior within a group or subgroup. to the extent that individuals adopt the positive values of their group or groups, and to the extent that they measure up to the norms, theyare judged favorably or unfavorably by the other members of the group
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Race
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physical, not a cultural, differentiator based on a common heredity, using as identifer characteristics such as skin color, head shape, and stature
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Rite
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prescribed, formal, customary observance
-ex: ceremonial religious act or graduation |
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Ritual
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stereotypic behavior regulating religioous, social, and professional behaviors in a variety of situation
- ex: please and thank you |
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Stereotype
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simplified, generally inflexible conception of the members of a group or subgroup
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subculture
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group or subgroup having values and behavioral patterns or other distinvtive traits that differentiate it from other groups or subgroups iwhin a larger culture. Individuals may share the traits of more than one group or subgroup and may with adatation, shed some traits and adopt others
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values
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ideals, customs, institutions, and behaviors within a group or subgroup for which the members of the group have a respectful regard. Values may be positive or negative and desirable or undesirable
- ex: with regard to charitable donation or criminal behavior/consesnual sexual relationships or rape |
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Developing Cultural Competence
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1. recognize that cultural diversity exists
2. respect patients as unique individuals 3. respect the unfamiliar 4. identify, examine, and discipline your own attitudes, biases, and beliefs if you are to work successfully with others 5. recognize that some cultural groups have definitions of health and illness, and practices that attempt to promote health and cure illness, that may differe from you own 6. be willing to modify health care delivery in keeping with the patient's cultural background it is better to mediate than to be coercive 7. do NOT expect all members of one cultural group to behave in exactly the same way 8. appreciate that each person's cultural values are ingrained and therefore very difficult to change |
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Understanding the patient's perspective on their health/healthcare
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ETHNIC
Explanation - what do you think may be the reason you have this problem? Treatment - what kins of medicines, home remedies or other treatments have you tried for this illness? Healers - have you sought out alternative or folk healers? Negoiate - Try to find options that will be mutually acceptable to you and your patient and that incorporate the patient's beliefs, rather than contradicting them Intervention - determine an intervention with your patient that may incorporate alternative treatments/healers Collaboration - collaborate with the patient, patients' family, and other health care team members |
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Growth and Development/ Pain Assessment
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2011
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Giantism
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excess growth hormone in Children
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Acromegaly
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excess growth hormones in Adults
- growth plates are closed so there is not further long bone growth but instead there is bone thickening leading to "coarse" features |
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BMI
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Weight(kg) / Height^2 (m^2)
Weight(lb) * 703 / height^2(in^2) |
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BMI measurements
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- undernutrition < 18.5
- Appropriate 18.5 - 24.9 - overweight 25 - 29.9 - obese 30 - 39.9 - extreme obesity > 40 |
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How to measure BMI
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- measure patients withOUT shoes and heavy clothing
- infants should be weighed on an infant scale, lying down - weight fluxuates over the course of a day, you may need to measure multiple times per day to track changes |
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Infants length measurement
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should be taken lying down until 2 years of age
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True or False
Growth rates should be recorded regularly on a growth chart |
True
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Head Circumference
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- tape goes around occipital prominence and the supraorbital promience
- should be measured every visit until 2 years of age - track on growth chart - high rate of growth in head circumference is associated with increased intracranial pressure or hydrocephalus |
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Gestational Age
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Preterm < 37 wks
Term 37 - 41 wks Postterm >41 wks |
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Sexual Maturity Rating (SMR)
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- usually based on Tanner criteria looking at development of secondary sex characteristics
- breast development, pubic hair, penis/scrotum |
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tanner criteria
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Tanner 1 - prepubertal
Tanner 4 - well developed but "not quite adult" Tanner 5 - normal adult characteristics |
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Puberty: FEMALE
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- breast buds (thelarche) usually first sign for most
- growth spurt 1 year before menarche - growth spirt occur earlier than boys |
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Puberty: MALE
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enlargement of scrotum/testis above 2 cm usually first sign
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Precocious Puberty
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- early onset of puberty
- before 6 - 7 in females - before 9 in males - may be related to endrocrine disorder |
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Pain Assessment
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- JCAHO requires that all patients be assed for pain
- pain is ver subjective to both the patient and the physician - interpretation of age depends on age, emotion, cultural background, sleep deprivation, and previous pain experience - visceral pain is often more diffuse and dull. Somtaic pain is generally sharper and well localized |
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Skin
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2011
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Functions of skin
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1. physical protection from environment
2. prevent body fluid loss 3. insulation 4. production of vit D precursors 5. regulation of body temp 6. provide sensory protection 7. excretion of waste (sweat, urea, lactiv acid) 8. contribute to BP regulation 9. Express emotion |
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Layers of skin
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1. Epidermis
- avascular a. S. Corneum b. S. Basale 2. Dermis -vascular CT layer, contains sensory nerves and autonomic motor fibers 3. Hypodermis - fatty CT layer, generates heat and provides insulation which prevents hypothermea |
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Types of Glands
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1. Eccrine glands (sweat)
2. Sebaceous glands 3. Apocrine glands |
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Eccrine glands
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sweat glands
- regulate body temperature - only places they are NOT located - lip margins - eardrums - nail beds - inner surface of prepuce - glands of penis |
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Sebaceous glands
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- produce oily sebum which keeps hair and skin from drying out
- secretions are stimulated by testosterone |
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Apocrine gland
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- secrete sticky white substance in response to emotion
- secretions are odorless but bacterial decomposition of these causes characteristic body odor - located in the - axilla - nipples - areola - anogenital area - eyelids - external ear |
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Hair
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1. Lanugo (infant)
2. Vellus (adult) 3. Terminal (adults) |
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Lanugo hair
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fine silky hair over shoulders and back of newborns. it is often shed in 10 - 14 days
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Vellus hair
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adult
- short, fine, soft, and nonpigmented |
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Terminal hair
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adult
- coarse, longer, thicker and pigmented |
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Nails
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- Ungus or Onchos
- Parts - nail plate - paronychium - soft tissue surrounding the nail border - Lunula - round white area, marks the end of the anil matrix, the site of nail growth - Eponychium - (cuticle) an extension of the epidermis over the proximal part of the nail body - proximal nail fold |
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Specifica Population
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1. Infants
2. Adolescence 3. Pregnancy 4. Elderly |
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Infants
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- Vernix caseosa- mixture of sebum and cornified epidermis covers the infant at birth
- Lanugo present for 10-14 days after birth - Terminal hair abscent at birth - subcutaneous fat is poorly developed - eccrine glands do NOT function - cutis marmorata- mottled appearance to the skin as a result of changes in ambient temperature Milia - small white papule that commonly occurs on the face of a newborn |
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Adolescence
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- apocrine glands enlarge and become active
- increased sebaceous gland activity - terminal hair appears in the axilla and pubic areas of both sexes as well as on the face of males |
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Pregnancy
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- increased blood flow to the skin
- vascular lesions such as hemangiomas and vascular spiders increase in size - increased eccrine and sebaceous gland activity - skin thickens and increased subcutaneous fat - increased pigmentation of the face, nipples, areola, axilla and vulva |
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Elderly
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- eccrine and sabaceous gland activity decrease
- epidermis thins and is less elastic - decreased numbers of melanocytes - transitio from terminal to vellus hair on scalp |
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Symptoms of Skin Disease
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- rashes, new lesions, changes in lesions, itiching, changes in color or texture of skin, changes in nails
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Flat Lesions
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1. Macule
2. Patch |
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Macule
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- flat lesion circumscribed area of change < 1cm diameter
ex: freckles |
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Patch
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- flat lesion circumsribed area > 1 cm
ex: cafe au lait spot, vitiligo |
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Solid elevated lesions
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1. Papule
2. Nodule 3. Tumor 4. Plaque 5. Wheal |
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Papule
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- raised, firm lesion, < 1 cm in diameter
ex: warts (verruca) |
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Nodule
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- raised, firm lesion, 1 - 2 cm in diameter
ex: erythema nodosum |
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Tumor
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- raised, firm lesion, > 2 cm in diameter
ex: neoplasm |
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Plaque
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- rasied, solid lesion with a flat topped rough surface, > 1cm in diameter. Usually large surface area relative to height
ex: psoriasis |
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Wheal
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- raised, solid lesion, transient with irregular shaped area of cutaneous edema with variable diameter
ex: hives, insect bites |
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Fluid Filled Elevated Lesions
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1. Vesicle
2. Bulla |
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Vesicle
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- raised, circumscribed, superficial, filled with serous fluid, < 1 cm
ex: varicella (chx pox) |
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Bulla
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- vesicle > 1 cm, superficial
ex: blister |
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Purulent Elevated Lesion
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1. Pustule
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Pustule
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raised, superfiscial, filled with purulent fluid, < 1 cm
ex: acne |
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Cyst
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raised, circumscribed, well encapusulated in dermis or subcutaneous layer, filled with liquid or semi-solid material
ex: sabaceous cyst, cystic acne |
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Abscess
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accumulation of purulent material in the dermis or subcutaneous layer surrounded by inflamed tissues
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Comedo
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- plug of sebum and keratin in the opening of a hair follicle
1. black head- comedo with a dialated follicle opening 2. White head - comedo with a closed follicle opening |
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Furuncle
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- acute localized staphylococcal infection. Starts as a perifollicular abscess which spreads to surrounding tissue producing a pustule with surrounding inflammation
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Carbuncle
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a coalescence of several furuncles
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Secondary Lesions
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arise from changes in primary lesions
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2 lesions below the skin plane
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1. erosion
2. ulcer 3. fissure 4. excoriation |
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Erosion
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loss of epidermis, depressed, moist, glistening; caused by rupture of vesicle or bulla
ex; varicells (chx pox) |
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Ulcer
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loss of epidermis and dermis; concave shape
- athletes foot |
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Excoriation
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trauma causes loss of epidermis; linear, hollowed out area
ex; abrasion or scratch |
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2 Lesions above the skin plane
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1. scaling
2. crusting 3. lichenification 4. scarring 5. keloid |
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Scaling
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- shedding of S. Corneum layer of keratinized cells; flaky ski, irregular borders, thick or thin, dry or oily
ex: seborrheic dermatitis |
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Crusting
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- Dried serum, pus, or blood on the skin; slightly elevated; size and color vary
ex: scab on abrasion |
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Lichenification
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- thickening and roughening of epidermis secondary to rubbing itching or skin irritaiton
ex: chronic dermatitis |
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Scarring
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- replacement of ormal tissue with fibrous CT following and injury to the dermis
ex: healed wound |
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Keloid
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- irregularly shapped, progressively enlarging, hypertrophied scar that grows beyound the boundaries of the wound
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2 lesions miscellaneous
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1. sclerosis
2. atrophy |
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slerosis
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diffuse or circumbscribed hardening of the skin
ex: scleroderma |
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Atrophy
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thinning of the epidermis and loss of skin markings; skin may appear translucent and paper like
ex: striae |
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Shapes of Lesions
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1. Round/Discoid- disk shaped without central clearing
2. Annular - ring shaped; round active margins with central clearing - erythematous border surrounding a cleared area of lighter skin - associated with Tinea (fungus) 3. Arcuate - partial rings 4. Reticulated - lace like 5. Serpiginous - snake like or wavy line tract 6. linear - line 7. Iris (target lesion) - circle within a circle |
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Vascular Lesions
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- Blanchable
1. Erythema 2. Spider hemangioma 3. Telangiectasia 4. Capillary hemangioma (nevus flammeus) - non blanchable 1. petechiae 2. purpura 3. ecchymosis (bruise) 4. Venous star |
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Erythema
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- pink or red blanchable discoloration due to dialated blood vessels
ex: sunburn |
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Spider hemangioma
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- red central body with radiating spider like legs; arterial origin, blanchable
- caused by liver disease, vit b deficiency or idiopathic |
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Telangiectasia
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- fine, irregular red lines due to dilation of venules. when blanced refill erratically
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Capillary hemangioma (nevus flammeus)
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- red, irregular, macular or patches caused by dialation of dermal capillaries
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Petechiae
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- red-purple nonblanchable, < 0.5cm diameter
- caused by intravascular defects |
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Purpura
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red-purple, nonblanchable, > 0.5 cm diameter
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Ecchymosis (bruise)
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red-purple nonblanchable lesion of variable size due to vascular destruction or vasculitis
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Venous star
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bluish spider, linear or irregulary shaped, nonblanchable
- caused by increased pressure in superficial veins |
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Normal Moles
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Color - uniform tan or brown
Shape- round or oval w/ well defined border Surface- flat, smooth spot, may become raised Size - < 6 mm Number - 10 - 40 scattered Location - most above the waist on sun exposed areas |
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Dysplastic Moles
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Color- mixture of tan, brown, black and red/pink moles on oner person
Shape - irregular borders, may fade into surrounding skin Surface - smooth, slighlty scaly, or rough irregular, "pebble" appearance Size - > 6 mm Number - may not increase or be > 100 Location - may occur anywhere but often on back, or below waist |
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Malignant Melanoma
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- cancer of melanocytes
- majority are new lesions; less than have come from existing nevi - prone to metastasis - should be suspected in anynew or changing nevus which meets the criteria of the ABCDE rule |
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ABCDE rule for melanoma
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Asymmetry
Borders Color Diameter Evolution |
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Nails
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naild bed color should be variations of pink under normal conditions
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Specific Nail Pathologies
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1. clubbing
2. lindsay's nails 3. terry nails 4. mee's line 5. beau's line 6. nail pitting 7. tic habit 8. spoon nail 9. tinea unguium 10. black or dark pigmented bands in nail |
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Clubbing
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if the angle approaches or exceeds 180 and the distal finger appears thickened and enlarge.
- associated with 1. cardiovascular 2. respiratory disease |
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Lindsay's Nail
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proximal half white, distal half pink
- associated with renal disease |
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Terry nails
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wihite except for a narrow zone at the distal tip
- associated with cirrhosis and hypoalbuminemia |
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Mee's line
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- transverse white lines across the nail
- associated with acute illness or heavy metal poisoning |
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Beau's Line
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- transverse depression where stress or illness temporarily interrupts nail growth
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Nail Pitting
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- associated with psoriasis
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tic habit
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a central band of sharp horizontal grooving extending to the tip of the nail
- associated with nail biting or picking |
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Spoon nail
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- central depression of the nail with lateral elevation of the nail plate produces a spoon like appearance
- associated with iron deficiency anemia, syphilis and hypothyroidism |
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Tinea Unguium
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fungal infection caused by dermatophytes. Yellow, brittle nail with oncholysis. Nails often break or crumble
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Black or dark pigmented bands in nail
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- history is very important
- a single black nail that suddenly appears and is painless, must consider MELANOMA - pigmented bands may be benign in persons with very dark skin, but very abnormal in caucasions - if assocaiated with trauma history and pain, consider subungal hematoma - painless green black discoloration, consider Pseudomonas infection |
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Communication Components
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- sept 13
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7 Essential elements of healthcare communication
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1. build the relationship
2. open the discussion 3. gather information 4. understand the patient's perspective 5. share information 6. reach agreement on problems and plans 7. provide closure |
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3 elements to Share Information
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1. relationship building
2. avoid medical jargon 3. elicit beliefs, concerns, questions, expectations about the illness and treatment. |
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Ask Tell Ask
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a great way to share information
- alternate b/w telling small amounts of information - check for understanding - ask how information will affect them 1. Ask to assess patient needs 2. Tell Information 3. Ask |
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Reach Agreement
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- present options where they exist
- elicit the patient's thoughts about options, offer opinion or advice - acknowledge agreements/disagreements - calidate the patient's right to make choices - integrate patient's feelings and preferences - avoid overwhelming the patient or pushing for a quick decision |
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Provide Closure
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- content closure
- personal closure |
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Counseling Patient Education
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9/20/11
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Collaborative Care
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- want self efficacy
- share agenda - behavior change comes from self management - patient and physician make goals together |
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Transtheoretical Model of Change
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- precontemplation - unaware of risks from behavior
- Contemplation - risks of benefits are actively being compared but no change has been made - Preparation - risks are preceived as greater than benefits - action - attempts to change behaviors are made - maintenance - continuing the change in behavior |
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Keller/White Model
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- 4 quadrants
X axis 1. Helplessness 2. Powerful Y axis 1. Ambivalent 2. Convinced - reaching each quadrant is based upon CONVICTION and CONFIDENCE 1. High Conviction - patient knows the importance of making a change 2. Low Conviction - patient does NOT think it is important to make a change - provide info, give options 1. High Confidence- patient thinks that they are able to make changes 2. Low Confidence - patient does not think they can make a change - review successful past experience, encourage small steps, teach problem solving and coping skills |
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5 A's of Counseling Patients
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1. Assess risk, past behaviors, readiness, convition and confidence
2. Advise and inform 3. Agree on goals and methods 4. Assist in overcoming barriers 5. Arrange follow up |
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Thearpeutic Triange
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Physican, Patient, EMR
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