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25 Cards in this Set
- Front
- Back
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Define Physical Diagnosis:
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“The determination of the nature of a disease made by means of physical measures such as inspection, palpation, percussion and auscultation”
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What are the steps used to arrive to a diagnosis?
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Recognizing patterns
Sampling the universe Using algorithms Hypothesis Generation and testing |
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Hypothesis Generation using Critical Thinking
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Information gathering
Organization of Information Assessment of Information Hypothesis formation Use probability and utility when sequencing hypothesis testing |
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What is the primary method to generate a diagnosis?
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The clinical examination can and should be based on empirical evidence of the predictive value of signs and symptoms used in diagnostic reasoning.
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What is included in a rapport
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Appearance
Attitude Respect Concern Kindness Sincerity Caring Confidentiality Communications |
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What is the best way to preserve the patient's dignity?
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Make sure the patient is properly draped. Avoid long waits.
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What is the diagnostic algorithm used?
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Baysian tree calculation
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What is the most important part of a patient's diagnosis?
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THE HISTORY!
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What is the order of interviewing a patient?
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1) Gather chief complaint
2) OLD CAARTS 3) MII MASH 4) Family history 5) SHORES 6) Review systems 7) Recap |
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What is the difference between a full and focused interview?
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Full interview is done when a new patient comes in. This is when the full history is taken.
A focused history is done when the patient needs immediate assistance or is a returning patient. |
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What are the cardinal principles of physical evaluation?
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Inspection
Auscultation Percussion Palpation |
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What do you palpate for?
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Temperature
Texture Tenderness Tone Mass |
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What is the exam sequence?
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Generally divided by symptoms
Adjusted for patient position Discuss findings as you go |
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The Exam: Patient Seated
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General appearance
Vital signs Skin, hair, nails HENNT Extremities Parts of the neurological exam and musculoskeletal exam |
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THE EXAM: seated and EXPOSED
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Thorax and breasts
Heart Lungs Parts of the structural and musculoskeletal exam |
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THE EXAM: Patient SUPINE
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Vessels, pulses
Precordium and supine cardiac exam Abdomen Parts of musculoskeletal exam External genitalia |
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THE EXAM: Patient STANDING
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Spine
Body habitus Parts of musculoskeletal exam Parts of neurologic exam Hernia/male genital exam Rectal exam |
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THE EXAM: Special Circumstances
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Infants
Children Adolescents Disabled Elderly Cultural differences Health literacy Challenging patients |
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THE ASSESSMENT
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This is your “Differential Diagnosis” section
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THE PLAN
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Diagnostic resources
Therapeutic procedures Referrals Patient education Follow up plan The plan should reflect a response to your assessment! |
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A complete history and physical will include all of the following steps:
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Chief Complaint
History of Present Illness (OLDCARTS) MIIMASH Family History SHORES Vital Signs Head to Toe Physical Exam Assessment Plan |
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What is important about "bedside manner"?
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“Bedside manner” has long been at the forefront of how people choose their doctors.
“Bedside manner” was in the popular lexicon decades before it was picked up as a professional issue warranting research and curricular change |
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What are "The Seven Osteopathic Medical Core Competencies"?
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Osteopathic Philosophy and OMT
Medical Knowledge Osteopathic Patient Care Interpersonal and Communication Skills Professionalism Practice-Based Learning and Improvement Systems-Based Practice |
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What are the essential elements of healthcare communication?
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Open the Discussion
Build the Relationship Gather Information Understand the Patient’s Perspective Share Information Reach Agreement on Problems and Plans Provide Closure |
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Why is an electronic health record important?
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Government mandate “meaningful use”
Patient safety Health care portals Data mining |
