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184 Cards in this Set
- Front
- Back
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self serving bias is usually…
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unintentional and unconcious
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meniscus shape.
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pleural effusion
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what are the 6 ethical obligations of a physician
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CRAPpINg. 1. consent 2. respect 3. non-abondment 4. patient privacy 5. best interest 6. no harm
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in a situation of crisis what changes and what doesn't change
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1. ethics do not change 2. standard of care is what a reasonable physician would do *can't change DNR to do not treat
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physical findings most consistent with pneumonia
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crackles at base of lung, egophony, whispered pectirlocly, dullness of percussion, postive tactile fremitus
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positive tactile fremitus
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pneumonia
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infiltration of lower lobe of left lung. Where most likely hear crackles?
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posterior thorax left of midline at 8th thoracic vertebral body
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hear mitral regurge where?
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holocystolic murmur at the apex
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congestive heart failure due to dilated cardiomyopathy signs
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prominent S3, lateral displacmeen of PMI, JVP 10, crackles at the base, diminished pulses (1+)
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jugular venous pressure
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jugular vein multiple pulsations, changes with position, reflects right atrial pressure, not palpable
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aortic regurge hearing location
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apex and right sternal border
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mitral stenosis hearing location
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does not radiate
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aortic stenosis hearing location
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carotid and left sternal border
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mitral regurge hearing location
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axilla
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large majority of cases reporting pain cardiogenic?
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false! Most are muscoskeletal
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palpatation due to normal sinus tach
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caffeine, pregnancy, chronic dehydration, nervousness
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palpatation due to cardiac complication
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hx of heart disease, duration of symptoms greater than 5 min, irregular heart beat
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lung field
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RIGHT has 3 lung fields, right upper (front), middle (front), and lower (back) LEFT has 2 lung field, left upper (front) and left lower (back)
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spinous process of T3 marker for…
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marker from where left upper and lower differentiate at the back, right upper and lower a tiny bit lower than this (according to the picture)
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tachypnea
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respiration greater than 20
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clubbing sign of?
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heart failure, HTN
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difference b/w broncho + vesicular breath souns
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bronchial - over large airways, vesicular over lungs
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hearing bronchial airsounds over lung parenchyma sign of…
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pneumonia
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mirror on same or opposite side as light?
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same side
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once it is already focused move head, light, or patient?
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patient!!
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increased AP diameter
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emphysema
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neck mass on kid
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most likely infectious or congenital
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neck mass on adult
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most likely to be neoplastic
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tachypnea
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respiration greater than 20
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hyperventilation
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respiration greater than 20 and deep
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varying periods of increasing depth interspersed with apnea
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cheynes stockes breathing
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webber: right louder than left, rhine - right side bone better than ear, left air better than bone
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conductive on the right
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bone greater than air in rinne test considered…
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conductive hearing loss
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air greater than bone
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normal
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cardiovascular risk factors
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menopause, obese, dm, high cholesterol, htn, atherosclerosis, depressed
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soap note: assessment for acute problem
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statement of problem, ddx, clinical reasoning
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soap note: assessment for chronic problem
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statement of problem, status, clinical reasoning
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exhaustive vs. deductive method
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exhaustive: ask every single thing, deductive: IVINDICATE METHOD
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deductive
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initial clues, early hypothesis in head, working diagnosis, narrow list down with I VINDICATE AID
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soap note: first paragraph of subjective
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CC and HPI
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soap note: second paragraph of subjective
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social history, revelant ROS, past medical history, family history
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soap note: two components of objective
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1. physical exam 2. write order by organ system not by order in which exam was completed
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do you write your physical exam same order in which you do it?
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no
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soap note: plan
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1. diagnostic (diagnosis) 2. therapeutics 3. patient education 4. followup
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good oral presentation (5 components)
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1. convince them of assessment 2. less than 10 minutes 3. maintain same order as write up 4. minimize excess verbage 5. coherent and formal
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medical student offers textbook but it is given by pharmaceutal company but they didn't know that. Conflict?
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conflict! Gift giving!! Bad! Unconcious even if you don't know
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pay for funds to travel and speak about topic. Even if you are the best in the field. Conflight?
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conflict
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do a trial in which they would give patients ipods who participate. Conflict? Iphone coersive
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conflict
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reduce conflict of interest
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1. eliminate gifts 2. no speakers bureau 3. no consulting contracts needed for drug discovey 4. drug makers shouldn't give $$ to medical
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consulting contracts for doctors. Conflict?
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Not a conflict, still need them for drug discovery
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doing more surgeries for more $$, letting residents instead of you saying patients because need to learn, spending resource on someone who will die anyway are all examples of?
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ethical dilemmas you will face as doctors
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one thing a doctor always has to do when there is a conflict
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act in the best interest of the patient
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is someone tries to convince you by saying they are a key opinion leader
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KOL don't take the money it is a scam, bias asscociated?
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pharm companies pay for money/gas for participants vs iphone
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money/gas justifiable. iphone not it is a conflict. Iphone coersive
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drug companies + physicians agreed on 2 things which are:
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1. develop drugs and techniques to help ppl 2. usually both have altrustic response to patients
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study that the drug company sponsored grand rounds and doctors didn't even know showed that…
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bias unintentnial and unconcious, no way to avoid it
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ppl respond to proposition depending on
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1. desirable "can I believe this" 2. threatining " must I believe this"
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anchoring bias
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first thing you learn is the hardest to change, when someone teaching it to you first you are going to have a bias to it!!
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is all bias self serving
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yes!
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ways to reduce bias
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1. no gifts 2. vouchers for drugs rather than samples 3. doctors shouldn't be on pharmaceutical company formurarly boards
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why do you need rules against bias
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maintain public trust
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how does policy affect bias?
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policy DOES NOT affect bias
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can you eliminate bias by training doctors on how to look for and prevent bias?
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no!
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can you eliminate bias by decreasing gift size?
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no!
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when do conflicts of interest occur
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when physicians have motives or are in situations for which reasonable observers could counclude that the moral requirements of the physicians roles are or will be compromised
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why you should have rules against conflict of interest
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1. prevent detrimental physician/industry interaction (usually have neg effects on clinical care) 2. disclosure inadequate safeguard 3. prevent potential bias 4. prevent perception of bias
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why shouldn't you have rules against confict of interest?
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1. prolong human suffering 2. inhibit communication 3. disrespectful to patient/research 4. cost time and money 5. inhibit establishment of new companies
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history of angina
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1. reproducible 2. last more than 15 min 3. pain squeezing tighting 3. repdocued by rest
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unstable angina
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1. angina at rest, rapidly accelerating, new
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stable angina
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1. reproducible on exertion@ predictable workload
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silent ischemia
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DM (due to neuropathy - no pain but low exercise intolerance, fatigue)
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atypical ischemia
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woman, old, heart failure
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ddx for chest pain
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1. muscokeletal 2. heart 3. GI 4. pyschogenic 5. undetermined 6. lung - least likely is PE
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cardiovascular risk factors
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MAC BODD - menopause, atherosclerois, coronary artery disease, blood pressure (HTN), obesity, depression, diabetes
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social history for cardiovascular
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lack of excersice, tobbacco, smoke, stress, socioeconomic
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normal range for pulse
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50-90
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normal change when stand up
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555 heart up 5, systolic down 5, diastolic up 5
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orthostatisic
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heart up 20, systolic down 20, diastolic up 10
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sound heart over valve
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murmur
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sound over vessel
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bruit
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palpable over vessel
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thrill
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head in diastole, heard at left sternal border with diaphgram, apex or right sternal border, blowing
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aortic regurgitation
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heard in systole, at base, with diaphgram, course sound
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aortic stenosis
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bell listen with
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mitral stenosis
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pulse of 4
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bounding
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pulse of 0
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absent pulse
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S1
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mitral and tricuspid closing
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S2
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aortic and pulmonic closing
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S4
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signifies late filling
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S3
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best heard near apex in lateral cubitus, heart failure, low intensitity
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S2 split normal? When?
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yes! On inspiration. At the base
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where listen to S1
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apex
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where listen to S2
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base
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peripheral vascular disease
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B politically correct 4r class. Bruit, pulses decreased, cool extremities, s4, risk factors, for development, claudication
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hear S3 better?
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lateral decubitus position
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hear aortic better
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lean forward
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neck - pulse that varies with respiration and position
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internal jugular vein
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1 pulse per beat + palpable
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carotid artery
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sternal agnle
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notch b/w manubrium + sternum
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sternal angle meets sternum
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2nd intercostal cartilage
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internal jugular vein above/below/parallel to SCM
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below
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normal PMI size
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less than 1 cm
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normal PMI longer or shorter than systole
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shorter
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normal PMI corresponds to JVP or carotid
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carotid
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location of PMI
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5th intercostal space midclavicular line
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heave
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stronger PMI
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lift
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additional impulse of PMI (extra beat)
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blowing sound
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regurge
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coarse sound
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aortic stenosis
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rumbling sound
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mitral stenosis
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which one doesn't radiate hearing
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mitral stenosis
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radiation left axilla, quality blowing, left lower sternal border, listen with diaphgram during systole
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tricuspid regurge - looks exactly like aortic regurge except during systole (AR during diastole)
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no murmur
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grade 0 murmur
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not heard immediately
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grade 1
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quiet immediately audible
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grade 2 murmur
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loud murmur
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grade 3
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loud with faint thrill
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grade 4
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audible with scope partially off chest
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grade 5
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audible withs cope off chest, thrill visible
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grade 6
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someone at 30 degree and don't see JVP what should you do?
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lower bed
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why would you get a false positive on JVP?
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patient holding breath
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congestive heart failure
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crackles, dyspnea, orthopnea, S3, change in PMI, lower extremity edema
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individual judgement of what is fair based on?
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self interest
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highest or lowest point of pulsation when measure JVP?
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highest
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domestic violence
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violence b/w intimates, caretaker to elder, sex assaults, stalking, threats, deprivation, intimadation
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how you know success in dealing with someone who was domestically abused
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1. reduce isolation 2. improve safety 3. improve health 4. sees as safe person 5. she know you can come back
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how many times ask for them to disclose violence?
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6 to 8 times
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never ask about DV when
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1. someone else there 2. unsafe for patient/doctor 3. family member acting as interpreter
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how to phrase asking domestic violence
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because DV is so common I ask all of my pts is domestic violence a problem you have faced?
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follow up question if they say no to DV
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be specific: have you ever been kicked, slapped, bunched, etc etc
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when you suspect DV and they say no.
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lambs say boh - listen believe affirm offer help
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if suspect suicidal
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hold them until psych eval
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patient admits to abuse what are next steps?
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1. refer to advocate 2. if emergency keep her until psych eval if suicidal 3. at subsequent appts ask - counseling or support group/escalation/develop safety plan/told family friends. Don't give them pamphlets if think person is going to find them
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do you screen everyone for abuse?
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yes even males
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gay male abuse vs. heterosex abuse?
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abuse frequency same as male on female abuse
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percentage of ppl abused
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7.5% males, 20-30% women
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standard of care
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reasonably good physician would do
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how does standard of care change in catastrophy
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1. ethics don't change 2. standard of care doesn't change but physicians may make diff choices based on what is reasonable
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in a crisis situation who is your first priroity: 65 yr old male, doctor, person bleeding out looks like dye, baby
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doctor
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standard care singular or wide range of tx options
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wide range
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best possible option to phrase public health: stop smoking b/c give lung cancer, stop smoking gives your wife lung cancer
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wife lung cancer - ppl don't like paternalism but don't want to make other ppl sick
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dyspnea
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sensation of breathing not matched by work
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wheezes
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COPD, emphysema, crackles, pneumonia, (heart failure)
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normal descent of diaphgram with inspiration
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??
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Webber: left louder than R this means..
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sensoneirual on right or conductive on left
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webber: right louder than left. Rinne left ear air louder thanb one, right bone better than air
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conductive right
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how to take informed concent
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crura: current med conditions, risk and benefits of taking treatment, uncertaintiies, my recommendation, and alternatives
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single best predictor of health status
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literacy
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explain legal requirements of informed consent in wisconsin
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1. patient has right to decide 2. full disclosure of risk and benefits 3. proesionally oriented standard what a reasonable physician would tell patient 4. reasonable person standard (tell what a reasonable person would like to hear)
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informed consent legal requirement or standard
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legal!
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ok not to tell someone everything if they don't want to hear about procedure before performing it?
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no! need informed consent
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someone had pneumonia, came back and still sick and missed a bunch of appointments. What should you expect?
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health illiterate
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2 consequences of limited literacy
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1. worse health outcomes 2. increase healthcare cost
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clubbing
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pulmonary HTN, CHF
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how to combat health literacy
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speak in normal jargon to everyone
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most ppl who are illiterate
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us born, hold full or part time jobs
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5 contributors to health literacy and which one control?
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1. level of education 2. level of experience in health care 3. complexity of info (heart failure explained complexly or simply)doctor controlled) 4. how material is communicated (doctor controlled)
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should you ask the patient "do you understand" when testing them for health literacy
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no
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average american literacy
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8th grade
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medical info conveyed at
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college level
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written material
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10th grade
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if patient doesn't understand should you take blame
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yes!
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how to enhance literacy
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1. teach back 2. simple language 3. don't ask if understand 4. brown bag test - bring in med show me how to use them
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definiction of health literacy in a person
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person ability to 1. obtain 2. process 3. understand
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when does deductive begin
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even before get in the room!
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frequently angry and says he forgot classes at home
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probably health illiterate
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prescription bottle test
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bring medicine and ask them how to treat it
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medical term definition
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ask patient to define HTN and see if they know answer
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screen for illiteracy
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no! just always dumb it down with all patients to make sure
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what to say if suspect patient is health illiterate
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important for me to make sure all of my patient understand. Is there things that work for you I'd like to know if I'm not being clear.
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good patient education material
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1. writing 2. organization 3. appearance 4. appealing
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I VINDICATE AID
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idiopathic vascular iatrogenic neoplasm drugs infection congenital allergic trauma enodocrine autimmune inflammation degenerate
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more literate men or woman
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woman
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more literate young or old
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young
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more literate hispanics vs am indian
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american indican
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4 box model
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1. context 2. med facts 3. patient prefrences 4. quality
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medical ethics
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priority to individual
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public health ethics
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priority to population
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biomedical advance
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priority to biomedical advancement
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state has right to
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1. enter private problem 2. excecute reasonable and necessary 3. access with any medical records without concents. 4. vaccinate 5. contact tracing (do not have ability have them go through with certain treatment)
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negative tactile fremitus
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COPD/emphseyma, effusion, pneumorthorax
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exhaustive method
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1. ask every question possible 2. write down everything
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how many take home messages best way to leave in information
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3-4 bullet points
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enhance literacy
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1.teach back 2. limit amt of info 3. simple language
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