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17 Cards in this Set
- Front
- Back
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entering the room
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knock on door
verify patients name introduction and shaking hands eye contact drape patient from waist down |
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history components
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CC
HPI ROS past medical history medications allergies past surgical history social history family history pediatric history obgyn history |
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how to get history
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avoid technical terms
show empathy address patient concerns maintain eye contact do not interrupt or rush patient |
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before physical exam
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summarize the history
ask if there's anything not covered ask if patient has any concerns or questions announce you will begin PE wash and dry hands warm up the hands |
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distribution of time
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doorway info --> 20 seconds
history --> 7-8 minutes PE --> 3-5 minutes closure --> 2-3 minutes |
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how to handle lengthy irrelevant stories
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"excuse me Mr. Jones, I understand how important those issues are to you, but I'd like to ask you some additional information about your current problem"
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when to summarize
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after taking history and before PE
right after PE and before closure may summarize more often |
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how to make transitions
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"I need to ask you some questions about…."
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non verbal clues
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watch patient carefully for every expression, movement or sign and ask about it
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during physical exam
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ask permission to untie the gown
expose as little of the patients body as possible do not examine through the gown start far from area of pain do not repeat painful maneuvers ask for permission for everything say thanks for everything do not uncover large parts of body |
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after physical exam
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tie the gown
summarize history and/or PE findings |
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things not allowed in PE
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corneal reflex
breast exam rectal exam pelvic exam genital exam if it's necessary to perform --> tell patient you will need to do it at a later time and add it the note |
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closure --> counseling
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summarize the history and physical findings
discuss diagnostic possibilities do not give definitive diagnosis explain work-up avoid complicated medical terms ask if patient has questions or concers |
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closure --> difficult questions
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be honest but diplomatic
avoid giving false reassurances if you don’t know the answer to a questions, say so before answering, try rephrasing the question to see if understood correctly |
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closure --> before leaving
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tell patient we will meet again with the test results
shake the patients hand say goodbye |
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if time is running out
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give priority to closure above complete PE
write differential diagnosis and work-up first |
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time notification alarms
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5 minutes before patient encounter ends
2 minutes before PN |
