Intro to PXDX

Question 1

What is the format/steps for an organized physical exam?

Answer 1

1. Make sure there is enough room and space
2. Get all your equipments ready
3. Good lightning
4. Wash your hands
5. Develop a sequence for the physical exam
6. Cephalo-caudad (head to toe) approach
7. Perform exam from pt’s right side
8. Make sure both the patient and you are comfortable (sit near pt if needed to comfort them)
9. Make sure you take adequate time to talk to pt and get complete history.

Question 2

What are the 5 fingers of the osler?

Answer 2

1. Observation/inspection (pt’s walk, dress, facial expressions, grooming, distress)
2. Palpation (feel)
3. Percussion
4. Auscultation (hear)
5. use other senses (smell?)

Question 3

What is the major component of diagnoses?

Answer 3

• History (70%)

- physical examination (20%) and investigation (10) are the other 2 components

Question 4

What is your objective in a clinical encounter with a patient?

Answer 4

1. to elicit relevant facts from pt’s history of present illness and symptoms
2. to derive a differential diagnoses
3. to elicit risk factors and significant co-morbid pathologies. (to rule out most dangerous/risky diseases first)

Question 5

What does a complete history comprise of? (8 things)

Answer 5

1. CC (chief complaint)
2. HPI (history of present illness)
3. ROS (review of system)
4. PMHX (past medical history)
5. PSHX (past surgical history)
6. FHX (family history)
7. SHX (social history)
8. Meds/allergies

Question 6

What is Chief complaint and what does it consist of and an example?

Answer 6

• Chief complaint is the symptom that patient is seeking medical advice for.
• It consist of pt’s complaint, age, and gender. Chief complaint is written in patient’s own words.
• 50 yrs old female complaining of shortness of breath.

Question 7

What is the OPQRST of the history of present illness?

Answer 7

• Onset (when/how did it first start?)
• Provocation/palliation (what makes it better or worse?)
• Quality (What does it feel like? sharp?)
• Region/Radiation (location? is it radiating/moving?)
• Severity (on scale of 0-10 how bad is it?)
• Time (how long has it been happening? is it constant or comes and goes at certain times?)

Question 8

What are the review of systems and how many do you need for a complete chart?

Answer 8

• Constitutional (fever? weight loss? weakness? anything different in general?)
• Skin (rash, bruising)
• HEENT (headache? blurry vision? loss of hearing? loss of smell? trouble swallowing?
• Respiratory (trouble breathing? shortness of breath? cough?
• Cardiovascular (heart palpitations? circulation? chest pain?)
• GI (constipation? abdominal pain? bloating? bloody stool?)
• Genitourinary (pain with voiding? frequency of void?)
• Musculoskeletal (muscle weakness, trouble moving any joints? muscle pain?)
• Neurological (numbness or tingling? trouble staying focused? slurred speech? sensation loss?)
• Psychiatric (uncontrollable thoughts? anxiety? depression?)
• Endocrine (excessive thirst? irregular menstrual cycle? any hormonal therapy? heat or cold intolerance?
• Hematologic/lymphatic (abnormal bleeding? enlarged lymph-nodes? easy bruising?)
• Allergies/immunologic (any allergies? if so what kind of reaction do you get or severeness of allergy? any recurrent infections?)
• Need 10 ROS for a complete chart.

Question 9

What does past medical history consist of?

Answer 9

• Childhood history (until age of 30ish)
• past trauma/injuries
• past psychiatric history
• immunizations
• past hospitalizations/surgeries
• previos diagnosis
• previous allergies
• previous medications

Question 10

What is the purpose of the soap note and who are the audiences?

Answer 10

purpose= memory aid, communication with colleagues and patient, assessment by preceptors/attending, insurance and legal matters, research.
audiences= yourself, colleagues, preceptors/attending, patient, insurance company, social and case management, quality assurance, administration and researchers.

Question 11

What does SOAP stand for?

Answer 11

• Subjective= what patient tells you or what you read from transfer notes (complete history)
• Objective= what you find or measure yourself (physical exam, vitals, labs)
• Assessment= differential diagnosis or what you made out from patient’s history and objective data, 1st differential should address pt’s CC.
• Plan= What are your next steps for this patient? (procedure? treatment? admission/discharge? follow up?)

Question 12

What are the Dos of documentation?

Answer 12

• be concise and accurate
• initial and date changes made
• use ink
• sign properly
• provide your contact info
• document soon

Question 13

What are the Don’ts of documentation?

Answer 13

• don’t use abbreviations
• don’t use good, negative, normal, abnormal
• don’t write false information/data
• don’t obliterate errors or omit data
• don’t leave any spaces
• don’t write too soon or write too much