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Chapter 1 Flashcards

1
Q

general structure and sequence of the clinical enounter

A

-initiate the encounter- setting the stage/preparation, greeting the pt and establishing initial rapport
-gathering information- initiating information gathering, exploring pts perspective of illness, exploring biomedical perspective of disease including relevant background and context
-performing the PE
-explaining and planning- provide correct amount and type of information, negotiate plan of action, shared decision making
-closing the encounter

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2
Q

biopsychosocial model

A

-explicitly acknowledges the interdependence of pts biological (disease), psychological and social characteristics, making it consistent with general system theory

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3
Q

behavioral medicine

A

-clinical psychology subspecialty
-to provide evaluation and treatment of presenting problems which have medical, behavioral and psychological elements

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4
Q

nonverbal listening behavior

A

-let the pt complete the opening statement
-listen to pt, he is telling you the dx
-good physician treats the disease, the great physician treats the pt

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5
Q

questioning style

A

-direction/clarification
-facilitation
-checking/summarizing
-when in doubt -> check

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6
Q

skills to assess and understand the pts problem

A

-survey problems
-impact of illness
-negotiate agenda
-develop narrative of the problem
-avoid leading questions
-explore pt perspective
-ICE- ideas, concerns, expectations

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7
Q

goal of the core functions

A

-help students and practicing clinicians master a core set of basic and advanced skills to facilitate: empathic, effective, efficient communication with pts
-integrating pt and clinician centered interviewing allows more complete picture of pts illness and allows the clinician to show respect, empathy, humility, and sensitivity

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8
Q

skills for partnership: Pearls

A

-Partnership
-empathy- reflection and legitimation
-support
-respect (affirmation)

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9
Q

assess and understand the pts problems

A

-use inductive and deductive information gather techniques
-to dx, assess, and understand pt problems as well as the pt as a person who is experiencing those problems
-inductive reasoning- look at a trend and generalize
-deductive- using a formulae to figure out whats happening

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10
Q

empathy

A

-NURS(*E)
-Naming the feeling/emotion
-Understanding
-Respecting (praising or appreciating the pt and/or acknowledging his/her situation)
-Supporting
-Explore- how else were you feeling about it

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11
Q

hierarchy of natural systems

A

-social -> psyhco -> bio
-social- culture, community, 2-person, family, clinician
-psycho- person (experience and behavior)
-bio- nervous system, tissues, cells, organelles

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12
Q

open ended skills

A

-nonfocusing- silence, nonverbal encouragement, continuers
-focusing- echoing, requesting, summarizing

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13
Q

emotion seeking skills

A

-direct
-if necessary use indirect
-indirect- impact on life or others, beliefs about the problem, intuit how the pt might be feeling, triggers

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14
Q

empathy

A

-name ->
-understand ->
-respect ->
-support

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15
Q

behavioral menu

A

-1. ask pt if he or she is interested in hearing ideas (ask permission)
-2. present a range of potential action ideas
-3. suggest that hearing other ideas may in fact trigger new ideas from the pt

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16
Q

patient centered interviewing: step 1- stage for the interview

A

-welcome pt
-use pts name
-introduce self and identify specific role (student/nurse/student doctor/resident/fellow)
-ensure pt readiness and privacy
-remove barriers to communication
-ensure comfort and put pt at ease

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17
Q

patient centered interviewing: step 2: elicit chief concern and set agenda

A

-indicate time available
-forecast what you would like to have happen during the interview
-obtain list of all issues pt wants to discuss, specific symptoms, requests, expectations, understanding
-summarize and finalize the agenda, negotiate specifics if too many agenda items

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18
Q

patient centered interviewing: step 3: begin the interview with non focusing skills that help the patient to express her/himself

A

-start with open ended request/question
-use non focusing open ended skills
-obtain additional data from nonverbal sources, nonverbal cues, physical characteristics, accoutrements, environment, self

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19
Q

patient centered interviewing: step 4: use focusing skills to elicit 3 things: symptom story, personal context, and emotional context

A

-further elicit symptom story- description of symptoms, using focus open ended skills
-elicit personal context- broader personal/psychosocial context of symptoms, pt beliefs/attributions, against focusing on open ended skills
-elicit emotional context- use emotion seeking skills, direct, indirect, impact (belief, triggers, self disclosure, resonate with unexpressed feeling)
-respond to feelings/emotions- use empathy skills to address the feelings and emotions (naming, understanding, respecting, and supporting)
-expand the store- continue eliciting further personal and emotional context -> address feelings and emotions (NURS)

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20
Q

patient centered interviewing
: step 5: transition to middle of interview

A

-brief summary
-check accuracy
-indicate that both content and style of inquiry will change if the pt is ready

21
Q

patient centered interviewing: step 6-11

A

-6. complete a chronological description of HPI/OAP
-7. past medical history
-8. social history
-9. family history
-10. review of systems - PE
-11. end of interview

22
Q

patient centered approach

A

-pt often do not seek healthcare only bc of a symptom
-pt usually bring more than 1 concern to their clinician
-allowing the pt to tell their symptom story- diagnostically useful and therapeutic
-pts do not want us to try to fix everything they tell us about
-pts may not experience our caring and compassion unless we give voice to them

23
Q

needs communicated by patients: very common

A

-needs to express symptoms, personal context of illness, feelings, and emotions, interests, desire for information and other ideas
-ex. worry about cancer, cant work with back pain, feeling down, wants to lose weight, fever

24
Q

needs communicated by patient: common

A

-special communication needs
-ex. non english speaker, deaf, cognitively impaired

25
needs communicated by patient: uncommon
-urgent, sometimes life threatening needs requiring immediate attention -biomedical- unconscious, hematemesis, symptoms of acute myocardial infarction, recent hx of syncope.. -psychosocial- suicidal, homicidal, disruptive, overtly psychotic, severe brain syndrome, anxious
26
biopsychosocial story
-synthesis of patient centered (psychosocial and symptom date) + clinician centered (symptom and psychosocial data)
27
obtaining and describing data without interpreting it
-expand the description of symptoms already introduced by the pt -describe symptoms not yet introduced in the already identified body system (and general health symptoms)
28
interpreting data while obtaining it
-testing hypotheses about the possible diseases causing symptoms -describe relevant symptoms outside the body system involved in the HPI -inquire about the presence or absence of relevant non symptom data (secondary data) not yet introduced by the pt
29
understand the patients perspective
-impact (meaning) of illness on self/others -health beliefs -triggers for seeking care
30
components of history
-chief complain -history of present illness- OLD CARTS -other active problems -past medical history -social history -family history -review of systems
31
medications
-dose -interval -route -home remedies -OTC -herbal/nontraditional -generic
32
past medical history
-if pertinent to HPI can put the specific section below or pertinent info in the HPI -childhood and adult -obgyn -past surgical history -past psychiatric history
33
collaboratively manage the problems
-education -pt activation -shared decision making -self management support -motivational skills to facilitate collaboration for management of pt problems
34
skills
-elicit -tell pt first chunk of info -ask about understanding and concerns -care -counsel -tell back/tech back
35
skills: Support self-management brief action planning
-is there anything youd like to do about your health in the next week or two -SMART behavioral planning- specific, measurable, achievable, relevant, time specific (what, where, when, how often) -commitment statement -about how confident do you feel you can carry out your plan from 1-10 (greater than 7) -when would you like to come back and review how youre doing with plan -plan is patient centered -> what the pt wants to do
36
problem solving
-if confidence is less than 7 -> low confidence -work with pt to overcome barriers to implementing the plan -achieve a 7 -patient should be on board
37
follow up
-nonjudgemental inquiry -reassurance if the plan was not completed successfully -checking into the pts ideas and desires about most appropriate next steps
38
end of interivew
-share information- orient pt to end of interview, ask permission to begin discussion, frame discussion, iteratively provide info, use plain language -assess understand- teach back, provide written plans -invite pt to participate in shared decision making -close the visit -next steps -encourage questions -acknowledge and support
39
skilled interview techniques
-active listening -empathic responses (reflection, legitimization) -guided questioning (open ended questions, echoing) -nonverbal communication -validation -reassurance -partnering -summarization -transitions -empowering pts
40
7 rules
-If you feel uncomfortable touching a patient, do not touch the patient (other than what is absolutely necessary for the physical examination). -Any sexual relationship between a medical practitioner and a patient is always an abuse of power and should never occur. -Do not answer medical questions during your time as a student. Refer questions politely back to the primary medical team. (I will share the information you have given me, and I will return with my preceptor to discuss the findings further) -Respond to an emotion as soon as it appears. -When in doubt about how to respond to an emotion, use reflection and legitimation. -Never promise a patient absolute confidentiality. -Communicate all clinically relevant information a patient may have told you back to the treatment team. Do it yourself
41
10 concerns
-Why should the patient want to talk to or Be examined by a student? -Is a student interview or examination a humiliation or indignity for the patient? -How should I dress? Should I wear a white coat? -Should I introduce myself as “doctor”? If I do that, am I not deceiving the patient? -If the patient is in pain or emotional distress, should I continue with the interview? -Should I shake the patient’s hand? Under what circumstances is it acceptable to touch a patient? -If the patient asks me questions, should I answer the questions if I know the answers? -What should I do if I do not know the answers? -What do I do if the patient starts crying or if the patient gets angry with me? -What should I do if the patient promises to tell me some important secrets if I agree to maintain his or her confidence? -What should I do if the patient tells me something his or her doctor does not know? -For example, what if the patient tells me that he or she is depressed or suicidal?
42
Sympathy vs Empathy
Sympathy- I feel sorry for you Empathy- putting yourself in shoes and showing that you understand
43
clinician centered approach
-clinician is asking all the questions -in an emergency situation you do not start with a patient centered approach
44
paper notes
-date -military time -patients name (initials)- HIPAA -age -gender -race (physical features)/ethnicity (cultural background) -reliability of info -source -location- hospital, clinic
45
hyposmia & anosmia
-hx- systemic illnesses, medication, injuries etc. -PEx- nose and nervous system focus -testing: -University of Pennsylvania Smell Identification Test (UPSIT)- self administered scratch and sniff test useful for hyposmia, anosmia, and malingering -treatment- secondary causes -> endoscopic sinus surgery -education- seasoning, safety issues
46
nose and sinus disorders
-epistaxis -nasal polyps -foreign bodies
47
epistaxis
-90% pts with this can be treated in ED -classification dependent on primary bleeding site -anterior- most common -posterior
48
VINDICATE
-used to build up differentials for any case -VASCULAR -INFLAMMATORY -NEOPLASTIC -DEGENERATIVE/DEFICIENCY -IDIOPATHIC/IATROGENIC, INTOXICATION -CONGENITAL -AUTOIMMUNE/ALLERGIC/ANATOMIC DEFECTS -TRAUMA -ENDOCRINE/EXPOSURES (ENVIRONMENTAL, OCCUPATIONAL) OSLER-WEBER-RENDU SYNDROME (HHT)

Behavioral Medicine (5 decks)

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