Exam 3

Question 1

What were the 2 screening tools used in workshop 2; and what hypothesis did they evaluate? Where are these charted?

Answer 1

Mallampati for OSA; Billewicz for hypothyroidism
Always charted in objective data

Question 2

You finish your history with Betty and are now talking to your preceptor before performing the physical exam. What 4 things must you consider to help determine what physical exam to perform?

Answer 2

CC
HPI
Possible hypotheses
Levels of evidence (EEP, Dynamed, LRs)

Question 3

Considering Betty, you are looking at Dynamed to determine what PE to perform for OSA and it lists general survey, HEENT, neck, and extremities. You are surprised that the lungs & heart are not listed. Should you add these systems to the exam to evaluate for OSA?

Answer 3

Yes, you must consider Betty’s HPI and PMH (she stated “she is breathless and tired” and she has a hx of asthma)

Question 4

Your classmate is preparing to do Betty’s PE for OSA and found a clinical decision-making tool, “modified Mallampati score”. Your classmate asks you what Dynamed level 2 means.

Answer 4

Dynamed has 3 levels of evidence.
Level 2 is mid-level which represents some level of scientific significance.

Question 5

What is the difference between a LR- and a LR+?

Answer 5

LR- is the significance of the absence of a symptom, and vice versa.

Question 6

A student thinks their patient may be in heart failure. The LR+ for wheezing is 1.5, and the LR- is 1.0.
Should they examine the patient for wheezing based on the LRs?

Answer 6

If present, the LR+ is 1.5, so it would slightly increase the probability.

Question 7

A student thinks their patient may be in heart failure. JVD has an LR+ of 34, and the LR- is 0.8. Can they assume the absence of JVD significantly decreases the probability of HF?

Answer 7

No, since the LR- is 0.8 it is not significant.

Question 8

What 2 systems are always examined regardless of the type of visit?

Answer 8

General survey and VS

Question 9

What is the order you strive to examine a body system?

Answer 9

IPPA (inspection, palpation, percussion, auscultation - except the abdomen)
You have to always keep your patients needs in mind and this cannot happen, but you ALWAYS chart findings this way.

Question 10

What helps to have good inter-rater reliability?

Answer 10

You and another clinician will examine the same patient, using the same tools/technique, and interpret/record the same findings.

Question 11

What is a Kappa value? What does the value of 0.71 mean?

Answer 11

Measures inter-rater reliability between 2 or more clinicians.
Kappa of 0.71 means there is likely good level of agreement
(we do not have to know specific interpretations for each value)

Question 12

You and your classmate complete an exam on Betty. You both were using the same techniques.
Is this good/poor and intra/interrater reliability?

Answer 12

Good inter-rater

Question 13

You examined Betty with the same tools/techniques as you always do
Is this good/poor and intra/interrater reliability?

Answer 13

Good intrarater

Question 14

You and your preceptor both examine Betty. Each of you used different tools/techniques on the exam.
Is this good/poor and intra/interrater reliability?

Answer 14

Poor interrater

Question 15

What are the 2 subsections of the Objective data on the SOAP note?

Answer 15

Physical Exam and Labs & Diagnostics

Question 16

Where do you document the results of the ESS, Mallampati, PHQ-9, and Billewicz score in the SOAP note?

Answer 16

Objective; under labs and diagnostics

Question 17

Why is it important to know where to document the results of a screening tool?

Answer 17

So we can have clear communication with interdisciplinary teams, so information can be located quickly

Question 18

Why do we never chart WNL?

Answer 18

WE NEVER LOOKED

Question 19

Your preceptor asks you if polyuria and polydipsia are risk factors for diabetes. Why or why not?

Answer 19

No, they are symptoms of diabetes

Question 20

Where are the following documented in the SOAP note?
1. A1c (no results at time of visit)
2. non-enlarged, non-tender thyroid
3. stopped OCPs after husband’s death
4. anemia
5. UA negative blood

Answer 20

1. Plan: diagnostics
2. Objective: physical exam, neck
3. Subjective: HPI
4. Assessment
5. Objective: labs & diagnostics

Question 21

Your classmate has written the following diagnosis for Betty
1. R/O hypothyroidism 2. Anemia
Are these appropriate or not? Why?

Answer 21

1. No, you must use a symptom (such as fatigue)
2. Yes

Question 22

What are the 5 parts to the plan?

Answer 22

Diagnostics, therapeutics, education, f/u, referrals

Question 23

Why are screening tools documented in objective data even though they are subjective data?

Answer 23

It is a holding place so all members of the healthcare team know where to go to find the result

Question 24

Where do most diagnostic errors occur in the patient encounter and what steps can you take to reduce the risk of making an error?

Answer 24

Most take place in the H&P exam. If you do not get an accurate story, the hypothesis you come to before starting the physical exam can lead you to not perform the correct techniques to arrive at the appropriate diagnosis.

Question 25

You are considering the hypothesis of sleep apnea. The Malampati score is 3/4. This piece of data is which of the following?

Answer 25

Significant positive

Question 26

The hypothesis is mononucleosis, the absence of a runny nose, head congestion and sinus pressure is what kind of data?

Answer 26

Significant negative

Question 27

The hypothesis is mononucleosis, the absence of nausea and vomiting, a child in the household with strep and age 58 is considered to be what kind of data?

Answer 27

Confounder

Question 28

One little puppy lying on a bed. Mom says "roll over" He falls onto the floor. Dad puts him on the bed and says "roll over" The puppy rolls over but now straddles between the night stand and the bed. Sister comes in, puts the puppy on the bed and says "roll over" The puppy does so and gets tangled in the quilt. This is an example of which of the following?

Answer 28

Poor interrater reliability

Question 29

The puppy lands on the floor six times on the night stand twice and gets tangled in the quilt twice. Mom, dad and sister believe that this landing on the floor that many times was just a happy accident. In order to adjust for the possibility that this happened by chance alone, they decide to apply which of the following?

Answer 29

Kappa statistic

Question 30

One little puppy lying on the bed. He rolls over and falls off landing on his feet. His mom picks him up and puts him back on the bed. The puppy rolls over and lands on his feet again. Mom repeats this sixth time and each time the puppy lands on the floor. This is an example of?

Answer 30

Good intra-rater reliability

Question 31

McGee sets the Kappa for identification of a liver greater than 9 centimeter using percussion to have a Kappa of 0.11. This may be interpreted as meaning which of the following? Two or more clinicians will...

Answer 31

Have slight agreement on the presence of a liver greater than 9 centimeters by percussion. (on the same patient under the same circumstances)

Question 32

Clinician A is seeing a patient for a comprehensive annual physical exam. The patient has no medical problems and no specific complaints or concerns. As part of the exams, DTRs are performed. The clinician checks patients patellar reflexes and notes 1+ reflex on the left knee and 4+ reflex on the right. The next step for the clinician is to do what?

Answer 32

Repeat patellar reflexes again, keeping technique consistent on both the right and the left knee.

Question 33

Kappa for auscultating present or absence of systolic murmur is 0.19 means.

Answer 33

Slight agreement