Unit 1 DOCS Flashcards by Angela Mitchell

Justify the value of gathering medical history.

Gathering medical history allows you to have a conversation with the pt to build a foundation of trust and rapport while obtaining data framing chief complaint and allowing pt to be heard

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Define pt-centered approach

An approach to care that respects and values the individual pt’s preferences, needs, and values. It involves giving a voice to the pt and including the pt in their care and treatment decisions.

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Outline the steps for setting the stage of an interview.

Greet pt, introduce yourself, obtain permission - “Good morning Mr/Mrs. ______, I’m Student Doctor ___________. I’m part of Dr. _________’s team today and I’ll be getting some information from you if that’s okay with you.”

Ensure pt readiness and privacy - ask if they want family to stay in the room, close door/curtain

Address barriers to communication, ensure comfort - sit down, get interpreter, make small talk

Indicate time availability and set agenda - “Well I’ve got about ___ mins with you today, can you tell me what’s brought you in?”

Summarize and prioritize - “So we’ve got A, B, C, D, E, and F written down here. So we don’t risk the quality of care you receive, let’s focus on A, B, and C today, and we’ll get you scheduled to come back so we have more time to take care of D, E, and F.”

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What are the elements of a comprehensive medical exam?

Identifying Information
Chief Complaint (CC)
History of Present Illness (HPI)
Medications and Allergies
Past Medical History (PMH)
Family Hx (FMH)
Social Hx (SH)
Review of Systems (ROS)

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Identify and give examples of subjective vs objective information on exams

Subjective - what the patient tells you, symptoms
“My chest hurts” “It’s been going on for one week” “I feel depressed”

Objective - what can be measured, signs
Tests, labs, weekly logs, physical exam

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Explain the value in using open-ended questions, describe the different tactics, and give an example.

Encourage the patient to continue giving information, makes pt feel heard

“What brought you in today?”, “Can you tell me more about that?”

Silence: staying silent after a pause to see if pt will continue
Nonverbal encouragement: silence with body language (sympathetic facial expression)
Continuers: brief, noncommittal statements (“uh-huh” “Go on”)

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Explain the value in using open-ended focused questions, describe the different tactics, and give an example.

Helps pt develop their narrative, expands on what’s been put on the table

“Can you describe that?” “How did that make you feel?” “Tell me more about…”

Echoing: provides encouragement to focus by repeating words or phrases
Open-ended requests: asking for more information
Summarizing: shows pt that clinician was listening, following story and is ready for more info

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Explain the value in using closed-ended questions, describe the different tactics, and give an example.

Useful for clarifying information toward the middle/end of the interview

“So you mentioned you fell, did you break skin?” “Did you fall on your right knee or left?”

Yes/no questions
Brief answer
Multiple choice

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Explain the value in using leading questions and give an example.

No value. Do not use.

“You don’t smoke, right?” “I’m sure you don’t but I have to ask…”

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Define palpation

The application of variable manual pressure to the surface of the body for the purpose of determining the shape, size, consistency, position, inherent motility, and health of the tissues beneath

Light placement of the hands or fingers on the pt’s body to discover abnormal changes of the soft tissue, bones, organs, or skin

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What are the layers of palpation?

Observation - lesions, wounds, etc
Temperature - felt with wrist or back of hand
Skin topography/texture - feeling drag, moisture, turgor, etc
Superficial fascia - gentle pressing; should slide with ease
Muscle - moderate pressing; more difficult to slide, more dense
Tendons - traced in periphery to bony attachments
Ligaments -
Bone - deep palpation; should once again slide with ease

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Explain FIFE and it’s use in exploring the patient’s perspective of their illness

Feelings - asking the pt how they are perceiving what’s happening
Ideas - what do they think may have caused it?
Effect on Function - how it is affecting their daily lives?
Expectations - what do they expect from the physician, the appointment, the illness, etc

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Explain NURSE and it’s use in building empathy during a medical interview

Name - give a name to what they’re experiencing “That sounds scary” “I see you’re upset”
Understand - validate their concerns/feelings
Respect - “You’re brave/strong to admit this”
Support - Collaborate with pt, ensure you’ll work together
Explore - “How else are you feeling about it?”

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What are the four qualities of empathy?

Perspective-taking
Staying out of judgement
Recognizing emotion in other people
Communicating

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Describe the elements of a SOAP note

_________ guides the __________ -> __________ and __________ give rise to the __________ -> __________ leads to the __________.

Subjective information (what the pt says)
Objective information (what you observe, examine, etc)
Assessment (what you think it is)
Plan (next steps)

Subjective guides the Objective -> Subjective and Objective give rise to the Assessment -> Assessment leads to the Plan

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OPPQQRRST

Onset
Position
Precipitating factors
Quality
Quantification
Radiation
Related symptoms
Setting
Transformation

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Describe the anatomic position

Standing upright
Head, gaze and toes pointed anteriorly
Arms adjacent to sides w/ palms facing anteriorly
Lower limbs together w/ feet parallel

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What are the 5 places to listen to the heart?

URSB - Upper right sternal border
ULSB - upper left sternal border
LMSB - lower medial sternal border
LLSB - lower left sternal border
Apex

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OLDCARTS

Onset: When did CC begin?
Location: Where is the CC located?
Duration: How long has the CC been going on for?
Characterization: How does the patient describe the CC?
Alleviating/Aggravating factors: What makes the CC better? Worse?
Radiation: Does the CC move or stay in one location?
Temporal factor: Is the CC worse (or better) at a certain time of day?
Severity: On a scale of 1-10, 10 being the worst, how does the patient rate the CC?

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OPQRST

Onset
Precipitating factors
Quality
Radiation
Severity
Timing

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TART examination sequence

Observation
Temperature
Skin topography/texture
Fascia
Muscle
Tendons/ligaments
Erythema friction rub

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General Spinal Examination Sequence

Inspection
Palpation
Range of Motion

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Active testing does/does not involve the patient moving themselves

Passive testing does/does not involve the patient moving themselves

does - the patient is active

does not - the patient is not actively moving

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Normal ROM for thoracic spine

Flexion - 45 degrees
Extension - 0 degrees
Side bending - 45 degrees
Rotation - 30 degrees

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Normal ROM for lumbar spine

Flexion - 40-60 degrees Extension - 20-35 degrees Side bending - 15-30 degrees Rotation - 3-18 degrees

You are performing a hip drop test on a patient. When the pt drops the right hip (puts all their weight on their left leg), you notice limited movement and a lack of sacral curve. What does that mean?

The pt has a restriction on the right side of the lumbar spine.

Myotomes of the Lumbar and Sacral spines used for strength testing

L2: Hip flexion L3: Knee extension L4: Ankle dorsiflexion L5: Great toe extension S1: Ankle plantarflexion, eversion, hip extension S2: Knee flexion

Dermatomes of Lumbar and Sacral spines used for sensation testing

L1: groin L2: inner thigh L3: medial knee L4: medial ankle L5: top of foot S1: lateral ankle S2: lateral knee

Reflexes of Lumbar and Sacral Spine (L3-L4, and S1-S2)

L3-4: Patellar S1-2: Achilles

Movement in a transverse plane about a vertical axis

Rotation

Movement in a coronal plane about an anterior-posterior axis

Sidebending

Anterior movement in a sagittal plane about a transverse axis

Flexion

Posterior movement in a sagittal plane about a transverse axis

Extension

Landmarks for scoliosis screening

Occipital plane Shoulder plane Scapular planer Iliac crest plane PSIS plane Greater trochanter plane

Soft tissue treatment is only considered a(n) ________ technique

direct

3 categories of lower back pain

with radiculopathy without radiculopathy associated with systemic disease, organ system or other cause (referred pain)

The hallmark "Grocery Cart Sign" associated with lower back pain typically leads to what diagnosis?

Lumbar stenosis

Lower back pain with bowel/bladder dysfunction and "Saddle Anesthesia" is typically...

Cauda Equina Syndrome

Lower back pain associated with stiffness, gets better with movement, does not respond to treatment, symptoms gradually getting worse. Sacroiliitis seen on Xray later on in disease progression

Axial spondyloarthropathy - type of inflammatory arthritis

Spinal Landmarks

C7 - C7 prominins T3 - spine of scapula T7SP/T8TP - inferior border of scapula L4 - superior border of iliac crest S2 - most inferior PSIS Sacral apex - upper greater trochanter

by mouth

BID/TID/QID

twice/thrice/four times daily

qhs/qAM

at bedtime/ in the morning

PRN

as needed

What to ask for medication hx

Formulation - pill, liquid, tablet? Dose - strength and amount Route of admin - oral, nasal, IM? Frequency of dosing - how often are you supposed to take it? Adherence - how often do you actually take it? Duration of treatment - how long have you taken it? Adverse effects - any noticed? Indication - why are you taking it?

You (as a physician) call child protective services in the case of suspected child abuse. What type of advocacy is this? Why?

Clinical Advocacy - providing care that integrates the full spectrum of the patient's needs.

You (as a physician) meet with hospital leadership to discuss starting a student-run free clinic for patients with limited funds. What type of advocacy is this? Why?

Institutional advocacy - making changes in your institution

You (as a physician) vote to expand state Medicaid coverage. What type of advocacy is this? Why?

Health Care Advocacy - targeting health care policies or laws

You (as a physician) write a letter to your congressman supporting prison reform. What type of advocacy is this? Why?

Community-based Advocacy - affecting the broader population beyond the patients seen in a typical healthcare setting

What goes into a PMHx?

Active medical problems (not CC) Childhood illnesses Adult illnesses Preventative Health Allergies

What does into a PSHx?

Surgeries, procedures When, why, complications, anesthesia type

What does into a FHx?

Common familial illnesses Illnesses specific to one generation up/down Relationship-age-disease

How is somatic dysfunction disgnosed?

Screening exams - posture, gait Regional exams - inspection, AROM/PROM, TART Segmental exams - palpation, motion testing, Fryette's principles

List the classification, indications and contraindications of soft tissue technique.

Classification: Direct, Passive Indication: Myofascial soft tissue disorder Absolute contraindications: consent, no SD Relative contraindications: Open wounds, fractured vertebrae, pain, contagious skin rash/disorder

List the classification, indications and contraindications of muscle energy technique.

Classification: Direct, Active Indication: Arthrodial, myofascial SD Absolute contraindications: consent, no SD Relative contraindications: Open wounds, fractured vertebrae, pain, contagious skin rash/disorder, neurological or vascular compromise, malignancy, muscle strain

Give an example of an external motivator of Self-Determination Theory

Some type of reward -Doing it because they want something out of it

Give an example of an introjected motivator of Self-Determination Theory

Self-critical, shaming, pressure to impress -Doing it because they want to avoid guilt

Give an example of an identified motivator of Self-Determination Theory

Understanding the feeling of needing to perform/accomplish - Doing it because they value the goal

Give an example of an integrated motivator of Self-Determination Theory

Congruence, awareness, synthesis with self and core love - Doing it because it's important to their self-worth

Give an example of an intrinsic motivator of Self-Determination Theory

Interest, enjoyment, satisfaction - Doing it because they really want to.

What are the stages of change?

Precontemplation Contemplation Preparation Maintainence Relapse

Differentiate between Deontology, Utilitarianism, and Virtue Ethics.

Deontology is rule-based; the right/moral thing to do is that which honors the rule. Utilitarianism is outcome-based; the right/moral thing to do is that which maximizes collective goodness. Virtue Ethics identifies a virtuous role model; the right/moral thing to do is emulate what our virtuous model would do in this situation.

What are the Four Quadrants approach to Clinical Ethics?

Medical Indications Patients Preferences Quality of Life Contextual features