Exam 1: History Taking and Communication Skills

define iatrotropic

define iatrotropic

indicates why the pt decides to seek care at a particular point in time

what is "OILD CARTS"

O-onset
I-intensity (0-10)
L-location
D-duration
C-quality (sharp, dull, pressure)
A-aggravation/alleviation
R-radiation
T-timing (when did it start, how long does it last and how often does it come)
S-setting (what pt was doing when it began)

what is "OPPQRST"

O-onset
P-palliative (alleviates)
P-provocative (worsens)
Q-quality
R-radiation
S-severity (scale of 1-10)
T-timing (constant, intermittent, morning, nocturnal)

what are ADLs

activities of daily living (personal daily care tasks: bathing, dressing, caring for teeth and hair, toileting and eating and drinking)

questions such as "are your parents still living?", "are you allergic to any medications" and "have you ever been anemic" are examples of what kinds of questions

closed-ended

questions such as "can you tell me more about that", "what else did you notice" and "what was the pain like" are examples of what kinds of questions

open-ended

the pt interview should contain more open or closed ended questions?

open-ended

what kind of questions should you avoid in pt interview

-leading Q's -> "you're feeling better now, aren't you?"
-rapid fire -> "do you have trouble sleeping and how about coughing?"
-med jargon -> "have you ever had an MI, any COPD exacerbations?"

differentiate between specificity and sensitivity

-specificity = w/out disease; requires that we use our interviewing skills to identify real cases of wellness
-sensitivity = w/ illness; requires that we use our interviewing skills to identify real causes of illness

what are all of the identifying components needed in an HPI

-name
-gender
-DOB
-age
-ethnicity
-source of hx
-reliability of historian
-date
-time of exam

T/F: chief complaint (CC) must include duration

True

how many generations should be included in exploring family history

3

do food allergies need to be included in pt note

yes, always

is it okay to have family medical history presented as a pedigree in the note

yes; make sure to have a legend and label each person in the pedigree with disease states/diseased, identify the pt

how should smoking be reported

in pack years
-EX. 1 pack-year is equal to smoking 20 cigs per day for 1/2 a year
- (packs smoked per year) X (years as a smoker)
= # of pack years

what is the goal for obtaining a family history?

to determine any genetic illnesses

what category does smoking go under

social

what format is used when performing ROS

head to toe

define pertinent positive

a symptom that a pt reports during your ROS question

define pertinent negative

a symptom that the pt does not report (or denies) that would support one of your diagnostic hypotheses

what are the objectives and goals of the ROS

-identify active problems that have not yet been discussed
-associated additional symptoms with the current illness

how should you perform the focused physical exam

examine one system above and one system below the targeted organ system

what are the 7 standards of critical thinking

(DABL CPR)
clarity, accuracy, precision, relevance, depth, breadth and logic

what are the critical thinking elements of reasoning

-purpose/goal/objective
-problem to be solved
-point of view
-assumptions
-information
-concepts
-interpretation
-implications/consequences

what is the differential diagnosis based on

-CC
-HPI
-ROS
-PMHx
-PSHx
-FHx
-SocHx
PE

what order should differential diagnoses be in

most likely to least likely

what information should accompany sx history

-when
-any complications
-why sx was performed

what is the purpose of a note

convey care issues to members of the care team

what time format is preferred

military time

what should you avoid in your SOAP note

-confusion
-redundancy
-omission of information

what should each entry of the SOAP note contain

-signature
-title (PA-S1)
-co-signature of supervising physician or provider
-source of information

is it okay to use correction liquid on a note

no

what should you do if you make an error in a note

cross it out with a single line, initial and date it

what vital signs must be included in a SOAP note

-temperature
-pulse
-RR
-BP
-height
-weight
-BMI

what does SOAP stand for

subjective, objective, assessment, plan

is a SOAP note usually used to record the entire medical hx or a first/new pt visit

no

how is a SOAP note typically used

in ambulatory settings for episodic or problem specific visits and in inpatient settings to document the pts progress or condition

what information is included in the S (subjective) portion

-CC
-HPI
-FH
-SH
-pertinent psychiatric hx
-cultural hx
-specialized hx related to CC such as OB/GYN for female w/ GYN complaint
-pertinent ROS

information that the subject tells you; pt's story/hx describes which portion of the SOAP note

S

are PE findings included in the Subjective portion of SOAP note

no

which portion of the SOAP note does the following describe

prima facie; others should be able to observe the same signs

O (objective)

what sections are included in the Objective portion of SOAP note

-vital signs
-PE findings
-lab or diagnostic studies with results
-procedures or interventions performed

if a system is not examined how should it be represented in the Objective portion of the SOAP note

do not include an unexamined system in the note

how should lab results be represented in the Objective portion of the SOAP note

give name of test first then the results
-document if the results are your own interpretation or another's

if you have a pt with a suspected ankle fracture and you apply a posterior splint and instruct a pt on the use of crutches what kind of information is this (where would this go in the SOAP note)?

Objective

advising a pt if you could not do an x-ray and advising them to return and go to radiology center would be an example of what kind of information (where would this go in the SOAP note)?

Plan

if unsure about the diagnosis, you may use a presumptive diagnosis such as

-symptom
-complaint
-condition
-problem
**** do not use "rule out" as a diagnosis

what does the "VINDICATE" universal DDX stand for

V-vascular
I-inflammatory
N-neoplasm
D-degenerative and deficiency
I-intoxication
C-congenital
A-autoimmune and allergic
T-trauma
E-endocrine

what assessment makes up the "problem list" and is after the primary assessment

Secondary assessment

what does ICD-XX-CM coding stand for

International Classification of Diseases -XX edition -Clinical Modification

who publishes the ICD-XX-CM and how often

-US public health service and centers for Medicare and Medicaid services
-published annually

what is a standardized system for applying a numeric code to each diagnosis and is used to determine the level of reimbursement, forecast healthcare needs, evaluate facilities and services

ICD-XX-CM

what does CPT code stand for

current procedure terminology code

what is a medical code used to report medical, sx, and diagnostic procedures and service entities such as physicians, health insurance companies and accreditation organizations

CPT codes

what is a CPT category 1

procedural and medical practices

what are the 6 categories of CPT category 1

1. evaluation and management (E&M)
2. anesthesiology
3. sx
4. radiology
5. pathology and lab
6. medicine

what is the most commonly used CPT category

CPT category 1

what are the components of the plan section of SOAP

-tests
-referrals
-pharmacological therapy
-pt education
-follow-up instructions

what additional information must you document that you provided the pt with (considered 2nd P, pt education)

-medical condition/illness or diagnosis
-preventative measures/discussing risk factors
-follow up info such as referrals to specialists, return to clinic or go to ER if pt notes life threatening or worsening signs and symptoms (S&S)
****be specific with S&S

-when documenting on a symmetrical body part, make sure to document the involved area consistently in the hx and PE
-failure to follow up on abnormal lab tests or studies
-coding for reimbursement purposes only
-not documenting pt education such as warnings, tests performed, consents, follow up instructions and including copies of handouts

These are all examples of what

medicolegal alerts

what are the personality types identified by Kahana Bibring to assist a clinician in interview

-dependent and demanding
-orderly and controlled
-dramatizing or manipulative
-long suffering or masochistic
-guarded or paranoid
-superior

what kind of pt personality is being described

-strives to impress clinician
-special attention
-appears initially as "good pt"
-pt makes you feel that you are the only one that ever listened to them

dependent and demanding

how to handle a dependent demanding style patient

-specify limits with pt (written instructions, F/U appointments, rx refill limits)
-avoid making promises
-emphasize pt responsibility
-remind pt that available time is limited
-do not take credit in remission of pt symptoms to avoid blame if they relapse

what kind of pt personality type is being described

-punctual, compliant, meticulous
-sickness threatens loss of control
-brings a list or diary to discuss symptoms or findings
-respond well to history taking, the PE and lab studies

orderly and controlled

how should you manage an orderly and controlled style pt

-take an orderly and systematic approach
-explain every symptom and each step of PE, DDx, etc
-do not leave loose ends, offer time for pt questions
-summarize often
-take notes to indicate your interest in what they're saying

what type of pt personality is being described

-charming, fascinating, frustrating or angering behavior
-always requires attention and may resent your interest in other duties
-described by others as histrionic, hysterical, manipulative or seductive
-inappropriate behavior

dramatic and manipulative

how to manage a dramatic or manipulative pt

-listen and observe -> try to figure out what pt is trying to gain by their behavior
-remain calm, gentle and firm
-use frequent summaries to remain in control
-remain descriptive and nonjudgmental
-uses phrases such as "well we're really not here to talk about me or my opinion"
-identify pts strengths and feed them back

what kind of pt personality type is being described

-reject help as a pt
-present a hx of continual suffering from disease, disappointment and adversity
-never ending stories of bad luck
-disregard their own needs
-no treatment will help them, hopeless cycle of symptoms
-do not respond to reassurance, optimism or hope

long suffering, masochistic

how to manage a long suffering, masochistic pt

-avoid being overly optimistic or cheerful
-steer clear of focusing on pts strengths or accomplishments
-avoid insensitive or patronizing remark

what kind of pt personality type is being described

-suspicious of healthcare professionals
-often mention how other healthcare professionals made mistakes
-often express failure of the system as a whole
-suggestive insensitivity of health care providers
-become anxious, guarded, suspicious and quarrelsome under stress

guarded or paranoid

how to manage a guarded or paranoid pt

-remain friendly and courteous
-clearly explain your diagnosis and treatment plan
-identify your role and the limitations
-openly acknowledge the pt suspicious attitudes, do not ignore them
-clarify your understanding of the pts beliefs while indicating that you do not necessarily agree with them
-when pt makes a provocative statement be sure not to contradict or argue

what kind of pt personality type is being described

-very self confident
-appears smug, vain or even grandiose
-entitlement to the best
-demand the "senior" clinician or specialist
-attempt to control the visit
-make excessive demands and threaten litigation
-respond with anger and hostility

superior

____________ is a process whereby people experience and express emotional discomfort or psychosocial stress in the language of physical symptoms

somatization

the following is describing what condition

-"doctors have not been able to find the cause"
-symptom description is vague or bizarre
-symptoms persist even after appropriate medical therapy
-illness usually follows a stressful event
-report numerous psychophysical disturbances
-seen multiple physicians/surgeons

functional somatic symptoms

what are signs of an anxious pt

-facial flushing, sweating, rapid speech or silence, fidgeting or even trembling

how can depression manifest physically

chronic fatigue, weakness, insomnia, backaches or headaches

what are the 5 P's of sexual history taking

-Partners (# and gender)
-Sexual Practices (oral, anal, intercourse)
-Past STD's (risk stratification)
-Pregnancy (hx and plans)
-Protection?

what are CAGE questions for detecting a drinking problem

-Cut down (ever felt you needed to cut down?)
-Annoyed with others comments about your drinking
-Guilty (about your use of.....?)
-Eye opener (need to use in AM to function?)
****2 or more positive responses are strongly associated with addiction

what is the leading cause of serious injury and the second leading cause of death among US women of reproductive age

intimate partner violence/domestic violence

what are the 5 stages of a person's response to loss

-denial and isolation
-anger
-bargaining
-depression or sadness
-acceptance

what are important pieces of information to gather during the infant/toddler interview

-any complications during pregnancy and labor
-problems during first few days of life
-detailed family hx if not already taken
-crying?
-sleeping?
-bowel and bladder function?
-immunization status
-developments stages/child temperament

what are components of the well-child visit

-prenatal and birth hx
-milestones
-immunizations
-teeth eruption
-habits
-nutrition
-parental concerns
-intercurrent illness/treatment

what are components of a sick visit

-HPI
-feeding
-hydration
-behavior
-temperature at home
-medications
-similar illness in the past

what are contents of the teenager interview

-parental concerns
-school progress
-habits (food, sleeping, physical activity)
-smoking, drugs, alcohol
-sexual activity
-PMHx
-immunizations
-injury prevention

what is the triangle of trust

-triangle configuration between you, the pt and your computer screen
-not guarding your computer screen from the pt, maintaining as much eye contact as possible and sharing your screen with the pt so that they do not feel excluded or that you may be keeping information from them

what is the "HUMAN LEVEL" in regards to enhancing pt centered EMR use

H-honor the "golden minute" (start of visit technology free)
U-use the triangle of trust
M-maximize pt interaction
A-acquaint yourself with chart
N-nix the screen (disengage from EMR when discussing sensitive info)
L-let the pt look on the screen
E-eye contact
V-value the computer
E-explain what your doing
L-log off (at the end of each visit log off pts chart)