HAPE Exam 1` LOs

Describe the clinician centered and the patient-centered approach to the clinical encounter.

• Clinician – symptom focused; acquires details and data needed to ID disease, emphasizes pathological disease, can dismiss personal perspective, information for proper management may NOT be elicited 

• Patient – patient-led, recognizes expressions of personal feelings, evokes personal context of symptoms, allows for understanding of patient’s thoughts, ideas, concerns, requests 

Describe the difference between disease and illness

• Disease – pathologic process, explanation clinical uses to organize symptoms and leads to diagnosis 

• Illness – explains how patient experiences disease, includes effect on relationships, function, well-being, outlook/experience of patient 

List and describe the five major steps of the clinical encounter.

1. Initiating encounter 

2. Gathering info 

3. Performing physical exam 

4. Explaining and planning 

5. Closing encounter

Describe disparities in health care.

• social determinants of health, racism, bias, cultural humility

Define implicit and explicit bias.

implicit - unconscious beliefs/associations, lead to negative evaluation of person on basis of perceived group identity

explicit - conscious or deliberate decisions, founded on beliefs, stereotypes, associations on basis of perceived group identity

describe various techniques to mitigate bias in the clinical encounter.

Reflect on patterns of emotion and

behavior

• Pay attention to how YOU feel and

behave

• Be aware of biases

Pause and prepare • Pay attention to triggers

Generate alternative hypothesis • Consider structural forces that

impact behavior

Practice universal communication and

interpersonal skill

• Create a systematic approach to the

patient interview

Explore your patients’ identities • Clarify what identity means to

patient

Explore your patients’ experiences of

bias

• Ask “what have been your

experiences with healthcare”

Define cultural humility

cultural humility - process requiring that indidivudals continue engaging in self-reflection and self-critiques as life-long learners and reflective practitioners

self-awareness, respectful communication, collaborative partnerships

list the 5 Rs of cultural humility.

Reflection, respect, regard, relevance, resiliency

Nonmaleficence

first, do no harm

• avoid causing harm

• minimize negative effects of treatments

beneficence

clinicians are to act for good by preventing or treating disease

autonomy

accept patient choices, patient must have decisional capacity, can opt to reject treatment, collaborative with patient

capacity

clinical designation assesed by clinicians

competency

judicial determinance determined in court

decisional capacity

ability to make autonomous choices that clinicians should respect

• must be able to:

  • understand relevant info, appreciate situation, use reason, communicate choice

• TEMPORAL AND SITUATIONAL

informed consent

communication process in which clinician educates patient about risks, benefits, alternatives of given procedure or intervention

• required elements

  • nature of procedure

  • risks and benefits

  • reasonable alternatives

  • assessment of understanding

Describe the fundamentals of a skilled interview.

• active listening (heart of interview)

• empathetic response

• guided questioning (open → focused, offers multiple choices, clarify, echo/repeat)

• validation

• reassurance

• transitions

• empowering patient

• partnering

• verbal communication (people-first language)

• nonverbal communication

• summarization

“ask me three” approach

1. what is my main problem

2. what do i need to do

3. why is it important for me to do this

List the components of HIPAA Regulations and describe their implementation in medical practice.

• protect privacy of PHI

• secure PHI physically and electronically

• adhere to minimum necessary standard

• specify patient for use and disclosure of health info

what are the patient identifiers

• name, postal address, date elements except year, email/url/ip address, biometric numbers, etc.

protected health info

• describes diagnosis, disease, etc

• past, present, future conditions

when does HIPPA not impose restriction of use and dislcosure of healthcare providers

if they are involved in care

HIPPA rights

• right to ACCESS AND RECEIEVE PHI

• right to REQUEST amendments to info

• right to REQUEST restriction of PHI

• right to RESTRICT disclosure

• right to REQUEST alternative forms of communications

• right to ACCOUNTING of PHI disclosures

Define Standard precautions and Personal Protective Equipment.

Personal protective equipment - specialized clothing or equipment worn by emplopyee for protection against infectious materials

List the various types of PPE utilized in the clinical setting.

Gloves – protect hands

• Gowns/aprons – protect skin

and/or clothing

• Masks and respirators– protect

mouth/nose

• Respirators – protect

respiratory tract from airborne

infectious agents

• Goggles – protect eyes

• Face shields – protect face, mouth,

nose, and eyes

gloves

Purpose – patient care, environmental services, other

• Glove material – vinyl, latex, nitrile, other

• Sterile or nonsterile

• One or two pair

• Single use or reusable

gowns or aprons

Material –

• Natural or man-made

• Reusable or disposable

• Resistance to fluid

penetration

• Clean or sterile

face protection

Masks – protect nose and mouth

• Should fully cover nose and mouth

and prevent fluid penetration

Goggles – protect eyes

• Should fit snuggly over and around

eyes

• Personal glasses not a substitute for

goggles

• Anti-fog feature improves clarity

face protection

Face shields – protect face,

nose, mouth, and eyes

• Should cover forehead,

extend below chin and

wrap around side of face

PPE respiratory protection

• Particulate respirators

• Half- or full-face elastomeric

respirators

• Powered air purifying respirators

(PAPR)

elements of respiratory protection program

• Medical evaluation

• Fit testing

• Training

• Fit checking before use

what is sequence for donning PPE

• gown first

  • if too small, use two. gown 1 tie in front and gown 2 tie in back

• mask or respirator

• goggle or face sheild

• gloves

  • if using two, put larger size first

contaminated areas of PPE

outside front; where PPE have likely been in contect with areas where infectious organism may reside

clean areas of PPE

inside, outside back, ties on head and back

• areas of PPE where contact with infectious organism is not likely

sequence for removing PPE

• gloves first

• face shield/goggles

• gown

• respiratory or mask

where to remove ppe

• at doorway, before leaving room, or in anteroom

• remove respiraotry outside room after door has been closed

standard precautions/universal precautions

• assumes blood or body fluid is infectious

  • Recommends PPE & other infection control practices

    • prevents transmission in any healthcare setting

    • Decisions about PPE use determined by:

    • type of clinical interaction with patient

when to use gloves

• touching blood, body fluids, secretions excretions, contaminated items

• touching mucus membranes, nonintact skin

when to use gowns

procedures and patient care activities when contact of clothing/exposed skin with blood/body fluids, secretions or excretions is anticipated

when to use mask/goggles or face shield

use during patient care activities liekly to generate splashes or sprays of blood, body fluids, secretions or excreitions

expanded precautions PPE

contact, droplet, airborne

contact precautions

conditions contracted through touching or contact (ex. MRSA, C. Diff)

• GLOVES AND GOWN

droplet precautions

spread through contact with secretions, esp through cough or sneeze

• droplets usually travel 3 feet (ex. flu, whooping cough(

• GLOVES, GOWN, MASK

airborne precautions

spread through air over long distances (ex. TB)

• patients in negative pressure room

• GLOVES, GOWN, RESPIRATOR MASK

Compare and contrast a comprehensive patient assessment and a focused patient assessment. Identify the clinical scenario in which each would be utilized.

comprehensive - all elements of history and exam, NEW patients, baseline for future, creates platform for health assessment

focused - RETURN, focused concerns, symptoms restricted to body system

 Differentiate between subjective and objective information.

subjective - symptoms the patient tells you, anything from CLINICAL INTERVIEW

objective - not influenced by personal viewpoint, vital signs, lab, diagnostic testing

components of the comprehensive adult health history.

1. initial information (date/time, data-name, age, gender, source of info/relability)

2. chief complaint (duration from onset, use patient’s words)

3. history of present illness (HPI) - relevant to CC, brief/concise/easily understood, expand on EACH SYMPTOM (OPQRST)

4. past medical history (PMH)

5. family history (FH)

6. personal and social history

7. review of symptoms (ROS)

gravida

number of pregnancies

parity

number of deliveries (term, preterm, spontaneous abortions and terminated pregnancies, living children)

medication allergy

adverse drug reaction mediated by immunologic response (ex. wheezing, hives)

medication side effect

expected and known effect of drug that is not desired outcome (ex. weight gain, nausea)

Compare and contrast the comprehensive physical exam and the focused physical examination. Identify the clinical scenario where each would be utilized.

comprehensive - head to toe, new patient exam, return annual physical

focused - methods relevant to assessment of targeted problem

stethescope

• older - bell (lower frequency) and diagphram (higher frequency)

• newer - big diaphragm and smaller diaphgram

  • tunable

  • light pressure - low frequency

  • firm pressure - high frequency

when to offer chaperone

during sensitive/vulnerable exam

draping patient

untie gown in back to listen to lungs while sitting, uncover one breast at a time, visualize one area at a time

where to stand in exam

• right side of bed and examine with right hand

inspection

close observation

palpation

tactile pressure from palmar fingers or finger pads

percussion

use of striking (plexor finger )to deliver rapid tap or blow against distal finger (pleximeter finger) to evoke sound wave from underlying tissue or organ

ausculatation

use of draphram of stethescope to detect characteristics of sounds (ex. location, timing, duration, pitch, intensity)

goals of examination

1. maximize comfort

2. avoid unncessary changes in position

3. enhance clinical efficiency

• right to left, cephalo-caudal approach

head to toe exam

• General Survey

• Vital Signs

• Cognition, Mental Status, and Cranial Nerves

• Skin, Hair, Nails

• Head, Eyes, Ears, Nose, Throat (HEENT)

• Neck

• Thorax and Lungs

• Cardiovascular system

• Abdomen

• MSK: Upper and Lower Extremity

• Nervous system: central and peripheral

clinical reasoning

differential diagnosis, testing hypothesis, assessment, plan

basic structure of clinical reasoning

• gather initial info (history and physical exam)

• organize and interpret info to synthesize problem

• generate hypothesis (differential diagnoses)

• test hypotheses (diagnostics, imaging)

• plan treatment strategy

diagnostic and treatment strategy

• Flows logically from your working diagnosis

• Diagnostic and therapeutic interventions

• Patient education

• Changes in medication

• Referrals

• Return visits

• *Obtain both patient’s agreement and their participation SHARED DECISION

MAKING

anchoring bias

tendency to lock into salient features in initial presentation early in diagnostic process and failure to adjust in light of later info

availability heuristic

assumption that diagnosis is more likely or more frequently occuring it it more readily comes to mind

confirmation bias

seeking supportive evidence for diagnosis at exclusion of more persusive info refuting it

diagnostic momentum

prioritizing diagnosis made by prior clinicians and discounting evidence of alternative explanations

framing effect

interpretation of information is influenced heavily by way in which information about problem is presented

representation error

failure to take prevalence into account when estimating probaility of diagnosis

visceral bias

visceral arousal (negative and positive feeling towards patients) lead to poor diagnostic decisions

epidermis

• thin outermost layer

• avascular keratinized

dermis

• interconnecting collagen

• nerves, blood vessels, glands

• thin papillary layer and thicker reticular layer

hypodermis

• subcutaneous layer

• fat and connective layer

• thicker than epidermis

epidermis layers

• stratum corneaum

• stratum lucidum

• stratum granulosum

• stratum spinosum

• stratum basal

COME LETS GET SUN BURNED

• old dead cells are shed as new keratinocytes

thin papillary level

• contains fibroblasts (collagen), macrophages

• detects fine touch and pain

• fingerprints come from this layer

thicker reticular layer

• contains fibroblasts (collagen), macrophages

• secretes elastin

• accessory structure

sweat glands

• eccrine - widely distributed; open directly onto skin surface and help control body temp via sweat production

• apocrine - axillary and gential regions, open into hair follices

  • bacterial decomposition of apocrine gland; sweat and body odor

pilosebaceous glands

• produce sebum/oil, secrete through hair follicle

hypodermis

• adipocytes store fat

  • plus fibroblasts, macrophages, nerves, vessels, lymphatics

• insulate deep tissue

• provides padding

• anchors skin to muscle

hair

• everywhere except palms, soles, lips

• shaft, root, bulb

• hair matrix inside bulb (site of hair growth and hair color)

• bulb in hair follice

what is hair follice associated with

• sebaceous gland

• apocrine gland

• arrector pili muscle

• nerve muscle

vellus hair

short, thin, minimal pigmentation (peach fuzz)

terminal hair

coarser, thicker, pigmented

• scalp hair and eyebrows

nails

• grow proximal to distal

• surrounded by nail folds

• proximal nail fold/eponychium forms cuticle

• nail growth comes from matrix/nail root

• grow 0.1mm daily

what is a sample ROS for derm

• new rash or lesion

• new lump or growth

• changing lesion

• itchiness, pain

• redness, irritation

• change in hair texture, quantity, distribution

• nail changes - discoloration, lifting, texture change

examples of objective findings/general appearance

• apparent state of health

• facial expression

• dress, grooming

• skin color

• height, weight

• odor of body

• LOC

• signs of distress (ex. cardiac, respiratory, pain/grimace, anxiety, positioning)

what is important for vital signs

• measure accurately

• recheck and confirm if in doubt to patient situation changes

• trends

height and weight

• height in stocking feet, height without shoes & minimal clothing

• build

• over/underweight

• BMI

components of vital signs

• BP

• HR/rhythm

• temperature

• RR/rhythm

• five vital sign - O2 saturation, used to be pain

normal vital

• BP - between 90/60mmHg and 120/80 mmHg

• pulse - between 60-100

• RR - between 12-20

• temp - 37 celsius, 98.6 F

• heigh - avg men: 5’9”, avg women: 5’4”

• weight - varies significantly

• BMI - normal 25

tachycardia

>100bpm

bradycardia

<60bpm

hypotension

<90/60mmHg

hypertension

>120/60mmHg

hyperpnea

increased volume with or without increased rate of breathing

• deeper breathing, might occur in exercise

if rate if normal and rhythm is regular then

count rate for 30 seconds and multiply by 2 (or 15sec × 4)

• do NOT use thumb

pulse amplitude

• 0 - no pulse

• 1 - faint, detectable

• 2 - slightly diminished

• 3 - normal

• 4 - bounding

contour of pulse

measured by waveform of brachial artery while using cuff

what to do if irregularity is noted with pulse

• assess rhythm at cradiac apex with stethoscope

• listen for full 60 seconds

• early beats with regular rhythm?

• irregularity vary with respirations?

• rhythm irregular?