Clinical Skills test 1

What is the definition of clinical skills

any discrete act within the overall process of patient care, like hx taking, performing PE, starting tests/procedure, diagnosing and using therapeutic intervention.

What do you need to become a skilled clinician?

gather info and establish trust

what consists of a patient encounter

what is pts concern and your concern

what are the five components of a pt encounter

initiating the encounter, gathering info aka health hx, performing the PE, explaining and planning, closing the encounter

how do you set the stage of a clinical encounter

check your professional appearance (hair nails body odor), make sure pt is comfortable bc they’re gonna expose important things to you, review the record before seeing the pt, determine your goal before the encounter (getting info, trying/delivering diagnosis/bad news). done bc pts priorities are different than ours. say your name and role when greeting pt, identify pt title, name, gender (don’t use first name, ask pronouns)

how long for initial encounter, how long for follow up

1 hr, 15 min

how do you take health hx on clinical encounter

ask problems

how do you explain and plan your tx

explain how dz causes sx, make sure pts understand condition w teach back. use 3 step process shared decision making

what are the three steps of shared decision making

give options if possible, explore pt preference, see if pt is ready to make decision. this is done to promote optimal therapy, adherence to tx, patient satisfaction

how to close the encounter

let pt know end of visit is near, address last min concerns, address new problems, summarize plan, tx and follow ups

what consists of comprehensive health hx

annual h&p, admission h&p, initial H&P

what consists of focused/problem oriented history

progress note, follow up notes, SOAP note

what is the difference b/w subjective and objective info

sub = what pt tells you vs PE and lab tests

comprehensive health hx should contain

initial info, CC, HPI, PMH, FH, SH, review of systems

what consists of initial info in comp health hx

date and time of hx, 2 pt identifiers, source/liability

what consists of CC in comp health hx

primary reason pt needs care. quote the pt

what are some recommendations for taking health hx?

take notes, keep eye contact, open ended ?s, let pt tell their own story

what are the characteristics of CC in HPI

location, quality, quantity/severity, timing-onset, duration, frequency, modifying factors, associated manifestations pertinent positives and negatives

what are pertinent positives

sx and signs that you’d expect to see if pts possible diagnoses were true

what are pertinent negatives

sx and signs that aren’t present, weakens possibility of diagnosis

what PMH should you include

childhood illness, adult illness, surgical, psychiatirc, OB/GYN, health maintenence (vaccines, screening tests), allergies/meds

what should you ask for FH in health hx

medical hx of immediate fam. age, health, age of death and cause if deceased

what do you ask in personal and social hx

sexual orientation and gender identity. so assigned sex, sexual orientation, gender identity, gender expression, transgender/cis/non binary. also living env, education, employment, religion, ADL. ask about substance abuse.

how to review systems in health hx

head to toe screening tool used to find sx and problems a pt has that allows to make a diagnosis. any new sx add to HPI

general sx =

weight changes/weakness

skin sx =

rash/lumps

HEENT sx =

rhinorrhea, rhinitis, pruritis, epistaxis, headache

neck sx =

lymphadenopathy, goiter

breast sx =

lumps, pain

sputum (color, blood), pleuritic chest pain

respiratory sx =

lay flat while sleeping, SOB

CVS sx =

dysphagia, odynophagia, bowel movement desc (color, size, quality, freq), rectal bleeding, tarry stool

GI sx =

claudication, varicose veins, blood clots in legs

peripheral vascular sx =

freq, dysuria, polyuria, nocturia

urinary sx =

hernias, sores, teste pain

male genital sx =

dysmenorrhea, menorrhagia, metrorrhagia, dyspareunia, ROM

female genetalia sx =

what are the steps of guided questioning

open ended questions to specific questions, avoid leading questions or yes/no qs. one question at a time, offer multiple choices to help, clarify what pt means, encourage with continuers (yes go on), echoing/repeat the pt

is it okay to say “dont worry everything will be okay”

no, bc that isnt fully guarenteed in hospital. acknowledge the pts feeling instead

what is informed consent

clinician educates a pt about risks and benefits and alternatives of procedure. nature of procedure/tx, risk and benefit, reasonable alt, risk and benefit of alt, assess pts understanding

what are advanced directives

document of person’s wishes regarding tx, ensures wishes are carried out if person can’t communicate anymore. aka healthcare proxy, power of attorney, POLST/MOLST, DNR/DNI, will

what is SPIKES of disclosing serious news

Setting (set up interview), perception (assess perception of pt), invitation (assess how much pt wants to know), knowledge (present info according to how much they want to know), emotions (be empathetic), strategy & Summary (make sure pt understands and teach back)

what are social determinants of health?

economic stability, education, social and community context, health and health care, neighborhood and built environment

what are the 5 r’s of humility

reflection, respect, regard, relevance, resiliency

what are the different principles of med ethics

nonmaleficence,, beneficence, respect for autonomy, decision making capacity, confidentiality, informed consent, truth telling, justice.

first do no harm is what principle of med ethics

nonmaleficence

how should you be positioned for a general survey, VS, and pain exam

sitting

where should you stand to greet the pt

on the right side of the pt

what are the five levels of consciousness of the pt

alert, lethargy, obtundation, stupor, coma

opens eyes when spoken to is what level of consciousness

lethargy

opens eyes with tactile stimuli is what level of consciousness

obtundation

arouses w painful stimuli is what level of consciousness

stupor

unarousable is what level of consciousness

coma

what is a tripod position when inspecting posture, gait, motor activity in GS

two hands on the table leaning forward. in COPD pts

a shorter than normal stature can indicate what conditions

dwarfism, turner syndrome

what does height loss indicate in a general exam

osteoporosis, vertebral compression fracture

what does weight loss indicate in a general survey

malignancy, DM, hyperthyroidism, depression

how to measure height

face forward, feet flat slightly apart. head at midline, headplate sits on top back half of head

how to measure weight

remove shoes, make sure stoma/catheter bags are empty, scale reads zero

how to measure BMI

weight in kg/height in m. elevated in muscular individuals

how to take manual blood pressure

pt is seated, comfortable, back supported, legs uncrossed, feet on floor, arm at heart level, free of clothing, and supported.. cuff 2.5 cm above antecubital crease

normal bp is

less than 120/80

elevated bp is

120-139/<80

stage 1 HTN is

130-139/80-89

Stage 2 HTN is`

140>/90>

what is hypertensive crisis

>180/>120

how to measure orthostatic HTN

measure BP laying down, then measure bp standing up. if there’s drop more than 20 in SPB or 10 in DBP = diagnosis. from meds, hypovolemia, blood loss, prolonged rest, autonomic dysfunction

normal pulse is

60-100 bpm

prolonged breath is common in what condition

COPD

normal respiraotry rate is

12-20

normal body temp

37 C/98.6 F

where can you take temps

core body temp, tympanic, oral, rectal, axillary

pyrexia (fever) is at what temp

100.4

hypothermia is at what temp

35 C/ 95 F

what is nociceptive pain

tissue damage to musculoskeletal system, viscera, skin but sensory system is intact. dull, pressing, throbbing, spasmodic

what is neuropathic pain

direct consequence from lesion/disease affecting somatosensory system. electric shock, stabbing, burning, pins and needles

what are the layers of the skin

epidermis (avascular), dermis (vascularized layer = sweat glands, hair follicles), subcutaneous tissue (fat)

vellus hair is

short fine unpigmented hair. peach fuzz

terminal hair is

coarse, thick, pigmented

clubbing nail angle is what

greater than 180

normal angle between nail fold and nail is

less than 180

what are pilosebaceous glands

oil glands that produce fatty substance onto skin surface. palms and soles don’t have them. lubricate and protects skin

what are eccrine sweat glands

control body temp by sweating

apocrine sweat glands are

axilla, genital area

steps for history of skin hair and nail problems

DEPSFAME. duration evolution periodicity social hx fam hx allergy meds exposure to subs.

develops due to direct damage to skin

what is a primary lesion

circumscribed flat area less than 1cm

macule

circumscribed flat area >1cm

patch

solid elevated area <1cm

papule

large elevation of skin, if papules are connected can = this

plaque

solid elevation of skin >1cm going into deeper layers

nodule

small circumscribed elevation of epidermis filled w purulent fluid

pustule

small circumscribed elevation of epidermis containing clear fluid, <1cm

vesicle

circumscribed elevation of the epidermis containing clear fluid >1cm in diameter

bulla

circumscribed raised lesion consisting of dermal edema

wheal

loss of epidermis

erosion

deeper loss of epidermis

ulcer

non blanchable hemorrhage

petechia

non blanchable raised and palpable hemorrhage

purpura

non blanchable large palpable hemorrhage

ecchymosis

how to describe skin lesions

number, size, color, shape, texture (verrucous aka rough/irregular), primary lesion (plaques), location, configuration, confluent (multiple lesions connect)