Fundie's 2nd Quarter Study Guide

HPI

history of present illness

-chronological description of symptoms/progression

-from onset to present

-all relevant medical events (recent=most important)

Why does the HPI matter?

-focuses on differential diagnosis

-guides physical exam & treatment plan

-social context of patient

Core Components of the Clinical Interview

-Chief Complaint (CC)

-HPI (History of Present Illness)

-Review of Systems (ROS)

-Past Medical/Past Surgical History (PMH/PSH)

-Medications

-Allergies

-Family History (FH)

-Social History (SH)

HPI Structure

-Start broad then narrow your focus

-Let the patient finish before asking specific questions

-Follow-up questions ("tell me more about that")

OLDCARTS

Onset, Location/Radiation, Duration, Character, Aggravating factors, Relieving Factors, Timing, Severity

SOCRATES (especially for pain)

Site, Onset, Character, Radiation, Associated symptoms, Timing, Exacerbating/Relieving factors, Severity

OPQRST

Onset, Provocation, Quality, Region/Radiation, Severity, Time

Specialized reproductive history of HPI?

Last menstrual period (LMP), pregnancy history, menarche (1st period), menopause (periods stop)

Specialized pediatric components included in HPI?

Pregnancy/birth complications, prematurity, immunizations, developmental milestones

Specialized infectious disease components included in HPI?

Travel, animal exposure, known disease contact

Focused/Targeted Interview

-Experienced clinicians ask fewer, more relevant questions

-Use illness scripts (pattern recognition)

-Beginners ask more detailed, full questions

Biases

-Anchoring

-Availability

-Context Error

-Premature Closure

-Representativeness Restraint

-Implicit Bias

Health Literacy

knowledge of health information needed to make good choices about your health

-be able to phrase in simple terms as a physician

Legal Issues

fear of disclosure

(immigration, drugs, etc)

Transference

Redirecting emotions (can be physician to patient of vice versa)

Clinician Pressure

Stress, interruptions, other things that affect one's listening or attention towards patient

Components of the Middle Interview

-HPI (History of Present Illness)

-Other active problems (OAP)

-Past Medical History (PMH)

-Family history (FH)

-Social History (SH)

-Review of Systems (ROV)

Other Active Problems (OAP)

-Part of HPI

-Explore each problem using 8 components

-Limit amount of OAP while setting agenda

-remember time but don't rush

What does Past Medical History (PMH) include?

Past illnesses, injuries, hospitalizations, surgeries, childhood/adult diseases/conditions, screenings, immunizations, reproductive history, medications, and allergies.

How should past medical history be documented?

Related to the chief complaint (CC):

-include it in the History of Present Illness (HPI)

Unrelated to chief complaint (CC):

-list it under Past Medical History (PMH)

Family History

-Can reveal contagious, toxic, familial, heritable conditions

-Understand genetic patterns and support systems

-Include parents, siblings, children, age, health, cause of death (if applicable), diseases

Social History

-Occupation

-Diet

-Exercise

-Safety/Risk Taking Behavior (use helmets, seatbelts, etc.)

-Substance use (CAGE)

-Personal/Sexuality: pronouns, partners, STD risk, contraceptive

-Intimate Partner Violence (IPV): ask safety questions

Review of Systems

-Systematic "head-to-toe" check to ensure no overlooked symptom

-Often used to confirm completeness of the HPI

What leads to stronger physician-patient relationships?

Effective communication builds trust and rapport, establishing a foundation for shared decision-making.

How does effective communication improve information exchange?

It improves the quality and clarity of clinical encounters and reduces errors or misunderstandings.

What are the benefits of effective communication in healthcare?

It leads to better patient adherence to treatment plans, higher patient satisfaction scores, and reduced medical utilization and healthcare costs.

What social factors can affect communication in healthcare?

Factors include patient stress, mental health conditions, substance use, intimate partner violence, financial hardship, and negative prior medical experiences.

What is the placebo effect?

A health change resulting from treatment with no medically active substance, influenced by the patient's expectations.

How can a physician's communication influence clinical outcomes?

The way a physician communicates about treatment efficacy and expectations can significantly change outcomes.

What did the Egbert et al. (1964) study demonstrate?

Patients receiving a confident discussion about postoperative pain experienced less pain, reduced opioid use, and earlier discharge.

What are key elements of creating a good communication environment?

Greet patients warmly, make eye contact, sit down, and create a safe, respectful space.

What is the importance of verbal communication in healthcare?

It conveys thoughts and emotions, improving comprehension and patient empowerment.

How should healthcare providers introduce themselves?

Introduce yourself and your role, identify everyone in the room, and be transparent when discussing with learners or supervisors.

Why is tone of voice important in verbal communication?

Tone affects meaning; identical sentences can convey enthusiasm, sarcasm, or indifference.

What strategies can improve patient engagement during communication?

Use visual aids, ask open-ended questions, and connect medical advice to patient values.

What is the 'Teach-Back' method?

A technique where patients recap key points in their own words to confirm understanding.

What role does non-verbal communication play in healthcare?

Non-verbal cues often communicate more than words, including posture, facial expressions, and eye contact.

What are the risks of using family or friends as interpreters?

Risks include misinterpretation, personal bias, and patient unwillingness to share sensitive information.

Why should children never be used as interpreters?

Children may be emotionally overwhelmed, likely to make errors, and can cause family conflict.

What is the purpose of the Qualified Bilingual Staff (QBS) program?

It allows bilingual employees to work with LEP patients after passing a validated language assessment.

What are the goals of the end of the interview in healthcare?

Share information clearly, create a plan together, motivate the patient, and ensure understanding.

What should be assessed before delivering information to a patient?

Assess how much the patient wants to know and respect their autonomy and preferences.

What does patient autonomy entail?

Patients have the right to make decisions, even against medical advice, requiring diagnosis, prognosis, and treatment options.

How should a diagnosis be delivered to a patient?

Tie it back to their original concern and explain the diagnosis, prognosis, treatment options, and necessary tests in simple language.

What is the purpose of clarifying the meaning of a diagnosis?

To ensure the patient understands their condition and its implications.

What should be reviewed regarding disease and treatment?

Side effects of the disease and treatment options.

Why is it important to address lifestyle modifications with patients?

To help patients make informed changes that can improve their health.

How should patient culture and beliefs be considered in education?

By respecting and integrating their cultural context into the treatment plan.

What types of resources should be provided to patients?

Written, visual materials, and resources in the patient's primary language.

What is shared decision making in patient care?

A collaborative process where patient values, goals, fears, and beliefs are incorporated.

What is the Teach-Back Method?

A technique where patients repeat the plan in their own words to confirm understanding.

What percentage of information do patients typically remember after a consultation?

Approximately 20%.

What are the stages of change in the Transtheoretical Model (TTM)?

Pre-contemplation, Contemplation, Preparation, Action, Maintenance.

What is a key strategy to improve patient adherence?

Good communication, which can double adherence rates.

What should be done to motivate patients effectively?

Connect recommendations to their goals and encourage small, achievable steps.

What is unconscious bias in patient care?

Cognitive shortcuts that can lead to stereotyping and assumptions about patients.

What are the types of patient visits mentioned?

New patient, follow-up, follow-up with bad news, and follow-up for provider-initiated topics.

What is the purpose of the Review of Systems (ROS)?

To identify additional symptoms and screen for problems unrelated to the chief complaint.

How should questioning begin in the ROS?

With a broad probe to gather general information.

What is the recommended style of questioning in the ROS?

Start with open-ended questions, then move to closed-ended questions.

What should be done if a patient provides too much data during the ROS?

Refocus the conversation to gather relevant information.

What is the difference between positive and negative ROS?

Positive ROS indicates the patient affirms many symptoms; negative ROS means no symptoms or fatigue.

What is a key strategy to minimize bias in ROS?

Active listening and asking one question at a time.

What is the standard ROS?

A comprehensive review covering all 17-19 body systems.

What is a targeted ROS?

An adjusted review based on age, sex, risk factors, and chief complaint.

What should be included in the general ROS?

Sleep problems, appetite changes, weight changes, fatigue, fever/chills.

What symptoms are assessed in the skin ROS?

Rashes, lumps, itching, changes in skin, hair, or nails.

What key questions are included in the cardiac ROS?

Chest pain, palpitations, indigestion, and chest pressure with exertion.

What should be asked in the pulmonary ROS?

Cough, sputum production, shortness of breath, and wheezing.

What are common questions in the gastrointestinal ROS?

Nausea, vomiting, diarrhea, constipation, and abdominal pain.

What is a strategy to help patients recall timing of symptoms?

Using holidays, birthdays, or major events to improve date accuracy.

When is the ROS typically conducted during a patient interview?

At the end of the interview

What type of questioning does the ROS use?

Open to closed questioning

What should be avoided during the ROS?

Bias

How is the ROS summarized?

By system

What is the main argument regarding the Chief Concern in medicine?

Narrative knowledge is essential to good medical practice.

What should replace or supplement the 'chief complaint' in medical records?

The 'chief concern' related to the patient's deeper worry or goal.

How does narrative knowledge benefit physicians?

It helps connect symptoms with meaning and understand patients' values, fears, and goals.

What are the three modes of understanding health according to Kenneth Boyd?

Disease, sickness, and illness.

What does the term 'katharsis' refer to in the context of medicine?

Purification/clarification in tragedy, linking understanding and healing.

What was the outcome of the case study involving the young mother with abdominal pain?

Her psychosocial roots of pain were identified through her narrative.

What are the five stages of the Trans-Theoretical Model for Behavior Change?

Precontemplation, Contemplation, Preparation, Action, Maintenance.

What is the focus during the Precontemplation stage?

Raise awareness and explore pros vs. cons of behavior.

What is the focus during the Contemplation stage?

Build motivation and reduce perceived negatives.

What is the focus during the Preparation stage?

Plan, set goals, and build confidence.

What is the focus during the Action stage?

Support consistency, reward progress, and avoid triggers.

What is the focus during the Maintenance stage?

Prevent relapse, stay motivated, and manage challenges.

What is the significance of decisional balance in behavior change?

Change occurs when benefits outweigh costs.

What is self-efficacy?

Confidence in one's ability to change, essential for progress.

What is the core purpose of an oral case presentation?

To communicate a patient's story to another clinician.

What is the one-liner in an oral presentation?

A summary that includes the patient's age, key identifiers, main problem, and duration.

How should the case be presented?

As a story, using chronology and patient perspective.

What should be included in the structure of an oral presentation?

One-liner, chronological story of illness, current evaluation, and follow-up outcome.

What is a key takeaway for giving a strong oral presentation?

It's about choosing details that tell the right story, not just listing everything.

What does the term 'relapse' signify in the context of behavior change?

It is a normal part of the change process and can be informative.

What is the role of narrative-based medicine?

To encourage collaboration and make the patient an active participant in defining health goals.

How can physicians be taught narrative and ethical awareness?

Through training in narrative comprehension and literary analysis.

What is the relationship between narrative knowledge and the chief concern?

Recognizing the chief concern enhances treatment effectiveness and patient well-being.

What does the cyclical nature of change imply?

Each cycle builds self-awareness and resilience.

What is the importance of follow-up after discharge in oral presentations?

It builds clinical judgment and shows ownership and professionalism.