FOPC Lecture Exam1 Part 1

Medical Professionalism According to ABMS

•Medical professionalism is a belief system in which group members ("professionals") declare ("profess") to each other and the public the shared competency standards and ethical values they promise to uphold in their work and what the public and individual patients can and should expect from medical professionals.

ACOFP Professionalism

Demonstrate respect, compassion, and integrity.

Demonstrate a commitment to ethical principles

Demonstrate sensitivity and responsiveness to patients' culture, age, gender, and disabilities

3 fundamental principles of professionalism (ABIM, ACP, and European Federation of IM)

•Primacy of patient welfare
•Patient autonomy
•Social Justice

10 Commitments of professionalism (ABIM, ACP, and European Federation of IM)

•Competence
•Honesty with Patients
•Patient confidentiality
•Appropriate relations with patients
•Improving quality of care
•Improving access to care
•Just distribution of finite resources
•Scientific knowledge
•Maintaining trust by managing conflicts of interest
•Professional responsibilities

Ethics definition

•"Ethics are a set of principles crafted through reflection and discussion to define right and wrong. Clinical ethics, which guide our professional behavior, are neither static nor simple, but several principles have guided clinicians throughout the ages."

Key Principles of Medical Ethics

•Nonmaleficence​
•Beneficence ​
•Autonomy​
•Confidentiality​
•Justice

AOA Code of Ethics

1.Confidentiality​
2.Be honest with the patient​
3.Do not discriminate​
4.Do not abandon your patients​
5.Promote health and LLL​
6.Maintain high standards/Regulate self​
7.Truth in advertising​
8.Don't lie about your degrees​
9.Ask for help​
10.Dispute about ethics, ask appropriate people​
11.Arguments about treatment decided by attending​
12.Do not commit fraud​
13.Obey the law​
14.Participate in Community Service​
15.Don't have sex with your patients​
16.Don't sexually harass anyone​
17.Gifts received to promote products should be used for patients​
18.Do not misrepresent self​
19.Follow laws regarding research

Year of osteopathic oath

1954

How to help pt feel comfortable when talking to them

•Wash your hands
•Clean your stethoscope
•Introduce yourself and use the patient's name
•Sit down in front of the patient
•Read the patient's nonverbal cues

Pt Interview tips

•Start with open-ended questions
•Patient-centered interviewing (verbal and nonverbal techniques)
•Use active listening

Things to do w/in the encounter

•Build rapport
•Elicit the patient's agenda
•Negotiate the agenda (Part of expectations)
•Elicit the patient's perspective
•Empathize
•Summarize
•Transition

How to respond to emotional cues

NURSE
•Name the emotion
•Understand or legitimize
•Respect the patient going through it
•Support the patient
•Explore other emotions that may be derived from this.

SOAP stands for

Subjective
Objective
Assessment
Plan

subjective components

•CC
•HPI
•PMH
•PSH
•FH
•Soc
•Allergies
•Medications
•ROS

chief complaint

•Simply put, the chief complaint is what the patient states is wrong. Usually just a few words at most.
•E.g. Ear pain, Cough, fever...
•This is easily obtained with a simple question.
•What brings you in today?
•How may I help you today?

History of Present Illness (HPI)

•This is their story. What happened and how?
•Make sure to get an entire story

OLD CAARTS A

•Onset
•Location
•Duration
•Character
•aggravating/alleviating factors
•Radiation
•Timing
•Severity
•Associated symptoms

past medical history

-childhood diseases
-chronic diseases
-if pediatric ask if born term vs pre-term, complications, and c-section vs vaginal
-preventative screenings and health maintenance
-mammogram/colonoscopy/pelvic exam/PAP/cholesterol check
-psychiatric

female obstetric history questions

•Do you have menstrual cycles?
•When was the First Day of your Last Menstrual Cycle (FDLMP)
•Have you ever been pregnant? How many times have you been pregnant?
•How many children did you deliver at term?
•Were any born prematurely (delivered between 20 and 37 weeks)
•Were any pregnancies terminated prior to 20 weeks?
•How many children do you have?
•(This is abbreviated GTPAL—Gravid, Term, Preterm, Abortion, Living)
•Alternately, there is the Gravid, Para method of documentation (i.e., G3P2)

past surgical history

what, why, when, who

family history

-parents alive? Age of death, cause, chronic disease dx
-sibling health
-children's health
-heart disease/cancer/alzheimer's run in family?

Alcohol CAGE Questionnaire

-Cutting down considered?
-Annoyed/criticized by others b/c of your drinking?
-Guilty about your drinking?
-Eye opener (need a drink right away to steady nerves or get rid of hangover?)

Social History

•Recent Travel, esp outside the country
•Occupation and occupational exposure
•Education Level
•Tobacco Use
•Alcohol Use
•Illicit or Recreational Drug Use
•Marital Status
•Sexual Orientation and Practices
•Gender Identity
•Family/Social Support
•Diet and Exercise
•Feel safe in relationship
•Activities of Daily Living

Medications

- Include all prescription medications—the dose, the frequency, and the route. Is the patient taking this medication as prescribed? Become familiar with generic names AND brand names.

- Ask specifically about inhalers

- Ask about OTC medications, i.e., ibuprofen, Tylenol, cough medicines, antihistamines, nasal sprays, PPIs, etc.

- Ask about supplements, vitamins, and herbal preparations

Allergies

- Any Drug Allergies? If yes, what reaction?? Hives? Anaphylaxis? Rash? Has the patient ever experienced an adverse reaction to a medication?

- Any Food Allergies? What reaction? (if the patient is aware of a food allergy, the reaction has typically been severe and the patient carries an Epi-pen)

- Any Allergies to Latex? WHAT REACTION?

- Any Environmental Allergies? Pollen? Dust? Pet Dander?

Immunizations

childhood and current?

Review of Systems (ROS)

- yes/no questions
- This often uncovers problems that the patient has failed to mention, or has overlooked.

List of systems for ROS

-general
- skin
- head, eyes, ears, nose, throat
-neck
-breasts
-cardiovasc
-GI
-UI
-genital
-MSK
-psychiatric
-neurologic
-hematologic
-endocrine

USPSTF Grades

A: recommends service (substantial benefit)
B: recommends service (moderate benefit)
C: clinicians may provide service to selected patients; but small benefit for most
D: does not recommend service
I: inconclusive evidence so far, unable to determine balance of harms vs benefits

Screening vs diagnostic testing

screening is the use of a test to identify a disease before any clinical signs or symptoms manifest- special type of testing, less accurate, less expensive, not basis for tx

in diagnostic testing, symptoms are already present, more accurate, more expensive, used as basis for tx, used to eval sx/signs/lab results

USPSTF hypertension screening guidelines

18+ yo w/o known hypertension (A)

yearly for 40+ yo and those w/ increased risk

every 3-5 years for 18-39 yo's w/o increased risk and prior normal results

risk factors for hypertension (HTN)

A. Older age

B. Black race

C. Family Hx

D. Excess weight and obesity

E. Lifestyle habits (lack of physical activity, stress, and tobacco use)

F. Dietary Factors (diet high in fat or sodium, diet low in potassium, or excessive alcohol intake)

How to measure BP outside of clinic

•Ambulatory blood pressure monitoring: patients wear a programmed portable device that automatically takes blood pressure measurements, typically in 20- to 30-minute intervals over 12 to 24 hours while patients go about their normal activities or are sleeping.

•Home blood pressure monitoring: patients measure their own blood pressure at home with an automated device. Measurements are taken much less frequently than with ambulatory blood pressure monitoring (eg, 1 to 2 times a day or week, although they can be spread out over more time).

*Blood pressure measurements should be taken at the brachial artery (upper arm) with a validated and accurate device in a seated position after 5 minutes of rest

BP categories

normal:

AAFP diagnostic criteria for HTN

Adults: HTN dx when blood pressure is \> 140/90 mm Hg (to reduce all cause and cardiovascular mortality)

USPSTF - Prediabetes and Type 2 Diabetes Mellitus (Type 2 DM) Screening

-asymptomatic 35-70 yo's who are overweight/obese (B)

- every 3 years may be reasonable for adults with normal blood glucose levels

How: There are three recommended blood testing methods to identify or diagnose prediabetes/diabetes
•A1c
•Fasting plasma glucose
2-hour post 75g oral glucose challenge

Diagnosis of Pre-/Diabetes: A1c and blood glucose

In general, an A1c:
•Below 5.7% is normal
•Between 5.7% and 6.4% is diagnosed as prediabetes
•\> 6.5% on two separate tests indicates diabetes
(pregnant/uncommon hemoglobin form can make A1c test inaccurate)

In general, fasting blood sugar levels:
•< 100 mg/dL (5.6mmol/L) is normal
•100-125 mg/dL (5.6 - 6.9 mmol/L) is diagnosed as prediabetes
•\>126mg/dL (7.0 mmol/L) on two separate tests is diagnosed as diabetes

oral glucose tolerance test

commonly used to diagnose gestational diabetes

•Patient's will fast overnight and then drink a sugary liquid at the office or lab testing site. Blood sugar levels are tested periodically for the next two hours.

In general:
•Less than 140 mg/dL (7.8 mmol/L) is normal
•140 to 199 mg/dL (7.8 - 11.0 mmol/L) is consistent with prediabetes
•\> 200 mg/dL (11.1 mmol/L) or higher after two hours suggests diabetes

Hyperlipidemia (HLD)

many kinds of lipid disorders (dylipidemia's) related to HDL, LDL, and TAG levels and increase risk for cardiovasc disease

low HDL, high LDL and TAGs

HLD screening USPSTF

-men 35+ yo (A)
-women 45+ yo w/ increased risk for chronic heart disease (CHD) (A)
-women 20-45 yo w/ increased risk for CHD (B)
-men 20-35 w/ increased risk for CHD (B)
-men 20-35 and women not at increased risk (C)

Heart Health Risk Factors

-age, family history, previous history, sex (things you can't change)

-BP, blood sugar/diabetes, BMI, chronic inflammation, diet, exercise, HDL, smoking, stress, total cholesterol (things you can change)

-environment, income, social isolation (social factors)

USPSTF Lung Cancer Screening

-adults 50-80 w/ 20-pack-year smoking hx and currently smoke or quit w/in past 15 years (B)

Pack year history

number of packs per day x number of years smoked

ex: (1 pack per day) x (30 years) \= 30 pack years

USPSTF Breast Cancer screening

-women 50-74 yo (B)
-women 40-49 yo (C)
-all women, women w/ dense breasts, women 75+ yo (I)

USPSTF cervical cancer screening

-women 21-65 yo (A)
-women under 21, or had hysterectomy, or older than 65 (D)

USPSTF prostate cancer screening

-men 55-69 yo *C)
-men 70+ yo (D)

prostate cancer risk factors

older age, african american race, family hx

prostate cancer testing

•Screening begins with measuring the amount of prostate-specific antigen (PSA) protein in the blood
•
•Elevated PSA level MAY be prostate cancer, but can also be caused by other conditions, including an enlarged prostate (benign prostatic hyperplasia or "BPH") and inflammation of the prostate (prostatitis)
•Some men without prostate cancer may therefore have false-positive results

USPSTF colorectal cancer screening:

-adults 50-75 yo (A)
-adults 45-49 yo (B)
-adults 76-85 yo (C)

colonoscopy every 10 years or cologuard every 1-3 years

Colorectal cancer screening tests

•Colonoscopy - allows for direct visualization of the colon in 98% of cases, allow for polyp removal at time of discovery in most cases for testing, quick result times
•Do have to bowel prep and undergo anesthesia for procedure
•
•Cologuard - is a stool DNA test that requires the patient to collect an entire bowel movement into a special sealed container, that is then mailed or brought to the lab for test. The test itself looks for microscopic blood in the stool and altered DNA
•Advantages: Done at home and without anesthesia
•Disadvantages: Less reliable and more prone to false positives. Also, patients must collect their own feces.
•If a patient has a positive Cologuard, then they must undergo a colonoscopy. So, in most cases, why not just do the colonoscopy?

USPSTF anxiety screening

-adults 64 and younger, including pregnant and postpartum persons (B)
-adults 65+ yo (I)

GAD-2 and GAD-7

USPSTF depression screening

-adults, including pregnant and postpartum persons, and older adults (B)

PHQ-2 and PHQ-9

osteoporosis screening tool

•DEXA (dual x-ray absorptiometry) scans - measure bone density (thickness and strength of bones) by passing a high and low energy x-ray beam (a form of ionizing radiation) through the body, usually in the hip and the spine.
•
•Diagnosis is based on 3 locations as determined by the Bone Health & Osteoporosis Foundation.
• the diagnosis of osteoporosis in clinical practice be made by DEXA using the lowest T-score of the lumbar spine (L1-L4), total proximal femur, or femoral neck


•

Osteoporosis vs. Osteopenia

•Osteoporosis - is characterized by low bone mass, microarchitectural disruption, and skeletal fragility, resulting in decreased bone strength and an increased risk of fracture
•Defined as T-score value \> -2.5

•Osteopenia - is a clinical term used to describe a decrease in bone mineral density (BMD) below normal reference values, yet not low enough to meet the diagnostic criteria to be considered osteoporotic
•Defined as T-score value between -1 to -2.5

USPSTF osteoporosis screening

-women 65+ yo *B)
-postmenopausal women

Osteoporosis Risk Assessment

•The Fracture Risk Assessment Tool, or FRAX, is a free online tool that estimates your risk of having a hip or other major fracture in the next 10 years, especially if you have osteoporosis

USPSTF Abdominal Aortic Aneurysm (AAA)

\-men 65-75 yo who have ever smoked (B) -men 65-75 yo who never smoked (C) -women who never smoked (D) -women 65-75 yo who have ever smoked (I)

USPSTF Gonorrhea/Chlamydia

-sexually active women (

Gonorrhea and Chlamydia testing

•The US Food and Drug Administration approves NAATs for use on urogenital and extragenital sites, including urine, endocervical, vaginal, male urethral, rectal, and pharyngeal specimens.

•Urine testing with NAATs is at least as sensitive as testing with endocervical specimens, clinician- or self-collected vaginal specimens, or urethral specimens in clinical settings. The same specimen can be used to test for chlamydia and gonorrhea

How to Assess Risk for Gonorrhea and/or Chlamydia

-women 15-24 have highest infection rates
-if women 25+ yo, increased risk if: previous or coexisting STI, new or more than 1 sex partner, sex partner has multiple partners at same time, sex partner w/ STI, inconsistent condom use, hx of exchanging sex for money/drugs, hx of incarceration

USPSTF syphilis

-asymptomatic nonpregnant adolescents and adults w/ increased risk (A)

Who is at risk for syphilis?

Who are at risk?
•Men who have sex with men
•Persons with HIV infection or other STI
•Persons who use illicit drugs
•Persons with a history of incarnation, sex work, or military service

*Always be aware of community prevalence

Syphilis screening tests

Testing:
•Traditional screening algorithm: Screen with an initial nontreponemal test (eg, Venereal Disease Research Laboratory [VDRL] or rapid plasma reagin [RPR] test). If positive, confirm with a treponemal antibody detection test (eg, T pallidum particle agglutination [TP-PA] test).

Interval:
•Although evidence on optimal screening intervals is limited for the general population, men who have sex with men or persons with HIV infection may benefit from screening at least annually or more frequently (eg, every 3 to 6 months) if they continue to be at high risk

USPSTF HIV screening recommendations

-pregnant persons (A)
-adolescents and adutls 15-65 yo (A)

ex: men who have sex w/ men

check for HIV antibodies/antigen

USPSTF hep C screening

-adults 18-79 yo (B)

HepC screening how often?

usually one time screening, periodic for those w/ continued risk (ie: persons w/ past or current IV drug use)

HepC risk factors

-most common: blood transfusions before July 1992 and hx of illicit IV drug use

-less common: born to mom infected with HepC, hx of chronic hemodialysis, etc

USPSTF Alcohol abuse screening recommendations

-adults 18+ yo including pregnant women (B)

Alcohol Screening questions to remember

If a patient does consume alcohol, you should ask:
•How often do they consume alcohol? - this needs to be SPECIFIC!

•How many drinks do they consume? - this needs to be as SPECIFIC as possible

•What type of alcohol do they drink - beer?, grain alcohol?, liquor?, mixed drinks?

•How big is the glass/bottle/etc. that they consume with each drink? - need to be as SPECIFIC as possible

vital signs go where in SOAP note?

objective

respiratory rate

•Assess the following:
•Rate - count for 30 seconds and multiply by 2
•Bates says to count for a full minute
•Rhythm - if irregular, count for a full minute
•Depth
•Effort of breathing
•Normal is 12-20 breaths/minute

(most lied about vital sign)

Ways to describe respiration

•Labored / Unlabored
•Comfortable
•Tachypneic (fast breathing)
•Prolonged expiratory phase
•Shallow
•Irregular

Heart Rate (pulse)

-usually at radial artery

-Evaluate: Rate, Intensity, Rhythm, Symmetry

Normal is 60-100 beats per minute
< 60 bpm is bradycardia
\> 100 bpm is tachycardia

HR intensity

Intensity:
0 - Not palpable; absent
1+ - Palpable, weak, easily obliterated
2+ - Easily palpable, brisk, normal
3+ - "Bounding", harder to obliterate

HR Rhythm

Rhythm:
- Regular
- Irregular
- Has a pattern
- Does not have a pattern

HR Symmetry

pulses same on both sides?

Pulse Oximetry (SpO2)

Indirect measurement of arterial oxygen saturation
Oxygen saturation - Percent of hemoglobin that is carrying O2
Normal is ≥ 95%
Fast, inexpensive, non-invasive, provides continuous data

Pulse ox sources of error

Poor probe placement
Motion artifact - shivering
Hypoperfusion/vasoconstriction/hypothermia
Nail polish
Bright light