Clinical Skills- Lectures 1-4

Definition of clinical skills

Any discrete act within the overall process of patient care

Examples of clinical skills

History taking, performing physical examination, initiating clinical tests/procedures, undertaking diagnostic and therapeutic interventions

Why are clinical skills important?

To become a skilled clinician with effective implementation of all clinical skills

What do you need to become a skilled clinician?

Be able to gather information and establish trust; approach the encounter from both clinician-centered and patient-centered perspectives

Five components of a clinical encounter

1) Initiating the encounter

2) Gathering information (health history)

3) Performing the physical examination

4) Explaining and planning

5) Closing the encounter

Step 1 of initiating a clinical encounter

Set the stage

What should you check about yourself before seeing a patient?

Your professional appearance - hair, nails, body odors

Factors that help make a patient comfortable during an exam

Lighting, room temperature, privacy, eye contact while being aware of personal space

Why is patient comfort important when setting the stage?

Because sharing personal information and getting undressed can be sensitive for patients

What should you review before seeing the patient (set the stage)?

Age, gender, problem list (past medical/surgical history), medications, allergies

Why review the patient's record before the visit?

To reconcile the information during the visit

What should you set before an encounter (set the stage)?

Your agenda - determine your goal: obtaining information, attempting to diagnose, or delivering a diagnosis/bad news

Why is setting an agenda important?

The patient's priorities might be different from ours, and time is limited

Typical length of an initial patient encounter

1 hour

Typical length of a follow-up patient encounter

15 minutes

What should you identify about a patient at the start of an encounter?

Patient's title, name, and preferred gender pronoun

When can you use a patient's first name?

Only after you have received permission

Terms to avoid when addressing patients

"Dear" and "sweety" - they can be demeaning

How should you find out a patient's preferred pronouns?

Ask what pronouns he or she prefers

Step 2 of the clinical encounter

Gather information, aka take the health history

Step 3 of the clinical encounter

Physical examination

Step 4 of the clinical encounter

Explaining and planning

What is "teach back" in explaining and planning?

Having the patient explain back their understanding of the condition to verify comprehension

What process is used for shared decision making?

A three-step process: give options if possible, explore the patient's preferences, and check if the patient is ready to make decisions

Why is shared decision-making important?

It promotes optimal therapy, adherence to treatment, and patient satisfaction

Step 5 of the clinical encounter

Closing the encounter

What should you do when closing an encounter?

Make the patient aware the visit is ending, address last-minute/new concerns, and summarize the plan, treatment, and follow-up

Case 1: 51-year-old man comes to the emergency department complaining of chest pain for 3 days. What is an example of a documented date and time of encounter?

6/16/26, 10 AM

Case 1: Case 1: 51-year-old man comes to the emergency department complaining of chest pain for 3 days. What are examples of documented patient identifiers?

Bob Mann, DOB 1/29/1974

Case 1:51-year-old man comes to the emergency department complaining of chest pain for 3 days. What is Bob's chief concern?

Chest pain (documented in his own words: "chest has been bothering me")

Two general types of health history

Comprehensive health history and focused/problem-oriented history

Examples of comprehensive health history

Annual H&P, admission H&P, initial H&P

Examples of focused/problem-oriented history

Progress note, follow-up note, SOAP note

Define subjective information (health history)

What the patient tells you

Define objective information (health history)

Physical examination findings and all laboratory and diagnostic testing results

Components of a Comprehensive Health History (7)

Initial information, chief complaint (CC), history of present illness (HPI), past medical history, family history, personal and social history, review of systems (ROS)

What does "initial information" in a health history include?

Date and time of encounter; patient identifiers (at least 2: name, DOB, SS#, MR#); source/liability (patient, family, bystander, facility)

How many patient identifiers should be documented?

At least 2

Examples of patient identifiers

Name, date of birth, Social Security number, medical record number

Examples of history source/liability

Patient, family, bystander, facility

Define chief complaint (CC)

The primary reason why the patient is seeking care, usually one or two complaints

How should the chief complaint be documented?

Quote the patient directly, e.g. "chest has been bothering me"

Elements of the History of Present Illness (HPI) (8)

Location, quality, quantity/severity, onset, duration, frequency, modifying factors, associated manifestations (pertinent positives and negatives)

Define History of Present Illness (HPI)

Details and characteristics of the chief complaint

Case 1: 51-year-old man comes to the emergency department complaining of chest pain for 3 days. Example of Bob's HPI - Location

Mid-epigastric

Case 1: 51-year-old man comes to the emergency department complaining of chest pain for 3 days. Example of Bob's HPI - Quality

Sharp/stabbing

Case 1: 51-year-old man comes to the emergency department complaining of chest pain for 3 days. Example of Bob's HPI - Quantity/Severity

7/10

Case 1: 51-year-old man comes to the emergency department complaining of chest pain for 3 days. Example of Bob's HPI - Onset

2 days ago

Case 1: 51-year-old man comes to the emergency department complaining of chest pain for 3 days. Example of Bob's HPI - Duration

30 minutes to 1 hour

Case 1: 51-year-old man comes to the emergency department complaining of chest pain for 3 days. Example of Bob's HPI - Frequency

Postprandial (after meals)

Case 1: 51-year-old man comes to the emergency department complaining of chest pain for 3 days. Example of Bob's HPI - Modifying factors

Spicy food

Case 1: 51-year-old man comes to the emergency department complaining of chest pain for 3 days. Example of Bob's HPI - Associated manifestations

Diaphoresis

Define pertinent positive

Symptoms and signs that you would expect to find if the patient's possible diagnosis were true, and that are present

Define pertinent negative

Symptoms and signs that are NOT present, which weakens the possibility of a potential diagnosis

Differential diagnoses considered for Bob's chest pain

MI, GERD, pneumonia, fracture (Fx)

Associated symptoms to consider with chest pain

SOB, palpitations, dyspnea, dizziness, N/V, diarrhea, trauma

Bob's full HPI summary

51-year-old man with 2 days of severe (7/10), sharp/stabbing chest/epigastric pain occurring after meals (especially spicy/acidic food), lasting 30 min-1 hr, with excessive sweating and burping, relieved by milk/ice cream; taking OTC medication for acid reflux

Categories of Past Medical History

Childhood illness, adult illness, surgical history, psychiatric history, obstetric/gynecological illness, health maintenance

Examples of childhood illness to ask about

Asthma, diabetes, chicken pox

Examples of adult illness to ask about

DM, HTN, heart disease

What should you ask about surgical history?

Have you ever had any surgery, and when?

What should you ask about psychiatric history?

Any psychiatric history, SI/HI (suicidal/homicidal ideation), SA/HA (suicide/homicide attempt), hospitalization

What should you ask about obstetric/gynecological history?

LMP, menstrual history, number of pregnancies, number of children

What does "health maintenance" in PMH cover?

Vaccines, screening tests

Questions to ask about allergic reactions

Headache? Diarrhea? Rash? Swollen tongue? Leg edema?

How do you document that a patient denies any allergies?

NKA (No Known Allergies) or NKDA (No Known Drug Allergies)

What should family history include?

Age, health status, and (if deceased) age of death and cause, for immediate family members

Define gender identity

How one identifies themselves, not necessarily visible to others

Define gender expression

How a person expresses themselves through clothes, odor, makeup, body characteristics, voice, and behavior

Define transgender

A person whose gender identity/expression is different from cultural expectations

Define cisgender

A person whose gender identity/expression is the same as typically associated with their assigned sex

Define nonbinary

A person whose gender identity is neither male nor female

How to ask about assigned sex

"What is the sex designated on your original birth certificate?"

Define assigned sex

Sex based on external genitalia

How to ask about sexual orientation

"How would you describe your sexual orientation?"

Examples of sexual orientation

Heterosexual, bisexual, gay

How to ask about gender identity

"How would you describe your gender identity?"

Examples of gender identity categories

Male, female, transgender, cisgender, nonbinary

Elements of sexual history to ask about

Partner (last intercourse, partner's gender, number of partners), Practice (oral/vaginal/anal sex, sex toys), Protection (condom use), History of STD, Pregnancy plans

What does CAGE stand for?

Cut down, Annoyed, Guilty, Eye opener

What is CAGE used to screen for?

Alcohol use/dependence

How do you calculate pack-year history?

Number of packs smoked per day multiplied by number of years smoked

Half a pack a day for 30 years equals how many pack-years?

15 pack-years

How should you approach asking about illicit substance use?

Be nonjudgmental, be clear and specific, and explain you are trying to help the patient

Components of social history

Living environment, relationships, education, employment, spirituality, ADLs (activities of daily living), sexual history

What does the ADL assessment cover?

Ambulation, feeding, dressing, toileting, grooming

Define Review of Systems (ROS)

A head-to-toe screening tool to uncover symptoms and problems the patient may be experiencing that can contribute to making a diagnosis

What should you do if new symptoms are discovered during ROS?

Add them to the HPI in the write-up

Common phrasing used to ask ROS questions

"Have you had…"

ROS - General

Weight changes, weakness, fatigue, fever

ROS - Skin

Rash, lumps, sores, itching, dry skin, color changes, hair and nail changes, changes in moles

ROS - HEENT

Headache, head injury, dizziness, lightheadedness, vision changes, glasses/contacts, eye pain/redness/tearing, double vision, spots/specks/flashing lights, glaucoma, cataracts, hearing difficulties, tinnitus, vertigo, earache, ear infection/discharge/itching, hearing aids, rhinorrhea, rhinitis, pruritus, epistaxis, sinus infection, poor dentition, gum disease/bleeding, dentures, mouth sores, sore throat, hoarseness

ROS - Neck

Lymphadenopathy, goiter, lumps, pain, or stiffness in the neck

ROS - Breasts

Lumps, pain or discomfort, nipple discharge

ROS - Respiratory

Cough, sputum (color, blood), SOB, wheezing, pleuritic chest pain

ROS - Cardiovascular

Heart problems, high BP, rheumatic fever, heart murmur, chest pain, chest tightness, SOB, orthopnea (lying flat), paroxysmal nocturnal dyspnea (waking gasping for air), swelling in feet/legs, SOB with exertion

ROS - Gastrointestinal

Dysphagia, odynophagia, heartburn, appetite, nausea, vomiting, bowel movement changes (color, size, quality, frequency), rectal bleeding, tarry stool, hemorrhoid, abdominal pain, food intolerance, excessive belching, jaundice, liver/gallbladder problems

ROS - Peripheral Vascular

Claudication, leg cramps, varicose veins, blood clots in the legs, swelling in legs and hands, skin color changes, tenderness

ROS - Urinary

Frequency, dysuria, polyuria, nocturia, UTI, flank pain, kidney stones, decreased urinary caliber, hesitancy, dribbling

ROS - Male Genital

Hernias, discharge, sores on the penis, testicular pain, masses, scrotal pain, STI, libido, function