PA PMI Exam 1

humanistic provider characteristics

empathetic, honest, respectful, present, communicative, establishes rapport

renders care with dignity and best practices

attends to psychosocial needs

treats people as people and not as a disease

provides quality care regardless of race, gender, politics, insurance

what precent of diagnosis are made by the history

75%

what percent of diagnoses are made by history and physical exam

88%

what percent of diagnosis are made by additional labs/diagnostics

11%

what percent of medial information is forgotten by the patient after an appointment

40-80%

clinical encounter structure and sequence

1. obtain the patients medical history

2. translate

3. document

4. share

obtaining the patients medical history

happens through the medical interview and perform the phsycial exam

be objective

communicate respectfully

translate

the history and physical exam

use your fund of knowledge to translate lay owrds into the appropriate medical terminology

document

the encounter

record the visit using EMR to create clear, concise, detailed note

share

the interview

form a concise oral patient presentationt o share with your preceptors and or colleagues

medical history includes

chief complaint (CC)

history of present illness (HPI)

past medical history (MH/PMH)

family history (FH)

social history (SH)

review of systems (ROS)

medical interview definition

type of interpersonal communication involving questions and answers with the purpose of facilitating therapeutic outcomes and sharing the information

documentation for the medical interview

coding and billing (reimbursement)

legal inquiries (medical notes are discoverable legal documents)

communication of patient information

quality improvement measures, compliance reports, outcomes data, and research

the clinical encounter is both

clinician-centered and patient-centered

clinician-centered

the clinician guides the interaction to gather the details necessary to identify a disease process

patient centered

the clinician acknowledges and explores the patients concerns, feelings, and personal context to understand their perspectives and requests

stages of of the clinical encounter

1. initiating the session

2. gathering information

3. physical examination

4. explanation and planning

5. closing the session

initiating the session

prepare for the interview

review the patient record

set your agenda

greet the patient and establish initial rapport

identify patient title, name,, and preferred gender pronouns

adjust the environment

gathering information

begin with open-ended questions

invite the patient’s story

gather information about the patient’s perspective of illness

identify and respond to the patient’s emotional cues

explore the biomedical perspectives

collect important background information and context

performing the physical examination

performing an exam enhances your relationship with the patient

physical findings help determine the presence or absence of a disease

during the exam, the patient interview can be continued

patient comfort must be maintain throughout the exam

explaining and planning

provides useful information

verify patient understanding

develop the plan of action using shared decision making

closing the encounter`

let the patient know that the end of the interview or the visit is approaching to allow time for any final questions

if a patient brings up a concern that is not life-threatening, assure the patient of your interest and make a plan to address the problem at a future visit

summarize the plans for future evaluation, treatment, and follow-up

fundamentals of interviewing

active listening

guided questioning

empathetic responses

summarizing

transitions

partnering

validation

empowering the patient

reassurance

active listening

carefully attending to what the patient is communication

connecting to the patients emotional state

using verbal and nonverbal skills to encourage the patient to expand on their feelings and concerns

guided questioning

moving from open-ended to focused questions

using questions that elicit a graded response

asking qualitative and quantitative questions

asking a series of questions, one at a time

offering multiple choices for answers

clarifying what the patient means

encouraging with continuers

using echoing/repetition

empathetic response

described as the capacity to identify with the patient and feel their pain as your own, then respond in a supportive, understanding manner

empathic responses are vital to patient rapport and healing

requires you to recognize the patient’s feelings

summarizing

communicates that you have been listening

identifies what you know and don’t know

allows the patient to add other information and correct any misunderstandings

allows you to organize your clinical reasoning and convey your thinking to the patients

helps learners when they draw a blank and what to ask next

transitions

let patients know when you are transitioning from topic to topic

transition statements help patients prepare for what comes next

make clear what you expect the patient to do or not do

partnering

healthcare is a partnership between the patient and the members of their care team

when building rapport with patients, express your ongoing commitment to their care

even as a student especially in a hospital setting this support can make a big difference

validation

affirm the legitimacy of the patients emotional experience

empowering the patient

the clinician-patient relationship is inherently unequal, though ultimately patients are responsible for their care

patients have many reasons to feel vulnerable

when you empower patients to ask questions, express their concerns, and probe your recommendations, they are more likely to adopt your advice, make lifestyle changes, or take medications as prescribed

reassurance

first identify and acknowledge the patients feelings

meaningful reassurance comes later after you have completed the interview, the physical examination and possible after laboratory tests/imaging

reassurance is most appropriate when the patients feels that problems have been fuly understood and being addressed

verbal communication

it is important that you are careful in what you say and how you say it

understandable language uses simple, recognizable and clear words

communicate to all patients with plain language, regardless of a persons education, socioeconomic status, or cultural background

use non-stigmatizing and person-first language

non-verbal communication

just as you are carefully observing the patient, the patient will be carefully observing you

you send messages using your words and your behaviors

postures, gestures, eye contact, and tone of voice all extent of your interest, attention, acceptance, and understanding

be aware that some forms of nonverbal communication are universal, but many are culturally bound

using EHR (electronic health record)

it has changed the patient clinician interaction

it can be difficult to engage patients while also trying to take accurate notes

make sure to maintain your body orientation towards the patient and remember to make eye contact throughout the visit

talk while you are writing notes

explain the use of the computer and even share the screen with the patient

use gaps in the interaction with the patient for computer work

goals for clinical encounter

establish rapport

gather information

arrive at a correct diagnosis

instruct and educate the patient

continue to support the patient during their treatment and further management

clinician encounter goals

be objective

be precise

be sensitive

be specific

be reliable

objective

removing biases, your own beliefs, prejudices, and preconceptions

focuses on the facts

listen to assure accuracy and validity

precise

asking questions and actively to gather all pertinent information to separate the patients interpretation from teh data and arrive at a carrect diagnosis

do not jump to comclusions

if you interpret any signs/symptoms prematurely you may miss the diagnsosis

be sensitive

measure the proportion of actual positives that are correctly identified

specific

measures the proportion of negatives which are correctly identified

SPIN and SNOUT

sensitivity vs specificity

SPIN or sensitivity

a specific test when positive, rules disease in

SNOUT or specific

a sensitive test, when negative, rules disease out

reliability

the reproducibility of a measurement when repeated at random in the same subject or specimen

things to avoid in patient interaction

ignoring the patient

not being present or fully engaged

minimizing the patient’s symptoms

asking multiple questions in the same sentence

repeating questions that have already been answered

leading questions

five Es of medical interview

engage the patient

eye contact

empathize

educate the patient

manage Expectations

5 steps of the medical interview

1. initiating the session

2. gathering information

3. physical examination

4. explanation and planning

5. closing the session

what two kinds of information will I elicit in every patient interaction

subjective and objective information

subjective information

symptoms, feelings, perceptions, and concerns

objective information

signs detected during the examination, laboratotry/diagnostic imaging results

what information helps you develop an assessment plan

subjective and objective information

SOAP

formal notes and oral patient presentations

scope and detail of history

depends on the patients needs and concerns, your goals, and the clinical setting

when is a comprehensive health history most appropriate

for new patients establishing in a primary care setting

when is focused history the most appropriate

for patients seeking care for specific concerns

comprehensive patient history

for new patients

provides fundamental and personal knowledge about the patient

strengthens the clinican-patient relationship

helps identify or rule out physical causes related to patient concerns

provides baseline for future assessments

creates a platform for health promotion through education and counseling

develops proficiency in the essential skills of physical examination

comprehensive patient history components

patient name/identifier, source/reliability, date/time of encounter

chief complaint, CC

HPI, history of present illness with focused ROS

MH, medical history

PMH, past medical history

FH, family history

SH, social history

CROS, complete review of systems

focused patient history

appropriate for established patients, especially during routine or urgent care visits

addresses focused concerns or symptoms

assess symptoms restricted to a specific body system

applies examination methods relevant to assessing the concern or problem as thoroughly and carefully

components of focused patient history

patient name/identifier, source/reliability, Date/time of encounter

CC, chief complaint

HPI, history of present illness with focused ROS

addressed without full detail- MH, PMH, FH, and SH

initial information

patient identifiers and name, source/reliability, date/time of encounter

patient identifiers and name

age

gender

name or initials

source/reliability

source is patient, family member, friend, caretaker, consultant, and clinical record

reliability should be documented if relevant

date/time of encounter

often automatically included by EMR

chief complaint, CC

the primary problem or condition of the patient prompting them to seek medical care

what does CC allow for

entry point to clinical reasoning

1-2 words should immediately activate pattern recognition and a mental framework of possible causes

narrows the field every possible disease to a manageable list of categories

form a working differential diagnosis (DDx) before even stepping into the room

ways to document the CC

1. in a short phrase with a brief timeframe/duration

2. in the patients words with a brief timeframe/duration

3. if there is no complaint

history of present illness, HPI

concise, clear, and chronological description of the problems prompting the patient’s visit

the story of the patients problem that includes the onset of the problem, setting in which it developed, manifestations of the problem, and treatments attempted

HPI includes

special first sentence

OLPQRST

focused ROS

constitutionals

HPI to develop differential diagnosis

questions asked help narrow the list of initial probable diagnoses

questions is like testing a hypothesis

think of the most likely cause and the most serious cause

special first sentence, SFS

includes basic patient information (name, age, gender, ethnicity), pertinent history, reiteration of the CC with timeframe and additional detail (where they are presenting), as well as pertinent positives

what does SFS provide

a foundation for the reader to begin to think of possible causes fro the patients condition

OLPQRST

Onset

Location

Prior

Palliation

Provocation

Quality

Radiation

Severity

Timing

onset

describes when the problem, symptom, or pain started, including the setting which it occurs

location

where in/on the body the problem, symptom, or pain occurs

Prior

determines if a similar problem, symptom, or pain has occurred previously

palliation

actions or activities taken to improve the problem, symptom, or pain and the outcome

provocation

actions or activities that seem to worsen the problem, symptom, or pain and the outcome

quality

descriptor of the problem, symptom or pain

radiation

if the problem, symptom, or pain extends from a central point

severity

how severe the problem, symptom, or pain is

Timing

describes the problem, symptom, or pain is always there (constant) or comes and goes (intermittent)

intermittent

ask about duration and frequency

duration

how long the problem, symptom, or pain has been present or how long the problem, symptom, or pain lasts for

frequency

how often the problem, symptom, or pain occurs

constant vs. consistent

constant: happening all the time

consistent: occurs in the same way every time

what if things are getting worse

there must be further investigation

is it worsening in severity?

is it worsening of a chromic condition?

is it worse at different times of the day?

focused ROS

FROS

targeted set of questions related to the CC that helps clarify, expand, or rule out diagnoses in the DDx

what is the FROS always included in

the HPI

complete ROS

CROS

done separately from the HPI in a systematic fashion

more so done for documentation, billing, or completeness

consitiutional symptoms

general, whole body symptoms that help you determine the general health of the patient and can signal systemic disease

general/constitutional

fever, chills, night sweats, fatigue, malaise, weakness, unintentional weight loss or gain, dizziness, bleeding, bruising, nausea, vomiting, diarrhea, constipation, arthralgia, myalgia

pertinent positives

symptoms or signs you would expect to find if a possible cause of a patient’s problem were true are present

the presence of symptoms or signs that strengthen or support a certain diagnosis

pertinent negatives

symptoms or signs you would expect to find if a possible cause of a patient’s problem were true but are not present

the absence of symptoms or signs that weaken or deprioritize a certain diagnosis

HIP documentation framwork

1. SFS

2. OLPQRST

3. pertinent positives

4. pertinent negatives

how HPI documentation is wrote

paragraph form

present tense

include the chronology

do not include all of the OLPQRST in your SFS

PMH

past medical history

includes all medical problems of the patient both active and past

documented in a bulleted list

very thorough in a comprehensive history

concise and problem based for a focused history

how to elicit the medical history

transition from taking the HPI into asking questions about the MH

components of PMH and MH

childhood illnesses

adult illnesses

hospitalizations/surgeries

trauma/injuries

medications

allergies

screenings/immunizations

CAHTMAS

childhood illnesses

everyone has normal childhood illnesses though some illnesses provide important context for long term health and risk factors