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Clinical Skills
Exam I Material
| Question | Answer |
|---|---|
| What are the first three steps of the 7 essential elements for doctor/patient communication? | 1. open the discussion 2. build the relationship 3. gather information |
| What are the last 4 steps of the 7 essential elements of doctor/patient communication? | 4. understand the patient's perspective 5. share information 6. reach agreement on problems and plans 7. provide closure |
| What are the two types of medical records? | source oriented and problem oriented |
| What is a source oriented medical record? | information is filed as it comes in; no table of contents; information can be difficult to find |
| What are the four elements of a problem oriented medical record? | data base, problem list, progress note, and initial plan |
| What does the data base of the problem oriented medical record contain? | past and present history, review of symptoms, physical exam, physiologic data and lab, consults |
| What does the problem list of the problem oriented medical record contain? | comprehensive list of the patient's past and present health; it is divided into acute and chronic |
| What does the progress note of the problem oriented medical record contain? | notes written on each visit; SOAP notes (subjective, objective, assessment, and plan) |
| What is the initial plan of the problem oriented medical record? | diagnostic tests, therapeutic treatments, and patient education |
| What is considered subjective in the medical record? | anything the patient tells you: history and symptoms of present and past problems |
| What is considered objective in the medical record? | physical exam info, physiologic data, x-rays, and lab results |
| What should you do if you make an error when writing information in a medical record? | DO NOT BLACK IT OUT OR DELETE IT; instead, put a line through the error, write error, initial, and date it |
| What should go under the assessment? | differential diagnosis |
| What are the four cardinal principles? | inspection, palpation, percussion, auscultation |
| Describe inspection: | starts when you walk in the room; most productive exam method; dependent on knowledge of the physician |
| What is palpation? | evaluation for tenderness, texture, temperature, tone, and mass |
| What is precussion? | the surface of the body is struck to emit sounds that vary in intensity according to the density of underlying tissue; tympanic, resonant, flat |
| What is auscultation? | heart sounds, vocal sounds, vessel sounds, lung/breath sounds, abdominal sounds (basically anything that requires a stethoscope) |
| What is the process by which an individual accommodates to the traits and behaviors of another culture? | acculturation |
| What is a complex, integrated system reflecting the whole of human behavior an experience: a group's adoption of shared values, the attempt to make sense of their world? | culture |
| What is a habitual activity of a group or subgroup: patterned responses to given occasions, generally passed on from one generation to the next? | custom |
| What is the process by which an individual assumes the traits and behaviors of a given culture, adapting to it, adopting its values, and taking on that particular cultural identity? | enculturation |
| What is the belief in the superiority of one's own group and culture, combined with disdain for other groups and cultures? | ethnocentrism |
| What is a group of the same race or nationality with a common culture and distinct traits? | ethnos (aka ethnic group) |
| What is a group that is different from the majority of the population, as with regard to religion, race, or ethnic origin? | minority |
| What is the prescribed standard of allowable behavior within a group or subgroup? | norm |
| What is a physical, not cultural, differentiator based on a common heredity, using as identifier characteristics such as skin color, head shape, and stature? | race |
| What is prescribed, formal, customary observance? (aka ceremonial religious act or gaduation) | rite |
| What is stereotypic behavior regulating religious, social, and professional behaviors in a variety of situations? | ritual |
| What is simplified, generally inflexible conception of the members of a group or subgroup? | stereotype |
| What is a group or subgroup having values and behavioral patterns or other distinctive traits that differentiate it from other groups or subgroups within a larger culture? | subculture |
| What are ideals, customs, institutions, and behaviors within a group or subgroup for which the members of the group have a respectful regard? | values |
| What BMI measurement is considered undernourished? | <18.5% |
| What BMI measurement is considered appropriate? | 18.5-24.9 |
| What BMI measurement is considered overweight? | 25-29.9 |
| What BMI measurement is considered obese? | 30-30.9 |
| What BMI measurement is considered to be extreme obesity? | >40 |
| How often should head circumference be measured in infants? | every visit until they are 2 years old |
| How is the head of infants measured? | the tape goes around the occipital prominence and the supraorbital prominence |
| What can a high rate of growth in infant head circumference indicate? | increased intracranial pressure or hydrocephalus |
| In terms of gestational age, what is considered preterm? | <37 weeks |
| In terms of gestational age, what is considered term? | 37-41 weeks |
| In terms of gestational age, what is considered postterm? | >41 weeks |
| In terms of sexual maturity rating (SMR), Tanner 1 is... | prepubertal |
| In terms of SMR, Tanner 4 is... | well developed but "not quite adult" |
| In terms of SMR, Tanner is... | normal adult characteristics |
| When do females generally finish puberty? | 14.5 (give or take two years) |
| When do males generally finish puberty? | 17.5 (give or take two years) |
| When is puberty finished? | when epiphysis of long bones are ossified |
| What is typically the first sign of puberty in females? | thelarche (formation of breast buds) |
| In girls, when does the growth spurt occur in relation to menarche? | about a year prior |
| What is the first sign of puberty in males? | enlargement of scrotum/testis above 2 cm |
| What is considered precocious puberty in girls? | 6-7 years old |
| What is considered precocious puberty in males? | 9 years old |
| What could cause precocious puberty? | endocrine disorders or exogenous hormone exposure |
| Visceral pain is often... | more diffuse an dull |
| Somatic pain is generally... | sharper and well localized |
| What are the vital signs? | temp, respiration, pulse, blood pressure, pulse ox, growth |
| What is the average temp in C? | 37 degrees |
| What is the average rate of respiration for adults? | 12-20 bpm |
| What is the average rate of respiration for newborns? | 40-60 bpm |
| What is the average rate of respiration for children that are 1-3 years old? | 20-30 bpm |
| What is the average rate of respiration for children that are 6-10 years old? | 16-20 bpm |
| What is the average pulse rate for adults? | 60-100 |
| What is the average pulse rate for newborns? | 120-170 |
| What is the average pulse rate for a three year old? | 80-120 |
| What is the average pulse rate for a ten year old? | 70-110 |
| What would we call an irregular heartbeat that is consistent? | sinus arrhythmia |
| What would we call a heartbeat that is inconsistently irregular? | atrial fibrillation |
| What are the two models of change? | Transtheoretical and Keller/White |
| Transtheoretical Model evaluates... | where the patient is on the continuum of change: Precontemplation, contemplation, preparation, action, and maintenance |
| Keller/White Model evaluates... | confidence (belief in success) and conviction (belief that the change will positively impact life) |
| What are the 5 A's for promoting behavior change? | Assess (risk, past behavior, readiness, conviction, and confidence), Advise (and inform), Agree (on goals and methods), Assist (in overcoming barriers), Arrange (follow-up) |
| The therapeutic triangle... | doctor, patient, EMR |
| What can you do to change the attitude of a patient with low conviction? | provide info and give options |
| What can you do to change the attitude of a patient with low confidence? | review successful past experience, encourage small steps, teach problem solving and coping skills |
| What is the goal of collaborative care? | self-efficacy (shared agenda b/w doctor and patient, behavior change comes from self-management, patient and doctor make goals together) |
Created by:
smuncy
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