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Clinical Skills

Exam I Material

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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