front 1 What are the core values of medical ethics?
Nonmaleficene
Beneficence
Respect for autonomy
Decisional capacity
Confidentiality
Informed consent
Truth telling
Justice | back 1 -
Nonmaleficence
-
(“first, do no
harm”) directive that health care professionals
should
avoid causing harm to patients and
minimize the negative effects of treatments.
-
Beneficence
- statement that
clinicians are to act for the patients’ good by
preventing or treating disease.
-
Respect for autonomy
- commitment to
accept the choices patients
with decisional capacity make about which
treatments to undergo, including to reject
treatment.
-
shifts patient -provider relationship from paternalistic
one to a more collaborative
one.
-
Decisional capacity
- ability to make an
autonomous choice that clinicians should respect.
-
ability for
patients to make there own choice!!
-
Confidentiality
- duty to prevent the
disclosure of patients’ personal information to parties who are
not authorized to learn that information.
- keeping
patients info confidential
-
Informed consent
- principle that clinicians
must elicit patients’ voluntary and informed
authorization to test or treat them for illness or
injury.
- Because patients cannot consent to treatment
without knowing what they are being treated for, this principle
also encompasses the
responsibility to inform patients of diagnoses,
prognoses, and treatment alternatives.
-
Truth telling
- value that
clinicians should disclose information beyond
that required by informed consent that may be relevant to
patients (e.g., the number of similar procedures a physician has
performed).
-
Justice
-
treat patients fairly
-
all must receive similar treatments/attention
|
front 2 What are proper communication strategies? | back 2 -
Ask Me Three
- What is my main
problem?
What do I need to do? Why is it important for
me to do this? -
People first language
- identify person
before the diagnosis
-
Motivational Interviewing
- 3 core
skills:
•
Ask: open
ended questions: invite the patient to consider
change • Listen: Listen
to the patient and repeat with reflective
listening • Inform: Ask
permission to provide information
-
5
As
-
Ask
-
Advice
-
Assess
-
Assist
-
Arrange
-
Open-ended questions
-
When collaborating: SBAR
- situations
- background
- assessment
- recommendations
-
Moving from Open ended to focus questions
- Start with the most general questions like, “How can I
help?” or “What brings you in today?” Then move to still open,
but more focused, questions like, “Can you tell me more about
what happened when you took the medicine?” Then pose closed
questions like, “Did the new medicine cause any problems?”
-
Echoing the patient
- Patient: “The pain got
worse and began to spread.” (Pause)
- Response: “Spread?”
(Pause)
- Patient: “Yes, it went to my shoulder and down my
left arm to the fingers. It was so bad that I thought I was
going to die.” (Pause) Response: “Going to die?”
-
Graded response questions
- “How many steps
can you climb before you get short of breath?” is better than
“Do you get short of breath climbing stairs?”
|
front 3 Importance of having an interpreter and how to obtain one? | back 3 - “cultural navigator” who is neutral and trained in both
languages and cultures
- Make your questions clear, short,
and straightforward.
- ** remember interpret
- Telephone interpreting is provided when an interpreter, who is
usually based in a remote location, provides interpretation via
telephone for two or more individuals who do not speak the same
language.
- Face to face interpretation for more
- Serious diagnoses or other bad news
- When the
patient is hard-of-hearing
- Family meetings or group
discussions
- Interaction requires visual elements
- Complicated or personal medical procedures or news
|
front 4 What is objective and subjective history? | back 4 -
Subjective information includes symptoms which are
health concerns that the patient tells you.
- Examples
include complaints of a sore throat, headache, or pain.
- It also includes feelings, perceptions, and concerns
obtained from the clinical interview.
-
Objective information is the physical examination
findings or signs you detect during the
examination.
- All laboratory and diagnostic testing results
are also considered objective information.
- For example,
“chest pain” is subjective information while “tenderness on
palpation of anterior chest” is an objective one
-
Clinical
record from the Chief Complaint (CC) through the Review of
Systems is considered subjective
-
All
physical examination, laboratory information and test data are
objective information.
|
front 5 What is in the History of Present Illness?
What is in the ROS?
What is in the Family and Social History? | back 5
HPI
- HPI is a concise, clear, and chronologic description of the
problems prompting the patient’s visit, including the onset of the
problem, the setting in which it developed, its manifestations, and
any treatments to date.
- The HPI in its most basic form is
the story of the patient’s problem
ROS
- Questions may uncover problems or symptoms that you or the
patient may have overlooked
- Documents the presence or
absence of common symptoms related to each of the major body
systems
Family history
- Family History is a record of health information about the
patient and his or her immediate relatives.
- It lists the
age and health, or age and cause of death, of each immediate
relative including parents, grandparents, siblings, children, and
grandchildren
Social History
- Purpose is to build rapport with patient
- Social
History includes the patient’s Personal History which captures their
personality and interests, their coping style, strengths, and
concerns.
-
Includes their sexual orientation and gender identification
(SOGI)
- Place of birth, and personal environmental
map
- Occupation and education
- Significant
relationships including safety in those relationships
- Home
environment including family and household composition
- Important life experiences such as military service, job
history, financial situation, and retirement; leisure activities;
sexuality, spirituality; and social support systems.
|
front 6 What does the CAGE Questionnaire mean? | back 6 It is best tool at detecting alcohol dependence.
CAGE questions about
- Cutting down
- Annoyance when criticized
- Guilty feelings
- Eye openers
Two or more
affirmative answers to the CAGE Questionnaire suggest lifetime alcohol
abuse and dependence alcohol use disorders (AUDs)
- Scoring 2 out of 4 is highly suggestive of alcohol abuse
CAGE Questions
1. Have you ever felt you should cut down on your drinking?
2. Have people annoyed you by criticizing your drinking?
3. Have you ever felt bad or guilty about your drinking?
4. Have you ever had a drink first thing in the morning to steady
your nerves or to get rid of a hangover (eye-opener)? |
front 7 What is general PE suggested sequence? | back 7 -
We
recommend examining the patient from the patient’s right
side, moving to the opposite side or foot of the bed
or examining table as necessary
- The key to a thorough and
accurate physical examination is developing a systematic sequence of
examination. Organize your comprehensive or focused examination
around three general goals:
- Maximize the patient’s
comfort.
- Avoid unnecessary changes in position.
- Enhance clinical efficiency.
|
front 8 What is proper patient positioning?
- when palpating breast
- cardiovascular assessment-
examining JVD vs listening to mitral stenosis?
- abd
assessment
- neuro: peripheral vascular assessment
- musc
| back 8 -
When palpating breast
- The patient position
is supine. Ask the patient to lie down. You should stand at the
right side of the patient’s bed
-
When examining heart sounds/ JVD
-
Elevate the head of the examining table or bed to
−30 degrees for the cardiovascular
examination, adjusting as necessary to see the
jugular venous pulsations.
- Ask the patient to
roll partly onto the left side while you listen at the
apex for an S3 or mitral stenosis.
- The
patient should sit, lean forward, and exhale while you listen
for the murmur of aortic regurgitation.
-
Abdomen inspection
- Lower the head of the
bed to the flat position. The patient should be supine.
-
Neuro
- When checking peripheral vascular
system (femoral pulses/popliteal pulses. Palpate the inguinal
lymph nodes, lower extremity edema, discoloration, or
ulcers/Palpate for pitting edema, inspect for varicose veins)
patient should be SUPINE
-
MUSC
- Checking muscle strength, gait, spine
alignment, and movement patient is STANDING
|
front 9 How do you prioritize patient complains? | back 9 - ALWAYS RULE OUT THE LIFE-THREATENING CAUSES!!
-
One rule of thumb is to always include “the worst-case
scenario” in your differential diagnosis and make
sure you have ruled out this possibility based on your findings and
patient assessment.
- Your goal is to minimize the risk of
missing unusual or infrequent conditions such as meningococcal
meningitis, bacterial endocarditis, pulmonary embolus, or subdural
hematoma that are particularly ominous.
|
front 10 What are the USPSTF screening recs for lung cancer? | back 10
What does the USPSTF recommend? B Grade
- Adults aged 50 to 80 years who have a 20 pack-year smoking
history and currently smoke or have quit
within the past 15
years: - Screen for lung cancer with low-dose computed
tomography (CT) every year.
- Stop screening once a person
has not smoked for 15 years or has a health problem that limits life
expectancy or the ability to have lung surgery
|
front 11 What is USPSTF screening recs for breast cancer? | back 11 What does the USPSTF recommend?
- Women aged 40 to 74 years: The USPSTF recommends biennial
(every other year) screening mammography.
- Not recommended
for women with dense breast
|
| back 12 - person is given antibodies to a disease rather than producing
them through his or her own immune system
- naturally
acquired from the transfer of maternal antibodies via
placenta/breastmilk
- passive immunity from
antibody-containing blood products/serums (IVIG)
- immediate immunity but does not last long
|
| back 13 - exposure to a disease organism triggers the immune system to
produce antibodies to that disease
- acquired naturally from
disease (chicken pox, hepatitis A)
- Acquired from a
vaccine
- active immunity takes several weeks to protect
but last a longer than passive
|
front 14 What is community (herd) immunity? | back 14 Benefits of immunization are not limited to the vaccinated individual
but also include promotion of herd immunity for the population at
large, including nonimmunized persons and those with waning immunity
or who may not have fully responded to prior vaccination |
front 15 Know immunization guidelines | |
front 16 What are general contraindications for immunizations? | back 16 -
Vaccination during pregnancy
- Live
attenuated viruses should not be administered
- Vaccination of immunocompromised persons
- Should NOT be
given live viruses
- Persons with
immunocompromised household members should NOT be given varicella,
herpes zoster or live flu
-
ALLERGY TO streptomycin, neomycin, polymyxin
B
- Antibiotic therapy concurrent to vaccine
administration only contraindicated in the oral typhoid vaccine
- Lets clear up some things…
- It is OK to give
vaccines if a previous local reaction occurred
- It is OK to
give vaccines with low-grade fever, mild respiratory, intestinal
infections
- Allergy to antibiotics not a
contraindications except with allergy to
streptomycin, neomycin and polymyxin B
|
front 17 Is there a link between vaccines and autism? | |
front 18 When do you give Tdap, vs Td, vs Dtap? | back 18
Dtap < 7 years old
- 5-dose series: 2 months, 4 months, 6 months, 15–18 months, and
4–6 years.
Tdap > 7 years old
-
Adolescents should receive a single dose of Tdap, preferably
at age 11 or 12 years.
- Pregnant people should
get a dose of Tdap during every pregnancy, preferably during the
early part of the third trimester, to help protect the newborn from
pertussis
Td is > 7 years
- usually given as a booster dose every 10 years, or
after 5 years in the case of a severe or dirty wound or
burn
|
front 19 ' What are contraindications of influenza vaccine? | back 19 - “flu shot” is an inactivated
vaccine containing killed virus
- DO NOT GIVE IF:
- < 6 months old
- History of severe allergic reaction
(e.g., anaphylaxis) to any component of the vaccine (other than egg)
or to a previous dose of any influenza vaccine (i.e, any egg-based
IIV, ccIIV, RIV, or LAIV of any valency)
- At the same time
as aspirin or salicylate-containing therapy in children and
adolescents
- Children aged 2 through 4 years who have received
a diagnosis of asthma or whose parents or wheezing episode has
occurred during the preceding 12 months
- Children and adults
who are immunocompromised due to any cause, including but not
limited to medications, congenital or acquired immunodeficiency
states, HIV infection, anatomic asplenia, or functional asplenia
(e.g., due to sickle-cell anemia)
- Close contacts and
caregivers of severely immunosuppressed persons who require a
protected environment
- Pregnancy
- Persons with
active communication between the CSF and the oropharynx,
nasopharynx, nose, or ear or any other cranial CSF leak
- Persons with cochlear implants (due to potential for CSF leak,
which might exist for some period of time after implantation.
Providers might consider consultation with a specialist concerning
risk of persistent CSF leak if an age- appropriate inactivated or
recombinant vaccine cannot be used)
- Taking influenza
antiviral medication within the previous 48 hours for oseltamivir
and zanamivir, 5 days for peramivir, and 17 days
|