Fall

PCM FALL OBJECTIVES

WEEK 1

PCM objectives 9/2

Intro to PCM •	Describe the structure and function of the PCM syllabus and website: syllabi on sakai, including weekly objectives and reading assignments •	Describe the process of PCM evaluation and grading: best score 10 “Consistently facilitates group functioning by actively bringing in other students into discussion and coordinating student activities. Demonstrates a willingness to expand on learning by offering additional information above and beyond assigned reading or assignment. Demonstrates high awareness of ethical dilemmas and approaches them with a respectful manner. Consistently demonstrates understanding and utilization of ethical and psychosocial issues. Consistently able to bring examples from their preceptorship to underscore their understanding of patient care issues.

Intro to Preceptorship: •	Describe the purpose of the Preceptorship as it relates to the overall curriculum: demonstrate the relevance and application of basic science curriculum, furnish opportunities to learn, apply, and practice clinical expertise, provide feedback regarding patient interactions, knowledge, skills, and attitudes, stimulate self-directed learning, provide clinical role models and experiences in primary care environments, allow for gradual advancement of the student’s clinical responsibilities over time •	Describe the organization of the Preceptorship, including what and how to bring issues to the administrative leadership: 3 terms with general internal medicine or a family medicine physician (Y1 or Y2). The other 3 terms, 3 specialty areas •	Describe the attendance expectations for the Preceptorship, including the need to make up sessions: be on time, dress professionally, act professionally, communicate, see patients, learn by doing, be value added, learn about your patients •	Describe the expectations regarding appearance: professional •	List strategies regarding travel to the Preceptorship •	List the resources that may be of assistance to you in the Preceptorship: andi jarone •	List the ways that you can be value added to the practice •	Describe the expectations regarding feedback and evaluation

The Patient-Physician Relationship: The Cornerstone of Medical Ethics •	Describe the basic ethical features of the patient-physician relationship, including the principles of beneficence, autonomy, social justice, and nonmalficience: DO NO HARM! Allow patients to make decisions for themselves. Give the same opportunity for care for each individual •	Distinguish paternalistic, consumerist, patient-centered, family systems, and ethnographic approaches physicians may use with patients: paternalistic-controlling; consumerist-give \people what they want and get paid for it; family systems- incorporating all of family in care; ethnographic approaches- have cultural sensitivity •	Describe responsibilities of the physician and responsibilities of the patient in the physician-patient relationship: •	Describe the laws and the codes of conduct which require and encourage physicians individually to promote the welfare of their patients: see Hippocratic Oath and AMA code of Ethics •	Discuss barriers towards developing an effective patient-physician relationship and how they can be overcome •	List commonly agreed-upon responsibilities of physicians toward patients: Duty to protect

WEEK  2

9.09.2009 The Medical Interview: Communication Skills I

Describe the characteristics of positive regard for patients (respect, genuineness, empathy) and how this leads to willingness to join patients as partners. SEGUE Set the stage – context of visit, introduction, purpose for visit, outline agenda, establish rapport, build trust Elicit information – OPQRST Give information Understand patient’s perspective – interpersonal relationships, work/school, sexual relationships, emotional stability End the encounter – have and review plan, diagnostics, therapeutics (education, negotiation, motivation), concludes with an implied contract.

Describe the purpose of each of the three basic functions of the interview: (a) gathering data, (b) building rapport and responding to patient’s emotions, and (c) education, negotiation, motivation. This one’s pretty obvious.

List the topics of an initial interview and written history: identifying data, CC, HPI, PMH, ROS, family, social, and spiritual histories. Identifying Information  name, sex, age, ethnicity or race, and ID of person giving history Chief Complaint  symptoms that caused the patient to seek medical care; in the patient’s own words; use open-ended questions History of Present Illness  OPQRST Past Medical Hx  any significant past health events (acute illness, chronic diseases, hospitalizations); past medical history; past surgical history; Allergies  medicines, food/environmental, etc. and their reaction Medications  current medications (prescription drugs, supplements, OTC drugs, ask if they have stopped taking any drugs) Review of Systems  any aspect of a patient’s physical or emotional health not previously discussed

Family Hx  Draw a tree; clarify blood relatives Social Hx  family status, children, occupation, education, cultural identity, sexual history, EtOH, smoking, and other drug use Spiritual Hx  Spiritual values and relation to health care decisions

Describe how to greet and put a patient at ease; typical comments to start the interview; typical comments to organize and guide the interview; and typical comments to close the interview. -What brings you here today? What’s bothering you today? How can I help you today? -How long has this been a problem? Are there any other issues you would like to discuss? -Review list of problems, discuss plan, make sure that the patient is on board with the plan. -Is there anything else that you think would be important for me to know?

Describe the difference between open-ended and close-ended questions. Close-ended questions can be answered with a yes/no or specific information, while open-ended leave room for the patient to explain themselves. Both strategies are useful. Open-ended questions can allow the patient the opportunity to accurately describe their condition. Close-ended questions can guide an interview back toward criteria for a diagnosis.

Describe and demonstrate the use of the “OPQRST” approach to the HPI. Onset – When/how did it start? Provocation/Palliative – What makes it better/worse? Quality – What does it feel like? Sharp/dull/stabbing/throbbing/etc? Region/Radiation – Where does it hurt? Does the pain radiate anywhere else? Severity – On a scale of 1-10 with 10 being the worst pain you can imagine, how would you rate your pain? Timing – How long has it been happening? How has it changed since it started?

Demonstrate the ability to efficiently elicit the patient’s priorities and concerns at the beginning of an encounter and thereby negotiate an agenda for the medical visit. -What problem concerns you most? -What worries you most about how you are feeling? -We are going to talk about that problem first and if we have time at the end of the appointment we can discuss your other problems or schedule another appointment.

Demonstrate the ability to engender a therapeutic relationship with a patient through use of communication skills such as expressing empathy, active listening, and eliciting information about the patient’s life, expectations, and concerns about medical care. -Express empathy. -Actively listen. -Be concerned about pt’s opinion/expectations/concerns

Additional Notes: -Don’t forget to use “normalizing language” in difficult situations eg: “people who feel that way sometimes think about hurting themselves. Have you had any such thoughts?” -Body language is key in patient interactions. The physician should try to maintain open body language and, ideally, take the history sitting at the same level as the patient. -Special situations for history-taking include: Children and adolescents: communication issues with younger kids (don’t forget to ask them closed questions, your entire conversation does not have to be with the adult), and confidentiality issues with adolescents (establish ‘rules of confidentiality,’ or what you will or won’t discuss with their parents, age 8 is a good time to establish the practice of giving a child time alone with their physician, without the parent present) Pregnant women: also consider previous obstetric history, occupational & environmental exposures, genetic history for both mother & father, and a social history including the emotional response of the patient and family to the pregnancy as well as risk for domestic violence. Elderly patients: need to be included in the history, do not speak exclusively to their child or forget functional assessments (nutrition, financial independence, depression and alcohol use, sexual history immunization status and preventative screening. Bilingual interviews: whenever possible use a professional medical translator and address the question as if to the patient and not the translator. The mentally disabled: include both patient and caregiver in conversation -Goals of partnering with patients: discovery, sharing, negotiation, union & support -Basic requirements of healthy communication: flexibility, specificity, clarity, subltelty, empathy -Steps of good communication: facilitation, reflection, clarification, empathetic response, confrontation and summary.

9.09.2009 Introduction to Exam Skills: Patient Introduction, Hand Hygiene, and Vital Signs

Describe the appropriate methods of hand hygiene. -Hand sanitizers. -Soap and water (15 seconds).

Describe OHSU policies for standard precautions and hand hygiene. -Before AND after touching any patient -Before inserting invasive devices. -After removing gloves. -After contact with body fluids, mucous membranes, non-intact skin, and wound dressing. -When visibly soiled. -After contact with contaminated equipment or items. -Alcohol based hand sanitizers are the preferred method of hand decontamination. -Soap and water washing (15 seconds) should be used in place of hand sanitizers when hands are visibly soiled with blood or body fluids, after using the rest room, and before eating.

Demonstrate effective hand hygiene – hand washing and using hand sanitizer. 15 seconds

Define vital signs. Vital signs are a means of rapidly quantifying the magnitude of physiologic stress. The more deranged the vitals, the sicker the patient. They include temperature, pulse, respirations, and blood pressure.

List normal values for respiratory rate, heart rate, BP, and temperature. -Temperature  Normal = 37.0 C, Range = 36.3-37.3 C, Fever = 38.0 C (infection, drugs, exogenous heat, inflammation, malignancy), Hypothermia = 35.0 C (exposure, infection) -Heart Rate (Count for at least 30 seconds.)  Normal = 60-100, Tachycardia = >100, Bradycardia = <60 -Respiratory Rate  Normal = 12-18, Tachypnea = ≥20, Bradypnea = ≤10 -Blood Pressure  Normal = <120/<80, Prehypertensive 120-139/80-89, Stage 1 Hypertension 140-159/90-99, Stage 2 Hypertension ≥160/≥100

Describe normal and abnormal pulse rhythms. -Regular -Regularly Irregular -Irregularly Irregular

Describe pulse amplitude and contour. The amplitude of the pulse is how big (or strong) the pulse is. Thus, a strong pulse will have a larger amplitude than a weaker pulse, which will have a smaller amplitude. The contour of the pulse is the pulse's shape. For instance, a slow pulse will make a longer, more rounded shape, whereas a quick pulse will have a sharper shape. -Amplitude  Graded 0-2, 0 = none, 1 = normal, 2 = strongest -Contour  normal or bounding

Describe the respiratory rate, rhythm, and effort. -Count for 60 seconds. -Rate  Normal = 12-18, Tachypnea = ≥20+, Bradypnea = ≤10 -Rhythm  Regular, Regularly Irregular, Irregularly Irregular (Many abnormal respiratory rhythms have eponyms.) -Effort  Labored or Unlabored

Demonstrate the proper technique of blood pressure measurement. -Use auscultatory method with a properly calibrated and validated instrument. -Patient should be seated quietly for 5 minutes in a chair (not on an exam table), feet on the floor, and arm supported at heart level. -Appropriate-size cuff should be used to ensure accuracy. -At least two measurements. -Clinicians should provide to patients, verbally and in writing, specific BP numbers and BP goals.

Describe the Korotkoff sounds. Phase I Heard at systolic pressure – A tapping sound. Phase 2 Between systolic and diastolic pressures – A soft swishing sound. Phase 3 – A crisp sound. Phase 4 Heard at pressures within 10 mmHg above the diastolic pressure – A blowing sound Phase 5 Occurs at diastolic pressure - Silence

Describe common technical problems in obtaining an accurate blood pressure. -Wrong size cuff. Too big gives a low reading. Too small gives a high reading.

Describe normal values of blood pressure and define those of hypertension. Normal = <120/<80, Prehypertensive 120-139/80-89, Stage 1 Hypertension 140-159/90-99, Stage 2 Hypertension ≥160/≥100

List what is assessed for “general appearance,” identifying normal aspects. Assess Mental State: - Alert and oriented - Alert and disoriented - Delerious - Coma State of Nutrition: - Anabolic (building up) vs Catabolic (breaking down) Discratia - bad mix of color Hydration - dry lips/mouth - skin without turgor Hygene - if bad tells you how they're living, look for calus' Assess: physical appearance: age, sex, LOC, facial features, skin pigmentation/intactness, presence of lesions body structure: Stature, nutrition, symmetry, posture, position, overall body build behavior: Facial expression, mood, affect, fluency of speech, ability to communicate, appropriateness of word choice mobility: gait and range of motion

Demonstrate ability to identify radial and carotid pulses, and the jugular vein. The radial pulses are felt in the distal forearm, just medial to the radius when the forearm is in the supine position. The carotid pulses are felt in the anterior triangle of the neck, just medial to the sternocleidomastoid muscle. You should stand behind the patient when feeling their carotid pulses. When feeling for the pulses, one should use the pads of their first two fingers. Check the pulses on both sides for rhythm, amplitude, and contour. The external jugular vein is the vein where jugular venous pressure is measured. It comes out of the root of the neck in the omoclavicular triangle (between trapezius and sternocleidomastoid) and then crosses the sternocleidomastoid as it travels superiorly.

Define hypertension, hypotension, tachypnea, arrhythmia, dysrhythmia, tachycardia, bradycardia, and apnea for an adult patient. Hypertension: BP above normal limits (120/80) Hypotension: BP below normal limits (90/60) Tachypnea: Resp rate faster than Normal (over 20) arrhythmia: electrical abnormality in heart dysrhythmia: electrical abnormality in heart tachycardia: Pulse faster than 100 bradycardia: Pulse slower than 59 apnea: absence of spontaneous respiration

Define and explain purpose of basic examination techniques: inspection, palpation, percussion, auscultation. NOTE: ALL TEST PERFORMED ON SKIN! -Inspection: process of observation. It can continue throughout the history-taking process and during the physical examination. Inspection uses mostly your eyes and nose to acquire data about color, texture, and mobility. It is important to validate what the patient is saying with what you observe. -Palpation: process of using the hands and fingers to gather information through the sense of touch. The palms and finger pads are more sensitive than the tips of fingers. Position, texture, size, consistency, masses, fluid, and crepitus are just some examples of what can be found. -Percussion: process involves striking one object against another, thus producing vibration and subsequent sound waves. Your index finger functions as a hammer and the vibration is produced by the impact of the finger against underlying tissue(3rd digit,distal IP joint). The density of the medium through which the sound waves travel determines the degree of percussion tone. Types of percussion tone(from loud to quiet): tympany, hyperressonance, resonance, dullness, flatness. -Auscultaion: listening for sounds produced by the body. Some sounds are audible by the human ear, while most require use of a stethescope. Some examples of auscultation are: Breath sounds in the chest, hear valves opening and closing, bowel sounds. Differential Diagnosis and pathology findings may be possible with auscultation alone.

Demonstrate proficiency in Vital Signs DVD checklist.

WEEK 3

9/16 PCM Objectives

The Medical Interview: Communication Skills II •	List what each letter of the AIDET acronym stands for and examples of actions for each: 	A-acknowledge- establish trust by demonstrating empathy (eye contact, shake hands, acknowledge others in the room and bond with each person, sit down) I-introduce- reduce anxiety by sharing with patients who you are and the skill set and experience of those who will be caring for them (introduce self, identify your experience level, manage up co-workers and hospital colleagues) D-duration- reduce anxiety by establishing time expectations (estimate time for procedure, test results, appointment time or bed availability, understand the psychology of waiting) E-explanation- enlist patient in treatment and care plan (explain what you are doing and why, explain the reason for ordering specific tests and how they will impact your decision making, explain to both the patient and person accompanying the patient) T-thank you- share your appreciation for allowing us the privilege of caring for them (“I’m sorry that you feel so poorly today but thank you for giving us the opportunity to make you feel better”, ask the patient and family if they have any questions) •	Describe the advantages for the patient and physician of using the AIDET approach to patient communication: increases patient compliance, leads to fewer malpractice claims (which leads to reduced legal expenses for healthcare organizations), increases patient’s education, their perception of your concern for their comfort •	Describe how the doctor-patient relationship maximizes quantity/quality of information obtained from the patient, and fosters patient commitment to treatment: •	Describe how attending to and utilizing nonverbal cues can improve doctor-patient communication: the way a person uses his or her body; paralinguistics (eg pressure of speech, dead voice tone); use of personal and social space; appearance and grooming; eye contact •	Demonstrate the ability to gather sufficient information needed to establish a differential diagnosis in a well-organized and efficient medical interview (knowing when to use open-ended questions, eliciting specific symptom descriptions, following up where appropriate on cues, etc) •	Demonstrate proficiency with PMH, ROS, family, social, and spiritual histories •	Demonstrate cultural assessment techniques of developing rapport/building mutual agenda with patient through basic listening skills: o	Respectful attention to story o	Paraphrasing to acknowledge patient’s concerns/feelings/ideas of what is causing illness o	Using perception check and behavior description in responding to patient’s affect, affect, social context and experience of illness o	Service excellence in communication skills

The Written History and Physical •	Describe the elements of a complete History and Physical presentation: o	CC/ID- chief complaint, a patient’s reason for seeking medical attention in their own words o	HPI- history of present illness- 	context (baseline)- Develop a sense of the person and understand pre-existing problems with potential relevance to the problem for which the patient is seeking help. Understand the patient’s baseline state of health and its characterization. Include relevant diagnoses (eg This is 65 y/o man with a 5 yr Hx of emphysema who presents with increasing shortness of breath over 5 days. At baseline he is able to walk one block before having to stop and catch his breath) 	 symptom (CC) 	 chronology- anchor to either 1. Time of encounter (eg 5 days prior to clinic visit) or 2. Dates (eg 9/19) 	 characterization of symptom(s) OPQRST •	O-onset- what was the patient doing when it started, was it sudden, gradual, or part of ongoing problem? •	P-provocation or palliation- whether any movement, pressure, or other factor makes better or worse •	Q-quality of the pain, “can you describe it for me?” sharp, dull, crushing, burning etc •	R-region and radiation- where the pain is or moves to •	S-severity- score of 1-10 •	T-time (history)- how long the condition has been going on and how it has changed since onset, whether it has ever happened before and whether and how it may have changed since onset, and when the pain stopped if it is no longer currently felt 	associated symptoms including pertinent positives (abnormalities which are relevant to the presenting problem) and pertinent negatives (findings which are normal, but are relevant to the DDx of the presenting problem) o	Review of Systems- see examples in syllabus, this is your failsafe to make sure you didn’t miss anything o	Past Medical Hx o	Surgical Hx o	Medications o	Allergies o	Family Hx o	Social Hx o	Physical Exam- 	I-inspection 	P-palpation 	P-percussion 	A-auscultation o	Database- labs, radiology, other diagnostic tests to highlight abnormals. This is for new results, old data typically goe in PMHx o	Assessment and Plan 	1. Problem •	 Differential diagnosis (DDx)- prioritized list of possible causes of a problem, discuss why you think a diagnosis is more or less likely (compare and contrast DDx, what is supporting and refuting data?) •	Diagnostic plan- What are you going to do to make the diagnosis? •	Therapeutic plan- What are you going to do to treat the problem?

•	Describe what elements are considered subjective or objective- subjective are things that the patient tells you or that you glean from the chart review; objective is the physical exam and database •	Describe where in the History and Physical each element or piece of data belongs •	Describe how the content of the written presentation will vary depending on the context of the visit and presentation: where you are, who you are presenting to, whether this person knows the patient, what is the purpose of the presentation, oral or written… (contexts vary such as new hospital admission, daily hospital follow up, new clinic patient etc) •	Demonstrate ability to write a patient History and Physical- SOAP Note o	S- subjective: CC, HPI, ROS, PMHx, Meds/Allergies, Soc Hx/Habits, FHx o	O- objective: PE, Data o	A-assessment o	P-plan Refer to “Guidelines for Written History and Physicals” p. 45 in syllabus for exact requirements for written history

WEEK 4

PCM Objectives for 9/23/09

1. Describe how patients’ psychosocial stressors can contribute to physical manifestations of disease. Stress, anxiety, depression, and other psychosocial stressors can often modify, attenuate or amplify the physical manifestations of disease. Probably the most common realization of this fact is acute hypertension in a stressed, fearful or alarmed individual. This will be seen time and again by all medical practitioners as the “white coat” syndrome. However, this is not just a giveaway observation; the hypertension is real and contributes equally to the negative consequences hypertension just as renal dysfunction would. It is important to realize that stress is often a contributing factor in our patients’ diseases, and that managing the psychological aspect of a patient’s condition can often make treatment of the organic disease much more successful. http://ibdcrohns.about.com/od/mentalhealth/f/ibdstress.htm

2. Describe how a physician’s awareness of psychosocial stresses can assist in both diagnosis and treatment of medical conditions. Because patients with psychosocial stressors often present with physical symptoms that are physical manifestations of the underlying disorder, physicians can be on the lookout for both the cause and effect of their patient’s symptoms if they are aware of psychosocial stressors. Physicians can also save patients pain, discomfort, unnecessary testing, and drug therapy by stepping in early to address psychosocial stressors as the cause of the ailment.

3. List what each letter of the BATHE acronym stands for and the interview questions associated with each. B: Background – What is going on in your life? A: Affect – How do you feel about that? T: Trouble – What troubles you most? H: Handling – How are you handling that? E: Empathy – An empathetic or supportive statement made by the physician, where appropriate, to conclude.

4. Describe the importance of each of the BATHE questions to the patient-physician relationship and overall patient care. Background: -	physician’s first insight into patient’s mental state -	probable origin of problem -	clues as to whether it’s an acute situation -	personality disorders can manifest here Affect: -	gives patient the opportunity to recognize and label feelings, important step before dealing with these feelings -	gives interviewer the opportunity to evaluate the appropriateness of the patient’s labeling of his/her feelings -	assess body language and nonverbal cues for more information about feelings Trouble: -	gives interviewer a sense of patient’s powers of perception, ability to prioritize, sense of self, etc. -	trouble is what brings the patient to the doctor most of the time -	physician’s ability to appreciate nature and magnitude of trouble is critical for helping patient develop a coping strategy Handling: -	gives interviewer a sense of patient’s problem-solving skills and coping mechanisms -	important for doctor to remember that patients in acutely stressful situations tend to regress to a lower level of functioning -	patient’s handling of trouble could be causing more problems than the trouble itself -	this is the time to offer beneficial suggestions to a stressed patient

Empathy: -	shows doctor is an ally in the process -	shows the interviewer was listening to and assimilating what the patient said -	doctors offer themselves as resources to patients with supportive statements -	often provides a great therapeutic benefit to a patient

5. Demonstrate the ability to use the BATHE technique as an aid in eliciting the psychosocial context for an encounter and to comfortably inquire about patients’ concerns, emotions, social situations and behaviors. •	BATHE technique is a – o	screening test for psychosocial status of patient – brief, focused, supportive o	therapeutic entity building upon preexisting PCP/patient relationship o	technique to allow PCPs to support patient as they try and solve problems o	technique that may be especially useful with unexplained symptoms or repetitive physical illness/problems •	BATHE goals o	exploring the context for problems affecting the patient’s life o	allowing patient to get in touch with emotional states o	assisting patients in identifying the most troubling aspect or problem o	focusing on how they are handling the problem o	providing empathetic response validating the patient 6. Demonstrate appropriate methods for gown and drape for heart exam. -Patient dresses into gown. With patient supine on exam table, place sheet over abdomen and lower     extremities. 2 draping methods -Expose entire left side of chest wall for examination OR -“To preserve modesty of patient” -First, pull gown down from neck to upper chest – expose just enough for inspection and then auscultation of Aortic and Pulmonic valve areas -Pull gown up at waist from under sheet (with sheet still over abdomen) to allow auscultation of Tricuspid and Mitral areas

7. Distinguish between the carotid pulse and the jugular venous pulse. –Jugular • Double pulse A wave-transmitted from atrial contraction V wave-transmitted from ventricular contraction • Location varies with position –Carotid • Single pulse • Location is independent of position

8. Describe thenormal jugular venous pressure (JVP) and what an elevation means. -Normal JVP is less than or equal to 8 cm water -Estimates the filling pressure of the right heart -High-Congestive heart failure and Pulmonary hypertension -Low-Dehydration and Hypovolemia

9. Demonstrate the measurement of the jugular venous pressure. First, lay the patient supine on the table and ask him/her to look in the opposite direction the examiner is standing. Second, locate the pulsating internal jugular vein. Third, raise the patient until a stop is seen in the pulsation of the jugular vein somewhere from the clavicle to the jaw. Finally, estimate the vertical distance from the point at which the JVP can no longer be visualized to the patient's right atrium. JVP is measured in "cm of water" above the right atrium.

10. Describe normal location and size of point of maximal impulse (PMI) and what causes it. The PMI is caused by the apical pulse being most readily seen and felt at the intersection of the MCL and the left 5th intercostal space. This point is less than 2cm in diameter (size of a nickle).

11. Describe a cardiac thrill. Cardiac thrills are vibratory sensations from turbulent blood flow across valves of the heart. They are a sign of serious cardiac pathology and can be palpated at the four classic valve areas.

12. Describe the location of the following areas: aortic, pulmonic, base, apex, mitral and tricuspid.

13. Describe what is meant by "systole" and "diastole." Systole: Ventricular contraction, tricuspid and mitral valves (AV valves) closed, aortic and pulmonary valves are open Diastole: When heart fills with blood, mitral and tricuspid valves open, aortic and pulmonary valves closed

14. Distinguish between S1 and S2 and descirbe what creates S1 and S2. S1: during systole, to hear S1 time the cardiac cycle with the carotid or radial pulse, the ‘lub’, closing of AV valves at beginning of systole S2: longer than S1, the ‘dub’, has two parts: aortic valve closure (A2), pulmonic valve closure (P2), P2 is slightly delayed with inspiration because P2 is dependent on the volume of blood returning to the right side of the heart, S2 physiological split cannot be heard during expiration, during inspiration A2 and P2 may sound like a blurred S2 rather than two distinct sounds

15. Describe the cause of a physiologically split S2. During inspiration, increased negative intrathoracic pressure which allows lung expansion also induces both increased blood return from the body into the right ventricle and simultaneous reduced blood volume return from the lungs into the left ventricle. Because of the increased blood volume in the right atria, the pulmonary valve stays open longer during ventricular systole whereas the aortic valve closes slightly earlier due to slightly reduced left ventricular volume. Thus the P2 component of S2 is delayed relative to the A2 component. This delay in P2 versus A2 is heard as a slight broadening or even "splitting" of the second heart sound, though usually only in the pulmonic area of the chest because the P2 is soft and not heard in other areas. During expiration, the less negative (than during inspiration) intrathoracic pressure no longer increases blood return to the right ventricle versus the left ventricle, the right ventricle volume is no longer increased. The pulmonary valve closes earlier, P2 occurs early and overlaps A2.

16. Describe what a murmur is and the characteristics that are used to describe one. A murmur is an abnormal heart sound. There are seven different characteristics used to classify the murmur: timing, shape, location, intensity, pitch, and radiation. Timing = whether the murmur is a systolic or diastolic murmur Shape = the intensity over time: crescendo, decrescendo, or crescendo-decrescendo Location = where the murmur is best auscultated: six locations: 2nd right intercostal space, 2-5 left intercostal space, 5th mid clavicular space. Radiation = where the sound radiates Intensity = loudness of the murmur and is graded on a scale of 0-6 Pitch = low, medium or high and is determined by whether it can be auscultated best with the bell or diaphragm of stethoscope.

General rule of thumb: sound radiates in the direction of blood flow. Example qualifiers: blowing, harsh, rumbling, musical.

17. Describe what a gallop is and distinguish between S3 and S4.

Gallops - extra (diastolic) heart sounds that sound like a horse galloping (best heard with bell). S3 - caused by rapid left ventricular filling against high pressure It occurs AFTER the normal two "lub-dub" heart sounds (S1 and S2). S4 - caused by atrial contraction against high pressure and a non-compliant left ventricle It occurs BEFORE the normal two "lub-dub" heart sounds (S1 and S2)

18. Identify and be able to describe locations of radial, brachial, carotid, femoral, popliteal, dorsal pedal and posterior tibial pulses.

19. Describe and identify the midsternal, mid clavicular, anterior axillary, scapular and vertebral line, costal margin and suprasternal notch. The midsternal line is a vertical plane which runs down the middle of the sternum. It is part of the midline. The midclavicular line runs vertically and inferiorly from the midpoint of each clavicle. The anterior axillary line runs vertically and inferiorly from the anterior axillary fold. The scapular line runs vertically through the inferior angle of the scapula. The vertebral line runs vertically along the vertebral column. It is part of the midline. The costal margin is the medial margin of the false ribs. It is the upside-down V formed by the anterior rib cage. The suprasternal notch is the indentation on the superior aspect of the manubrium of the sternum.

20. Identify the angle of Louis (the Manubrial-sternal junction and the structures corresponding to this level). The manubriosternal junction is the palpable part of the sternum where the manubrium meets the body. It protrudes slightly anteriorly. It marks the approximate level of the 2nd pair of costal cartilages and the level of the intervertebral disc between T4 and T5. It also marks the beginning and end of the aortic arch, and the bifurcation of the trachea into the left and right main bronchi. For physical exam purposes, it is a useful landmark for where to listen to the aortic valve (to the right of the manubriosternal junction) and the pulmonary valve (to the left of the manubriosternal junction).

NOTE: Did not include the last 2 objectives because they are demonstrating proficiency of heart and pulse exams with the checklist, which is to be done in person.

WEEK 5

Sept 30 Lung Exam Skills 1.	Demonstrate appropriate methods to gown and drape for a lung exam: 	Allow a patient to get changed in private. 	It is disconcerting and demeaning to be uncovered unexpectedly. Tell the patient what you are going to do before you do it and/or offer to allow the patient to do it themselves, e.g. “I’m going to untie your gown to listen to your chest”. As a general rule, you control the drape and the patient controls their clothing. 	Uncover only the part you are examining, and cover it up when you are done. 	When you are examining the back, or need to move the gown forward at the front, untie the gown 	If the anterior chest is being examined in the upright position, a patient can lower the gown to just above the nipple level to examine the upper chest. 2.	Describe normal and abnormal respiratory rates: Apnea, tachypnea, bradypnea, hyperventilation and hypoventilation. 	Normal= 12-18 (variable depending on source) 	Apnea= Apnea is a period of time during which breathing stops or is markedly reduced. 	Tachypnea= > or = 20 	Bradypnea= < or = 10 	Hyperventilation-breathing faster and/or deeper than necessary 	Hypoventilation-breathing slower and/or more shallow than necessary 3.	Identify and describe the use of accessory muscles of respiration 	Respiratory muscles during normal breathing are: •	Diaphragm •	Intercostal muscles 	During times of strenuous breathing, accessory muscles may be recruited. This is normal during exercise. This is abnormal at other times and may be sign of impending respiratory failure •	sternocleidomastoids, scalenes, and trapeziuses •	These muscles pull up on the clavicles and increase thoracic cavity volume

4.	Describe where the lung lobes project on the chest.

5.	Demonstrate lung percussion technique. 	Press firmly against chest with non-dominant hand, 3rd DIP joint 	Don’t be shy 	Strike 3rd DIP with end of the opposite 3rd finger 	Move side to side using symmetry as your control. 6.	Describe the typical percussion notes and where they are normally found. 	Normal Lung- Resonant-Low pitched, hollow- Except in areas over the scapulas (flat) •	Solid Structures-Flat/Dull •	Dullness over the lungs indicates: consolidation (Fluid filled lung), Mass (Tumor),Pleural Effusion (Fluid filled thoracic cavity) 	Abdomen-Tympanic-High pitched, drumlike •	Hyperresonant-Louder and lower pitched than resonant: Too much air, such as in emphysema or pneumothorax 7.	Demonstrate Lung auscultation techniques 	Use diaphragm of stethoscope- DON”T LISTEN THROUGH CLOTHING 	Ask patient to breathe through open mouth 	Listen side to side comparing symmetry- Don’t forget the axilla and anterior chest 	Listen for the type and intensity of breath sound and for adventitious (extra) sounds Pattern:

8.	Describe and distinguish between tubular and vesicular breath sounds and where they are normally heard. 	Vesicular (also called alveolar) breath sounds are typically heard over the lung parenchyma- Peripheral chest 	Tubular (also called bronchial) breath sounds are typically heard over the tubular structures, such as the trachea and bronchi- Central chest 	Vesicular and tubular breath sounds are distinguished by: •	Inspiratory/Expiratory (I/E) ratio    Alveolar-1:1/4       Tubular-1:1 •	Quality of sound Alveolar are typically more quiet than tubular Tubular sounds are air rushing through tubes Alveolar sounds are the result of the attenuation of the breath sounds from the tubular structures by the lung parenchyma 9.	Describe why you would hear tubular breath sounds in the peripheral chest. 	Tubular breath sounds heard over the peripheral chest are always abnormal. It is a sign of consolidation (area of fluid filled alveoli) because fluid filled lung (solid) transmits sound more efficiently than air filled lung. Therefore, you can hear the tubular sound from the bronchus in the periphery 10.	Describe the adventitious breath sounds and what they signify. 	Crackle: Discontinous, high pitch, velcro-like. Almost always inspiratory. Caused by alveoli snapping open under increased alveolar surface tension from Fluid in interstitium or Fibrosis in interstitium. Disease found in include congestive heart failure and pulmonary fibrosis. 	Wheezes: Continuous, high pitch, musical. Expiratory (mostly). Caused by airway obstruction from diseases such as asthma exacerbation, bronchitis, emphysema. 	Stridor: Continous, low pitch, coarse.Expiratory. Caused by airway secretions in the bronchi from diseases such as bronchitis, Pneumonia, Tuberculosis. 	Rubs: Dry, grating, leathery sound. Both inspiratory and expiratory.Caused by pleural inflammation from diseases such as Pneumonia, Viral pleuritis, Malignancy, Autoimmune disease 11.	Define lung consolidation: Mass or fluid filled lung. 12.	Demonstrate the technique for tactile fremitus and describe what it means. 	Test used to distinguish consolidation from pleural effusion 	Test: Palpate bilateral chest with palms/fingers or ulnarsides of hand, Ask patient to say “toy” “ninety nine” or “E” every time you move your hand •	Solid (fluid filled) lung transmits vibration more efficiently than does fluid or air •	Consolidation increases tactile fremitus •	Pleural effusion decreases tactile fremitus 13.	Describe consolidation and plural effusion and what exam findings distinguish between them. 	Consolidation: Fluid filled lung 	Pleural effusion: Fluid filled pleural cavity 14.	Demonstrate the technique for egophany and describe what it means. 	Have the patient say “E” every time you move your stethoscope 	Listen in all the same areas you auscultated 	You hear “E”= normal 	You hear “A”= consolidation

Sept 30 Motivational Interviewing 1.	Describe 3 aspections of motivational interviewing: collaborative, evocative and automony supportive. 	Collaborative: The patient is an active participant, joint decision making. With health behavior change, it is ultimately only the patient who will enact the change. 	Evocative: The resources and motivation for change are presumed to reside within the patient- Focus on client’s reasons for change. A patient may not be motivated to do what you want – but the part of the Art of Motivational Interviewing is connecting what your patients care about with their own values and concerns. 	Automony supportive: Honors independent choice or autonomy. Acceptance that people can and do make choices about the course of their lives. 2.	List the four guiding principles of motivational interviewing using RULE: 	Resist the Righting Reflex 	Understand 	Listen 	Empower your patient 3.	Identify motivational interviewing strategies that form the acronym OARS. 	Open ended questions 	Affirmations 	Reflective Statements 	Summaries

WEEK 6

Group F PCM Fall Term Objectives Lecture 10/7/2009

Describe the legal concepts governing the physician-patient relationship, truth telling and the confidentiality of medical information. While not binding by law, the American Medical Association's Code of Medical Ethics addresses the patient-physician relationship, stating that “the information disclosed to a physician during the course of the patient-physician relationship is confidential to the utmost degree.” Full and frank disclosure of information to a physician is important for effective treatment. Such disclosure can be attained through trust and the knowledge that the physician will protect a patient’s confidentiality. Legal concepts governing the patient-physician relationship and confidentiality, however, are taken largely from HIPAA, the Health Information Privacy and Accountability Act – and, specifically, the HIPAA Privacy Rule. The Privacy Rule outlines the protection for the privacy of a patient’s individually identifiable health data, referred to as protected health information (PHI). The regulations require that appropriate administrative, technical, and security safeguards be taken to ensure the privacy of protected health information – both written and oral. HIPAA requires a Notice of Privacy Practices to be distributed to patients at the time of first service delivery. The notice explains how a physician may use and disclose a patient’s information and what rights a patient has with respect to the medical information about him/her. Delivery of service also requires a patient’s informed consent – a detailed form that acknowledges that the physician has informed the patient of the following (known as “PARQ requirements”): Procedure to be undertaken Alternatives to procedure Risks of the procedure Answers to Questions or additional information, as requested by patient •	Other important concepts from HIPAA Privacy Rules: •	 Protected Health Information o	Any information, whether oral or recorded in any form or medium that: 	is created or received by a health care provider, health plan, public health authority, employer, life insurer, school or university, or health care clearinghouse 	or relates to the past, present, or future physical or mental health or condition of an individual; the provision of health care to an individual; or the past, present, or future payment for the provision of health care to an individual. •	 Minimum necessary standard Standard that requires a physician to make reasonable efforts to limit the amount of protected health information that the physician uses or discloses to the minimum amount that is necessary to accomplish the purpose of the use or disclosure. This requirement does NOT apply when a physician discloses information to another provider or requests information for treatment purposes. •	 Need to know Protected health information should be shared on a “need to know” basis. Unless you need the information as part of your job, you should not be exchanging protected health information. •	Common Law Exception to Confidentiality: Tarasoff v. Regents of the University of California (1976) – mentioned in lecture and small group o	 Patient kills ex-girlfriend after disclosing to psychiatrist his intention to do so. o	Psychiatrist contacts police but not the intended victim. o	Courts ruled psychiatrist had a duty to warn victim directly. •	 "When a physician determines that a patient presents a serious danger of violence to a specifically identifiable third party, the physician is required to use reasonable care to protect the intended victim even if such steps result in the disclosure of a confidential communication." Describe the ethical principles that guide truth telling and the confidentiality of medical information. •	From Dr Potter’s lecture: Confidentiality: “a duty to restrict access to a private situation.” •	Guided by the following principles: 1.	Protecting patient’s privacy. Privacy protects moral space; patient can be true self 2.	Respecting patient and maintaining patient’s dignity. Dignity maintained by avoiding shame/embarrassment. Implication here is that disclosure of personal information can result in loss of dignity and diminished respect for patient 3.	Establish Patient-Physician Trust. Allows personal information to flow freely between patient and physician Enables full disclosure that allows physician to more effectively treat patient •	From the Mengel chapter on Medical Ethics (Chapter 26): Issues of confidentiality could also be guided by four basic ethical concepts/questions: 1.	Beneficence/Non-maleficence: Will the patient be benefitted/harmed? 2.	Autonomy: Will the action respect the patient’s privacy/autonomy? 3.	Justice: What would be fair in the situation? 4.	Virtue: Will an action allow me to remain faithful to my values and ideals, and to those of the medical profession? •	Values of the Medical Profession, as a whole, also guide patient confidentiality: 1.	Hippocratic Oath. Classical version “What I may see or hear in the course of the treatment or even outside of the treatment in regard to the life of men, which on no account one must spread abroad, I will keep to myself holding such things shameful to be spoken about.” 1.	Modern version “I will respect the privacy of my patients, for their problems are not disclosed to me that the world may not.” 1.	Declaration of Geneva, adopted by General Assembly of World Medical Association. (Declaration of physician’s dedication to humanitarian goals of medicine) “I will respect the secrets which are confided in me, even after the patient has died” 1.	Principles of Medical Ethics, adopted by American Medical Association •	Principle VIII: “A physician shall, while caring for a patient, regard responsibility to the patient as paramount.” Describe harms to the patient and society for not telling the truth and for breaches in confidentiality. Patients who are uniformed about their medical condition (whether that be because the physician did not disclose the diagnosis to the patient or because the physician lied outright) may fail to obtain medical attention when they should. This delay in accessing healthcare can lead to a worse health outcome for the patient. A lack of honesty can also harm a patient, if that patient makes a decision affecting their life that they would not have made if they were aware of their condition.
 * Principle IV: “A physician shall respect the rights of patients, colleagues, and other health professionals, and shall safeguard patient confidences and privacy within the constraints of the law.

When there is a breach of confidentiality a patient can be harmed as they may lose confidence in their physician and other healthcare professionals. The experience of breached confidentiality may impact the patient to such an extent that they avoid seeking medical attention.

Both dishonesty and breaches of confidentiality are detrimental to society as well because they undermine the public’s confidence in the medical profession and the medical system.

Identify situations of appropriate and inappropriate information sharing per the OHSU and HIPAA policies. Appropriate •The OHSU health information disclosure policy (found at: http://www.ohsu.edu/xd/about/services/integrity/ips/regulations/upload/Permitted-Uses-Disclosures-of-PHI.pdf) states that health information can be used and disclosed as follows: o  To the patient about themselves for OHSU treatment purposes o  For OHSU payment activities o  For OHSU health care operations o  To another health care provider for their treatment activities. o  To another covered entity for the payment activities of the entity that receives the information o  To another covered entity for the health care operations if the entity has a relationship with the patient, the health information disclosed pertains to this relationship, and disclose is for quality assessment and improvement, case management or care coordination, professional performance review or credentialing, and/or healthcare fraud and abuse o  For public health purposes (i.e., mandated reports to state registries (immunizations, cancer, trauma), vital statistics reports (i.e., birth and death certificates), newborn screenings, communicable disease reports (i.e., HIV, STD, TB)) o  To the Food and Drug Administration for purposes related to the quality, safety, or effectiveness of a FDA-regulated product or safety. o  About victims of abuse, neglect, or domestic violence to the proper authority (including reports on child abuse, elder abuse, abuse of mentally ill or developmentally disabled) o  For health oversight activities (including audits and inspections by federal and state agencies such as the Center for Medicare and Medicaid Services, the Department of Health & Human Services, OMPRO, etc) o  For judicial or administrative proceedings under certain conditions o  For law enforcement purposes o  About decedents to Coroners, Medical Examiners, or Funeral Directors as required by law for each to carry out their duties with respect to the decedent o  For cadaveric organ, eye or tissue donation and transplantation purposes o  For human-subject research that receives a waiver of authorization by the IRB. o  As necessary to avert a serious threat to health or safety of a person or the public or certain specialized government functions o  As required by law for worker’s compensation purposes •Hospitals can disclose patient’s name, location in the facility, and condition described in general terms to clergy and those who inquire about the patient by name. Patients must be able to opt out of being listed in the directory. •If a patient is unconscious or incapacitated, health information can be shared with individuals who are directly involved in making decisions about the patient’s care or payment for care, as long as there are no restrictions in the patient’s chart regarding the release information. •The health record of a deceased patient may be disclosed in two scenarios. First, it can be released to a health care provider to facilitate that provider’s treatment of a surviving family member. In addition, it can be disclosed to family members if the requester has the legal authority to act for the decedent or the decedent’s estate. Inappropriate: •There shall be no discussion of health information, including, without limitation, patient cases in public places such as elevators or hallways. •If a patient requests that the physician communicate in a confidential manner (i.e. not leaving messages about care with other members of the household) the physician must accommodate the request if it is reasonable. •Health information cannot be shared with the press. •Health information cannot be shared with the following unless patients provide explicit authorization: o  Disclosures for life insurance purposes o  Disclosures for disability purposes o  Disclosures to schools o  Disclosures to attorneys o  Disclosures to individuals (such as family, friends, or other identified persons) who are directly involved in the care or payment activities of the patient o  Disclosures for marketing activities o  Disclosures to the OHSU Foundation for fundraising purposes (if more than patient demographics or dates of service will be used) o  Disclosures to employers o  Disclosures of health information for human-subject research activities Exam Skills Demonstrate methods for draping patient and positioning patient for ease of examination. 1.	Ask the patient to lie on a level examination table that is at a comfortable height for both of you. At this point, the patient should be dressed in a gown and, if they wish, underwear. 2.	Take a spare bed sheet and drape it over their lower body such that it just covers the upper edge of their underwear (or so that it crosses the top of the pubic region if they are completely undressed). This will allow you to fully expose the abdomen while at the same time permitting the patient to remain somewhat covered. The gown can then be withdrawn so that the area extending from just below the breasts to the pelvic brim is entirely uncovered, remembering that the superior margin of the abdomen extends beneath the rib cage. 3.	The patient's hands should remain at their sides with their heads resting on a pillow. If the head is flexed, the abdominal musculature becomes tensed and the examination made more difficult. Allowing the patient to bend their knees so that the soles of their feet rest on the table will also relax the abdomen. Describe the four and nine part naming systems for the abdomen and what organs are in each area. •	4 divisions: left upper quadrant, left lower quadrant, right upper quadrant, right lower quadrant •	9 divisions: •	 Identify inguinal and femoral lymph node regions. Identify and describe inspection, auscultation, palpation, and percussion techniques for the abdominal exam. Inspection: •	Contour: –Flat, Scaphoid, Protuberant, Distended, Obese •	Scars •	Veins •	Pulsations •	Hernias pay particular attention to: 1.	Appearance of the abdomen. Is it flat? Distended? If enlarged, does this appear symmetric or are there distinct protrusions, perhaps linked to underlying organomegaly? The contours of the abdomen can be best appreciated by standing at the foot of the table and looking up towards the patient's head. Global abdominal enlargement is usually caused by air, fluid, or fat. It is frequently impossible to distinguish between these entities on the basis of observation alone (see below for helpful maneuvers). Areas which become more pronounced when the patient valsalvas are often associated with ventral hernias. These are points of weakening in the abdominal wall, frequently due to previous surgery, through which omentum/intestines/peritoneal fluid can pass when intra-abdominal pressure is increased 2.	Presence of surgical scars or other skin abnormalities. 3.	Patient's movement (or lack thereof). Those with peritonitis (e.g. appendicitis) prefer to lie very still as any motion causes further peritoneal irritation and pain. Contrary to this, patients with kidney stones will frequently writhe on the examination table, unable to find a comfortable position. Ausculatation: Compared to the cardiac and pulmonary exams, auscultation of the abdomen has a relatively minor role. It is performed before percussion or palpation as vigorously touching the abdomen may disturb the intestines, perhaps artificially altering their activity and thus bowel sounds. Exam is made by gently placing the pre-warmed (accomplished by rubbing the stethoscope against the front of your shirt) diaphragm on the abdomen and listening for 15 or 20 seconds. There is no magic time frame, but for a very sick patient, the clinical criteria is five minutes without a bowel sounds is necessary to say the bowel is inactive. The stethoscope can be placed over any area of the abdomen as there is no true compartmentalization and sounds produced in one area can probably be heard throughout. Three things should be noted: 1.	Are bowel sounds present? 2.	If present, are they frequent or sparse (i.e. quantity)? 3.	What is the nature of the sounds (i.e. quality)? Palpation: 1.	   First warm your hands by rubbing them together before placing them on the patient. a.	The pads and tips (the most sensitive areas) of the index, middle, and ring fingers are the examining surfaces used to locate the edges of the liver and spleen as well as the deeper structures. b.	You may use either your right hand alone or both hands, with the left resting on top of the right. 2.	Apply slow, steady pressure, avoiding any rapid/sharp movements that are likely to startle the patient or cause discomfort. 3.	Examine each quadrant separately, imagining what structures lie beneath your hands and what you might expect to feel. 4.	Gently push down (posterior) and towards the patient's head with your hand oriented roughly parallel to the rectus muscle, allowing the greatest number of fingers to be involved in the exam as you try to feel the edge of the liver. 5.	Advance your hands a few cm cephelad and repeat until ultimately you are at the bottom margin of the ribs. Initial palpation is done lightly. 6.	Following this, repeat the examination of the same region but push a bit more firmly so that you are interrogating the deeper aspects of the right upper quadrant, particularly if the patient has a lot of subcutaneous fat. 7.	Pushing up and in while the patient takes a deep breath may make it easier to feel the liver edge as the downward movement of the diaphragm will bring the liver towards your hand. 8.	The tip of the xyphoid process, the bony structure at the bottom end of the sternum, may be directed outward or inward and can be mistaken for an abdominal mass. You should be able to distinguish it by noting its location relative to the rib cage (i.e. in the mid-line where the right and left sides meet). Percussion: The technique for percussion is the same as that used for the lung exam. •	First, remember to rub your hands together and warm them up before placing them on the patient. •	Then, place your left hand firmly against the abdominal wall such that only your middle finger is resting on the skin. •	Strike the distal interphalangeal joint of your left middle finger 2 or 3 times with the tip of your right middle finger, using the previously described floppy wrist action (see under lung exam). •	There are two basic sounds which can be elicited: 1.	Tympanitic (drum-like) sounds produced by percussing over air filled structures. 2.	Dull sounds that occur when a solid structure (e.g. liver) or fluid (e.g. ascites) lies beneath the region being examined. •	Special note should be made if percussion produces pain, which may occur if there is underlying inflammation, as in peritonitis. The two solid organs which are percussable in the normal patient are the liver and spleen. In most cases, the liver will be entirely covered by the ribs. Occasionally, an edge may protrude a centimeter or two below the costal margin. The spleen is smaller and is entirely protected by the ribs. Demonstrate techniques for abdominal palpation and percussion. PERCUSS: Unlike the usual sequence, auscultation of the abdomen always precedes percussion and palpation, because these maneuvers may alter the frequency and intensity of bowel sounds. Percuss all quadrants or regions of the abdomen for tympanic dullness. Percuss downward from the chest in the right midclavicular line until you detect the top edge of liver dullness. Percuss upward from the abdomen in the same line until you detect the bottom edge of liver dullness. Measure the liver span between these two points. This measurement should be 6-12 cm in a normal adult.

PALPATE: Light palpation first then deep palpation. The most sensitive indicator of tenderness is the patient's facial expression (so watch the patient's face, not your hands). Voluntary or involuntary guarding may also be present. Palpate liver by placing your fingers just below the right costal margin and press firmly. Ask the patient to take a deep breath. You may feel the edge of the liver press against your fingers. Or it may slide under your hand as the patient exhales. A normal liver is not tender. Palpate the Aorta by pressing down deeply in the midline above the umbilicus. The aortic pulsation is easily felt on most individuals. A well defined, pulsatile mass, greater than 3 cm across, suggests an aortic aneurysm. Palpate the Spleen by using your left hand to lift the lower rib cage and flank. Press down just below the left costal margin with your right hand. Ask the patient to take a deep breath. The spleen is not normally palpable on most individuals. Describe the percussive findings of splenomegaly. The spleen should be percussed just posterior to the midaxillary line on the left side of the body. One should start percussing as areas of lung resonance and move in many directions from there. Splenic dullness (sound produced by percussion when solid organs reside beneath) may occur from the 6th to the 10th rib A small area of dullness can be produced and is considered normal. A large area of dullness in this region can indicate an enlarged spleen. Next, the lowest intercostal space should be percussed just anterior to the left axillary line before and after the patient takes a deep breath. This area should remain tympanic (the sound produced by percussion over air-filed space) throughout the breath. If the spleen is enlarged, the tympanic sound will become dull with exhalation. Note- It is not possible to distinguish between the dullness of the posterior flank. Note- The tympany of colonic air can obscure the dullness created by an enlarged spleen. In summary- generally spleens, when normal size, may or may not produce a dull sound upon percussion. With splenomegaly, the tympanic sound of the subcostal space may become dull upon expiration. However this test can be largely inconclusive as colons full of air or feces can mask or mislead findings. Demonstrate Murphy’s sign and describe what it means. Murphy's sign is when you place your hand in the patients upper right quadrant of their abdomen. With your fingers placing moderate pressure in and up towards there liver(underneath the rib cage), ask them to take a deep breath two. The first breath is to relax there abdominal muscles. The second breath is to actually palpate the liver and gallbladder. Positive Murphy's sign is when the patient experiences a sharp pain upon palpation. A positive Murphy's sign is a indicator of Gall badder disease. Describe the findings of shifting dullness and the fluid wave. Shifting dullness and fluid wave are two tests/findings from the abdominal exam that support an ascites diagnosis. Briefly, ascites is excess intraperitoneal fluid typically caused by cirrhosis.

Shifting dullness: To perform a shifting dullness maneuver, place the patient in the supine position. Percuss across the abdomen as for flank dullness, with the point of transition from tympany to dullness noted. The patient then is rolled on his/her side away from the examiner, and percussion from the umbilicus to flank area is repeated. Positive test: When ascites is present, the area of dullness will shift to the dependent site. The area of tympany will shift toward the top.

Fluid Wave: This exam is performed by having the patient (or a colleague) push their hands down on the midline of the abdomen. The examiner then taps one flank, while feeling on the other flank for the tap. Fluid allows the tap to be felt on the other side. Soft tissue will not transmit a wave

Describe the findings of peritonitis. Clinical setting — In general, patients with SBP have advanced cirrhosis. Fever — Fever is clearly the most common manifestation of SBP. It is important to appreciate in this regard that patients with advanced cirrhosis are usually mildly hypothermic. Thus, a temperature of 37.8ºC (100ºF) or greater must be taken very seriously. There is frequently a very short window of opportunity in which to intervene to ensure a good outcome. If this opportunity is missed, shock ensues, followed rapidly by multisystem organ failure. Survival is unlikely in patients who develop shock prior to initiation of empiric antibiotics. Abdominal pain and tenderness — The main manifestations of peritonitis are acute abdominal pain, abdominal tenderness, and abdominal guarding, which are exacerbated by moving the peritoneum, e.g. coughing (forced cough may be used as a test), flexing one's hips, or eliciting the Blumberg sign (a.k.a. rebound tenderness, meaning that pressing a hand on the abdomen elicits less pain than releasing the hand abruptly, which will aggravate the pain, as the peritoneum snaps back into place). The presence of these signs in a patient is sometimes referred to as peritonism. The localization of these manifestations depends on whether peritonitis is localized (e.g. appendicitis or diverticulitis before perforation), or generalized to the whole abdomen. In either case pain typically starts as a generalized abdominal pain (with involvement of poorly localizing innervation of the visceral peritoneal layer), and may become localized later (with the involvement of the somatically innervated parietal peritoneal layer). Peritonitis is an example of an acute abdomen. Diarrhea — An alteration in gut flora with overgrowth of one organism (usually Escherichia coli) has been documented in an animal model of cirrhosis and SBP. These animals regularly develop diarrhea as this occurs, followed by extraintestinal dissemination of the pathogen which may herald the onset of ascitic fluid infection. Altered mental status — The clinical sign of infection that is frequently overlooked in the patient with cirrhosis is a subtle change in mental status. This finding was present in 54 percent of patients in a 1990 series and 54 percent of those in a later large review. Both the infection itself and hepatic decompensation may contribute to this problem. Ammonia levels do not correlate well with mental status. This alteration in mental status may be so subtle that it can only be detected by a spouse or a physician who knows the patient well. The Reitan trail test is helpful in detecting subtle changes in mental status in the patient with cirrhosis. This is a connect-the-number test that is timed. Patients without hepatic encephalopathy should finish the test in a matter of seconds comparable to their age in years. In other words if a patient is 50 years old, he should be able to finish the test in <50 seconds. If he cannot, he probably has hepatic encephalopathy. This test can be administered in the clinic or on the ward by a physician, nurse, or assistant. It is much more helpful, cheaper, and more rapidly available than a plasma ammonia concentration. The key is having a copy of the test on hand and to keep an unused copy for photocopying. Paralytic ileus, hypotension, hypothermia — These more severe signs are indicative of advanced infection and a poor likelihood of survival. As noted above, it is important to detect infection and begin antibiotic treatment before this stage is reached. Laboratory abnormalities — Occasionally an infected patient with cirrhosis will have no clinical signs or symptoms, but will have subtle laboratory signs of infection. These include leukocytosis, metabolic acidosis, and azotemia. The otherwise unexplained presence of one or more of these abnormalities should prompt abdominal paracentesis in a patient with cirrhosis and ascites.

Demonstrate and describe the findings of appendicitis. usual pain characteristics: * initially periumbilical or epigastric * later becomes localized to RLQ possible associated findings: * guarding * tenderness * positive iliopsoas - perform when suspect appendicitis - patient lies supine - place hand over lower thigh - ask patient to raise leg and flex at hip while pushing down on leg - patient w/ positive iliopsoas sign will experience lower quadrant pain * positive obturator sign - perform when suspect ruptured appendix or pelvic abscess - patient lies supine - ask patient to flex leg at hip and knee to 90 degrees - hold leg above knee, grasp ankle and rotate leg lateral and medially - positive obturator sign causes pain in hypogastric region * nausea or vomiting after onset of pain * low grade fever Identify surface anatomy of: anterior superior iliac spine, symphysis pubis, inguinal ligament including bony landmark of attachment. The anterior superior iliac spines are in the right and left iliac regions, inferior and lateral to the abdomen. The pubic symphysis is the bony protuberance at the inferior border of the hypogastric region. The inguinal ligament attaches on the lateral edges of the pubic symphisis and the medial edges of the anterior superior iliac spine.

Demonstrate proficiency in Abdomen Exam using DVD checklist. 1. Have patient lie back, make sure table is flat, expose abdomen and make sure it is relaxed, and stand at patient's right side. 2. Inspect the abdomen for contour, markings, venous markings and changes with respiration. 3. Ascultate each of the four quadrants of abdomen. 4. Palpate the left upper quadrant. 5. Palpate the left lower quadrant. 6. Palpate the right lower quadrant. 7. Palpate the right upper quadrant. 8. Palpate the spleen - Place your hand on the left upper abdomen. Instruct the patient to inhale as you begin palpating. Instruct the patient to exhale as you deepen you palpation. 9. Percuss the liver span. 10. Palpate the liver - Place your hand on the right upper abdomen. Then ask the patient to inhale as you palpate. Instruct the patient to exhale as you deepen your palpation then inhale again. WEEK 7

1. Describe the ethical and legal aspects of patient autonomy and self-determination. Patient autonomy is the ability for individuals to be self determined We assume that rational people can determine for themselves what is best for their lives. Therefore, paternalism is a direct affront to autonomy. The ethical basis for this is respect for person.

2. Describe the Specific elements of decision-making capacity •	Understand basic information •	Appreciate’s consequences •	Evaluate’s information rationally •	Communicate’s decision

3. Define the ethical and legal requirements of disclosure (PARQ): nature of the procedure, alternatives, risks and questions. This question defines itself. You must inform a patient about what type of procedure they will be having, the alternatives to that procedure, the risks of that procedure and see if they have any questions. Remember, to ensure that the patient has full understanding ask them to “teach back.” 4. Identify issues complicating informed consent in special circumstances: A: Medical emergency Incapable adult (guardian/HCR>spouse/dompartner>adult child>parent>adult sibling>agreed upon other adult>other adult relative/friend>patient advocate) Minor where consent by parent/guardian is refused (e.g. faith healing)-Court authorities can overrule the parents and possibly take custody of the child. Telephone informed consent-if written con sent is not possible, then telephone consent may be given. physician and witness must be present on the telephone and the caller must ID themselves. Research informed consent Another student answered: -minor patients (under 15 years) need parental or guardian to sign unless they are married or emancipated -IRB approved consent forms must be signed before the research procedures (witness also signs) -consent must be filed in patient's record -documentation should support an inability to obtain consent in medical emergencies -if approved IRB form not avaialable, add consent discussion to progress notes in patient's chart

Describe the differences between the written and oral case presentation. 1. Describe the differences between the written and oral case presentation. a. Basic Structure i. Identifying information/chief complaint ii. History of present illness iii. Other active medical problems, medications, habits, and allergies iv. Physical examination (key findings) v. Laboratory vi. Assessment and plan b. Oral presentation i. Focuses on HPI and Assessment and Plan ii. Tells a good story (doesn’t bore the listener) iii. Always less than 5 minutes and ideally 3 minutes iv. Contains only those few facts essential to understanding the current issue(s) c. Written presentation i. Comprehensive ii. Contains all the facts

2. "Describe how to adapt the case presentation to the context of that presentation."

A: In short, adaptation of case presentation requires sharing as much pertinent and as little impertinent information as possible. If the presentation is on a brand new clinic patient or new hospital admission, the presentation will be thorough, often covering HPI, PMH and RoS in depth. If the presentation is a follow-up in or out of the hospital, however, following the SOAP format -- sharing brief subjective and objective information gleaned from interview and exam, along with assessment (which includes any recent changes in hospital patients) and plan for care -- should be sufficient.

Example contexts amenable to oral presentation: i. New hospital Admission ii. Daily hospital follow up iii. New clinic patient (Thorough presentations should be used with any new patients) iv. Follow up clinic patient (presentations for follow up patients should follow the  SOAP format) v. Calling a specialist to ask for a consult

3. (The oral case was demonstrated by two 3rd year medical students during our large group PCM section)

Tips: should be under 3 minutes and includes: identifying data, chief complaint, and history of present illness (HPI). In our case follow the SOAP format: Subjective is the patients’ history of present illness (HPI), and the Objective are the physical exam and lab/radiological studies. These sections conclude with a summary statement followed by your Assessment of what is going on with the patient and your Plan to further diagnose or treat.

Step 1: The chielf complain (cc) ---make an opening statement of the chief complaint and should contain: age, race, gender, reason for presentation, and duration of the problem. ---example: This a a (age) year old (race) (gender) with (highly relevant; concurrent medical problem) who present (reason for presentation and duration) ---example: This is a healthy 18 year old caucasion male who presents with a chief complain of "sore throat" for the past two days.

Step 2: The history of Present Illness (HPI) --Briefly set the context within which present illness occurs --example: The pagient was in good health until... --example: the patient has been on stable dose of prednisone for her Lupus without complaints for the last 6 months until 2 weeks ago Step 3: now describe the symptoms using OPQRST format (Onset, Provoking factors, Quality, etc) Example: This patient has been on a stable dose of prednisone for her Lupus without complaints for the last 6 months until 2 weeks ago. Over the past two weeks she has noticed gradual onset of fatigue, malaise, decreased appetite and a progressive feeling of shortness of breath. The shortness of breath came on gradually, but has steadily worsened over the last two weeks. She is now unable to walk more than 10-20 feet or carry on a conversation due to the shortness of breath. Her symptoms improve with rest or remaining still. She has tried a friend’s albuterol inhaler without relief. Over this same time period, she also noted mild “3 out of 10” stabbing pain in her lower left anterior chest that only occurs when taking a deep breath. The pain is not worsened by exertion, and does not radiate to her arm or jaw. Of note that the patient's sister and mother also have lupus, and her mother had a “blood clot” in her lungs a few years ago. The patient does not have any personal history of thromboembolic disease, and has not traveled or taken prolonged car rides. She denies any history of any cough, hemoptysis. orthopnea, paroxysmal nocturnal dyspnea, or pain in her arm or jaw. She denies any fevers or night sweats, hematuria, or edema.

Step 4: Context of the Patient's Life/Medical History Organized by section of the medical history: social history; past medical history; past surgical history; medications; allergies and immunizations; family history; review of symptoms

Step 5: Physical Exam Opening statement: "paint a picture" of your patients overall appearance by telling them your "first glance impression" ---level of consciousness (alert, obtunded, etc); vitals ---Report your physical findings: describe in detail only pertinent findings Example: This is an alert, thin, female who appears older than her stated age and in moderate distress. She is unable to speak without stopping to catch her breath, Patient has an irregularly irregular pulse at a rate of 120 beats/min with a blood pressure seated of 100/50 mm hg, a respiratory rate of 30 per minute, and an axillary temperature = 99.2° f.            Example for reporting physical findings (note the emphasis on the lung and heart exam given the chief complaint of shortness of breath with chest pain and elevated heart rate) Examination of the head, eyes, ears, nose, and throat were unremarkable. The jugular venous distension was 4 cm measured at 30 degrees. Lungs were normal to percussion and auscultation bilaterally. No crackles were appreciated. Cardiac exam revealed normal S1 and a loud S2, and mild tachycardia with an irregularly irregular rhythm. No murmurs, rubs, or gallops were appreciated. Abdomen was soft, non-tender and non-distended with normal bowel sounds. No rashes were appreciated. Step 6: Ancillary Data (lab, radiologic, etc) ---Limit presentation to RELEVANT normal labs and all abnormal results.

---Example: the CBC was notable for white blood cell count of 16 thousand with a leftward shift. The blood chemistyr, urinalysis, were normal etc.

Step 7: SUMMARY The summary statement should: identify key data necessary for yoru audience to from an accurate differential diagnosis. Second, a powerful summary statement conveys your ability to clinically reason. ---Example: In summary, this is a 44 year-old woman with risk factors for venous thrombo-embolic (VTE) disease, who now presents with sub-acute onset of dyspnea, hypotension, a loud S2 with clear lungs, and right heart strain on EKG.

Step 8: Differntial diagnosis and plan: Now is the time to explicitely state your prioritized differential, and argue yoru case for the most likely diagnosis in addition to yoru plan for further tests and/or treatment. WEEK 8 PCM Objectives: October 21 Adaptation to Acute Illness: Illness as a Life Crisis Group H (See footnotes for source of answers)

Differentiate between disease and illness. •	Disease = abnormalities in the structure and function of body organs and systems; what modern physicians diagnose and treat •	Illness = experiences of disvalued changes in states of being and in social function; the human experience of sickness; what patients suffer •	Therefore there is not a one-to-one relation: illnesses may occur in the absence of disease and similar degrees of organ pathology may generate different reports of pain/distress •	Elsewhere in the article, these terms are defined in the context of a Western paradigm: disease is malfunctioning or maladaption of biologic and pyschophysiologic processes in the individual; illness represents personal, interpersonal, and cultural reactions to disease or discomfort

Define “explanatory model.” Interpretive notions about an episode of sickness and treatment that are employed by all those engaged in the clinical process. Importantly, both health care providers and patients utilize explanatory models extensively; the lenses through which cultures perceive and understand illness.

Define “cultural group.” A cultural group is a self-defined group of people who share a commonality of cultural experience. Cultural groups may be defined by many types of commonality, such as ethnicity, religion, or physical commonality, as seen in Deaf culture.

List the Kleinman questions that will help elicit the patient’s explanatory model for their health problem. 1.	What do you think has caused your problem? 2.	Why do you think it started when it did? 3.	What do you think your sickness does to you? How does it work? 4.	How severe is your sickness? Do you think it will have a long or short course? 5.	What kind of treatment do you think you should receive? 6.	What are the most important results you hope to achieve from this treatment? 7.	What are the chief problems your sickness has caused for you? 8.	What do you fear most about your sickness?

Describe how cultural beliefs and behaviors affects perception of disease and treatment strategies.1 Specific examples from the reading: At a Massachusetts hospital, a Chinese man with symptoms of depression but denied emotional complaints. In his culture mental illness is highly stigmatized so he refused to believe he had such a problem and agreed to psychotherapy only after it was agreed he would also get medication. In the beginning he sought treatment through herbal medicines that he continued along with his Western treatment. Due to the stigma of psychiatric problems, he labeled his symptoms as physical and therefore his expectations of treatment were affected. In this case his disease was depressive syndrome and his illness was a culture-specific type of somatization. In another example, an Italian-American patient held a view of his illness (as did his family) that affected his course of treatment. He was evaluated for chest pain and his cardiologist explained the etiology, pathophysiology, and course of artherosclerotic cardiovascular disease. Two years later he had an acute myocardial infarction. Only then did he report his model of the problem: in his view, there are two major heart diseases, angina and coronary thrombosis with the former being mild. He (and his family) also believed that the two are mutually exclusive and if he already had one he would not suffer the other. This resulted in noncompliance of his prescribed medical regimen, with the support of his family.

Describe the cultural remedies used for fever, teething, and colic as described in the required reading and explain which ones are potentially harmful.5 Fever: Placing sliced potatoes/onions in socks Isopropyl alcohol (Harmful: It is absorbed through the skin and large amounts used topically may be inhaled and cause alcohol poisoning in the child.)

Colic: Tobacco (Harmful: Pulmonary disease) Paregoric (tincture of opium): (Harmful: Risk for respiratory depression) Bicarbonate (Harmful: associated with hypernatremia, cognitive delays, and in some cases death) Catnip tea Ginger tea Castoria Chamomile Senna Asafetida (Harmful: has been associated with mehtemoglobinemia in young infants - cyanosis)

Teething: Whiskey (Harmful: Puts infants/young children at risk for ethanol poisoning and hypoglycemia) Chew on chicken bone (the reading does not list this as harmful, believe it or not) Puppy licks mouth Tying a penny/buttons a string around infants neck (Harmful: strangulation/entrapment hazard)

WEEK 9

October 28 PCM Objectives Introduction to Exam Skills: Eyes and Ears

Describe the normal landmarks of the auricle, external canal, and tympanic membrane using a hand-held otoscope. Auricle: expect a regular (and varied from individual to individual) appearance of the external ear with no lesions and appearing the same color as facial skin. The top of the external ear will be in line with the external canthus of the eye. There may be either smooth skin of pits in the “pre-auricular” area. External Canal: The external acoustic meatus should be free of discharge, odor and the canal walls should be pink. There should be cerumen (earwax) present in varying textures and colors (yummy!) Hair will be present in the outer third of the canal. Cerumen should not obscure the tympanic membrane. Typmanic Membrane: Expect to see the umbo, handle of the malleus and the light reflex. The membrane should appear a pearly gray. It will be slightly conical with a concavity at the umbo. It should move in and out.

Demonstrate techniques to maximize visibility and patient comfort on exam. * Pull scapha of ear posterior-superiorly in order to open up auditory canal. Firm but gentle grasp. * Rest ulnar side of hand gently against patient's face. This gives you a cushion if the patient jerks. * Insert speculum of otoscope gradually. •	Avoid touching speculum to inner 2/3 of auditory canal (bony). --> pain.

Demonstrate ability to check membrane mobility with insufflation and describe how to interpret it. Seal the canal with speculum and gently apply positive (squeeze) and negative (release) pressure with pneumatic attachment. The membrane should move in and out.

Demonstrate the Weber and Rinne tests and describe how to interpret their findings. The Weber test is when you place a vibrating tuning fork on the midline vertex of the patient’s head. It should be repeated with one ear occluded. The sound should be equal in both ears (unoccluded) and better in the occluded ear. The Rinne test is when you place a vibrating tuning fork against the mastoid bone (behind the ear), note seconds until no sound is heard by patient and then quickly move the fork 1 to 2 cm from the auditory canal and note seconds until sound is no longer heard. The measurement of air conducted sound should be twice as long as bone conducted sound.

Describe the exam findings of conductive and neurosensory hearing loss. Conductive hearing loss •	Due to pathology in the external canal, tympanic membrane, or ossicles. •	Weber test results – the sound will be heard BEST in the AFFECTED ear. •	Rinne test results – bone conduction will be GREATER than air conduction (which is opposite of normal). Neurosensory hearing loss •	Due to pathology of CN VIII. •	Weber test results – the sound will be heard BEST in the UNAFFECTED ear. •	Rinner test results – air conduction is great than bone conduction (normal finding). Both types of conduction are decreased, but remain in the same ratio.

DEMONSTRATE ASSESSMENT OF CRANIAL NERVES II, III, IV, VI

o Cranial nerve II: Optic nerve. Special sensory. Abnormal if patient has abnormal acuity. o Cranial nerve III: Oculomotor. Innervates sphincter papillae muscle, levator palpebrae superioris, inferior rectus, medial rectus, and superior rectus. Abnormal if patient's eye is directed down and out when at rest. Eye may also be dilated. o Cranial IV: Trochlear. Innervates superior oblique muscle. Abnormal if patients have double vision with vertical diplopia (eye drifts upward relative to normal eye). o Cranial Nerve VI: Abducens. Innervates the lateral rectus. Abnormal if there is excessive adduction of eye at rest and inability to abduct eye.

Examination procedure:

1. Inspect eye externally. Examine sclera as patient looks up and then down. 2. Test visual acuity. Have patient read the lowest line they can on the Snell chart. 3. Test pupillary contraction to light. Shine light in each eye twice. 4. Test strength of eye muscles by standing 3 to 6 feet in front of the patient and ask the patient to follow your finger with their eyes without moving their head. Check gaze in the six cardinal directions using a cross or "H" pattern. This isolates the action of the muscles. 5. Check convergence by moving your finger toward the bridge of the patient's nose.

Identify the extraocular muscle and cranial nerve abnormalities for cranial nerve abnormalities of III, IV and VI. Cranial Nerve III – Oculomotor Nerve - Medial Rectus (Adducts eye). Check via convergence test, or simultaneous inward movement of both eyes toward each other, by having the patient fix their eyes on your fingers as you move them towards a point between the eyes. Action mediated by Medial Rectus. - Superior Rectus (Elevates eye). Fully Abduct eye and only the superior rectus can elevate the eye. - Inferior Rectus (Depresses eye). Fully Abduct eye and only the inferior rectus can depress the eye. - Inferior Oblique (Extorsion of eye and Up and Out). Fully Adduct eye and only the inferior oblique can elevate the eye. Cranial Nerve IV – Trochlear Nerve - Superior Oblique (Intorsion of eye and Down and Out). Fully adduct eye and only the superior oblique can elevate the eye. Cranial Nerve VI – Abducens Nerve - Lateral Rectus (Abducts eye). Fully abduct eye and lateral rectus is major player involved in this movement.

Demonstrate assessment of pupil reactivity including direct and consensual response and interpret the cranial nerve abnormalities that cause abnormal papillary response. Direct pupil light reflex is pupil constriction due to direct light. Consensual pupil light reflex is contralateral pupil constriction. Cranial Nerve III Lesion – Loss of consensual pupil light reflex. Cranial Nerve II Lesion – Loss of direct pupil light reflex.

Demonstrate the assessment of visual acuity and describe how to interpret a Snellen Chart Normal acuity in healthy adults is one or two lines better. Average acuity in a population sample does not drop to the 20/20 level until age 60 or 70. This explains the existence of the two lines smaller than 20/20: 20/15 and 20/10.

•When checking visual acuity, one eye is covered at a time and the vision of each eye is recorded separately, as well as both eyes together. In the Snellen fraction 20/20, the first number represents the test distance, 20 feet. The second number represents the distance that the average eye can see the letters on a certain line of the eye chart. So, 20/20 means that the eye being tested can read a certain size letter when it is 20 feet away. If a person sees 20/40, at 20 feet from the chart that person can read letters that a person with 20/20 vision could read from 40 feet away. The 20/40 letters are twice the size of 20/20 letters; however, it does not mean 50% vision since 20/20 sounds like it is one half of 20/40. If 20/20 is considered 100% visual effiency, 20/40 visual acuity is 85% efficient. •If a patient sees 20/200, the smallest letter that they can see at 20 feet could be seen by a normal eye at 200 feet. This is the Snellen Acuity (English). In Metric Acuity, 20/20 equals 6/6.

Chart 1. Allow the patient to use their glasses or contact lens if available. You are interested in the patient's best corrected vision. 2. Position the patient 20 feet in front of the Snellen eye chart (or hold a Rosenbaum pocket card at a 14 inch "reading" distance). 3. Have the patient cover one eye at a time with a card. 4. Ask the patient to read progressively smaller letters until they can go no further. 5. Record the smallest line the patient read successfully (20/20, 20/30, etc.) 6. Repeat with the other eye. 7. Unexpected/unexplained loss of acuity is a sign of serious ocular pathology.

Demonstrate the assessment of visual fields and describe the abnormalities of homonymous hemianopsias, binasalhemianopsia, bitemporalhemianopsia, and upper and lower homonymous quadrantopsias. The demonstration of visual fields is when you take both of your hands and hold them in different quadrants (upper nasal/lower nasal, upper/lower temporal) while holding out your fingers. You ask the patient to tell you how many fingers you are holding out. It is a peripheral vision test.

Execute a funduscopic examination, noting location of optic disc, optic nerve, macula, and retinal vessels. Optic disc and nerve are medial, while the macula is lateral. The retinal vessels should be emanating from the center of the optic disc and nerve.

Describe the anatomy of the retina. The fundus is the observable retina. The macula is the site of central vision. It is lateral to the optic disc and nerve. The fovea is the center of the macula. It is the point of highest visual acuity. The optic disc and nerve appear medially. The retinal vessels emanate from the optic disc.

Describe the normal cup:disc ratio. The disc is a lighter yellow color about 1.5 mm in diameter. The cup comprises the central area of the disc and is typically 1/3 the diameter of the disc. Thus, the normal cup:disc ratio is 1:3.

Health Promotion: Put Prevention into Practice

Define the concept of health promotion, including the principles of patient education and counseling. Health Promotion involves promoting preventative services, educating patients in order to prevent disease instead of treating advanced disease, which often costs more money and time. Patient Education & Counseling -      Counseling, more valuable than conventional diagnostic testing -      Patients should assume more responsibility -      New skills needed for physicians (motivational) -      Share Decision Making o      Balance benefits/risks (follow-up tests and procedures) o      Patients differ, some want treatment to prolong life vs. treatment morbidity o      Acknowledge uncertainty when working with patients -      Be Selective when ordering tests and preventative services o      Tests may be ineffective, many false positives o      Consider: age, gender, risk factors, adverse effects and unnecessary costs -      Seize opportunities especially when there is limited access to care o      At risk patients are often least likely to receive services (e.g. immunizations) o      Use every visit to plant seeds -      Community level interventions may be more effective than clinical preventive services o      Youth/family violence o      Tobacco use o      Teen pregnancy o      injuries

Define the concept of health promotion The process of enabling people to increase control over, and to improve, their health. This may involve promoting lifestyle changes, etc.Health promotion has basic prerequisites of peace, shelter, education, food, income, a stable ecosystem, sustainable resources, social justice and equity. Once these are in place, the coordination of all areas (healthcare, government, economic sectors, inviduals, families…) are involved in promotion of health. Principles of Counseling: 1. Develop therapeutic alliance 2. Counsel all patients 3. Ensure that patients understand the relationship b/w behavior and health 4. Work w/ patients to assess barriers to behavior change 5. Gain commitment from patients to change 6. Involve patients in selecting risk factors to change 7. Use a combination of strategies 8. Design a behavior modification plan 9. Monitor progress through f/u contact 10. Involve office staff Describe the role of the physician in health promotion activities. Doctors should be the point-people for interventions and tracking life-style/preventive med changes, especially those in primary care, a discipline which will hopefully gain in not only prestige, but also financial backing and infrastructure improvement to help PCPs do health promotion. Practically speaking, physicians (really any) can perhaps be of most use by becoming conversant with such resources as Dr. Toffler gave us, i.e., the Agency for Healthcare Research and Quality (AHRQ) and the Healthy People project. The former is a great website with tons of evidence-based recommendations for PCPs (also PDA-compatible programs) for everything from addiction to well baby checks to various cancer screenings. Healthy People 2010 is an effort toward health promotion with the 2 major stated goals of 1) increase quality and years of life, and 2) decrease health disparities.

EXPLAIN HOW BEHAVIOR CHANGE FUNCTIONS IN HEALTH PROMOTION EFFORTS

Behavior change is integral to the concept of health promotion – encouraging health means encouraging healthy behaviors, and the changes necessary to achieve these.

Demonstrate screening strategies recommended for selected patients, using history, physical exam, and lab/diagnostic procedures.

As Fundamentals of Clinical Practice states, “Screening is not worthwhile (and may cause more harm than good) if the condition cannot be treated more effectively as a result of early detection.” This means screening every person for every thing is not cost effective and may cause harm. Based on risk factors we should selectively choose which screens to do. The USPSTF is a good source of evidence-based screening recommendations.

Here are some examples (the most appropriate I could find) from Table 17.7 of the text: •	Example risk factor – appropriate screen •	Native American, Hispanic, African American adults OR family hx – diabetes (plasma glucose) •	Family hx of hyperlipidemia or early MI, PVD, CABG, or angioplasty – cholesterol (total cholesterol) •	Family hx (1st degree relative) of breast cancer – mammography •	Family hx (1st degree relative) of colon cancer – colonoscopy •	Men over 40 – DRE or PSA (though this is debated) •	Diabetes – comprehensive eye exam •	Diabetes OR chronic pulmonary/respiratory disease OR splenectomy OR renal dysfunction OR immunosuppression (e.g. HIV+) – influenza and pneumococcal immunizations •	Multiple sexual partners OR risky sexual behavior (e.g. prostitution) – HIV and other STDs •	Alcohol abuse – TB, oral exam, pneumococcal immunization, injury •	Tobacco use – oral exam (oral cancer) •	Illicit drug use – HIV, hepatitis B, TB •	Homelessness – TB

Describe counseling pertinent to selected patients including: Diet and Exercise- Counseling patients about nutrition and exercise can be a primary form of prevention to many diseases and chronic conditions-heart disease, diabetes, etc. May also be necessary for those already afflicted with the above chronic conditions. Counseling should include what foods to avoid, exercise planning, and possibly support groups. Substance Abuse- Pertinent for adolescents. May be relevant for people in substance abuse recovery and for those attempting to quit. Counseling should include treatment options, recovery centers, outside counseling centers, and support groups. Sexual Practices- Pertinent for adolescents or those engaging in risky sexual practices. Counseling should include birth control, disease prophylaxis, abstinence, and single-partner components. Injury Prevention- Pertinent for all ages. Counseling may include helmet use, seatbelt wearing, child proofing in the home, etc.

Other primary preventive measures, including Screening Examination- Screening well patients for various cancers (i.e. breast, prostrate, rectal). Diabetes screenings. Blood work-ups. Immunizations- Vaccination clinics, insuring vaccinations are current, publicizing vaccine requirements. Chemoprophylaxis-Treating with medication before a patient contracts a disease.

Define primary, secondary and tertiary prevention. Primary prevention avoids the development of a disease. Most population-based health promotion activities are primary preventive measures. Secondary prevention activities are aimed at early disease detection, thereby increasing opportunities for interventions to prevent progression of the disease and emergence of symptoms. Tertiary prevention reduces the negative impact of an already established disease by restoring function and reducing disease-related complications.

WEEK 11 (Week 11) PCM Objectives: Describe the prevalence of substance abuse in the US and its impact upon public health Alcohol dependence and abuse are current problems for nearly 10% of the US population (Kessler et al., 1994). More than 20% of adults in the primary care setting have a past or current substance abuse disorder and many physicians are unaware of their patients’ substance use histories (Buchsbaum et al. 1995). Definition of key terms and concepts used in substance abuse literature (e.g. “drug use behavior”) and describe common patterns among addictions, including genetic, behavioral and community-linked trends. Addictive disorder includes the clinical problems of alcohol and drug dependence as well as other disorders that have often been classified as addictions, such as eating and gambling disorders. Alcohol or drug disorder used to describe the spectrum of problems associated with the negative consequences of mood-altering drugs. Substance abuse and substance dependence used based on standardized alcohol and drug criteria such as those from the DSM-IV Populations at a greater risk and common patterns in addictions Elderly population – increasing prevalence of alcoholism among the older population, is often “under detected”. Children and teens susceptible to influences that encourage risk taking and experimentation with substances. Children who start using illicit drugs before 15 is a strong predictor of later problems with substance. Risk factors for adolescent dependence genetic risk factors, biological markers, childhood aggressiveness or antisocial behaving, psychiatric disorders, suicidal behaviors. Societal risk factors for adolescents are parenting, family environment, peer influences, positive expectancies regarding drinking, child abuse and advertising. Features of the behavior disorders underlying substance abuse problems Inability to cut down or stop Social and emotional consequences such as family problems or work and school problems Physiological symptoms such as: insomnia, gastrointestinal pain, liver toxicity, tolerance, and withdrawal. Criteria for men: >14 drinks/week; > 4 d; For Women > 7 drinks/week, or 3 > d; For anyone over 60yo > 7 drins/week, or 3 > d. Demonstrate methods to assess behavioral disorders in clinical practice. Physicians can assess alcohol use by using the CAGE questions: C Have you ever felt you should CUT DOWN on your drinking/drug use? A Have people ANNOYED YOU by criticizing your drinking? G Have you ever felt bad or GUILTY about your drinking? E Have you ever had a drink in the morning to steady your nerves? (EYE OPENER) Or…use an opened ended question/statement: “so tell me about your drinking….” Dependence questions: 	Are you ever unable to stop drinking once you start? 	How many drinks does it take to get high? Does it take more drinks that it used to get high? 	Do you drink in the morning to get over a hangover or stop the shakes? 	Do you have strong urges to drink? Do many of your everyday activities revolve around drinking? Describe complications of these disorders: 	physical dependence 	tolerance 	withdrawal 	substance-associated organic mental disorders 	alcohol-induced liver disease 	Pancreatitis 	Cardiovascular disease 	Cancers 	Fetal Alcohol Syndrome 	Injury and violence, “accidents” Describe the range of community and clinical resources available for treatment of substance abuse for individuals with and without health insurance coverage Alcoholics Anonymous or Rational Recovery and Women for Sobriety Alcohol and Other Drug Abuse (AODA) treatment program or specialist State alcohol and drug abuse agencies will have publicly and privately funded treatment programs Community Alcohol and Drug Treatment Resource Guide will have numbers of key professional in the community Employee assistance programs

Define hazardous and harmful drinking. “Risky” or “hazardous” drinking has been defined in the United States as more than 7 drinks per week or more than 3 drinks per occasion for women, and more than 14 drinks per week or more than 4 drinks per occasion for men. “Harmful drinking” describes persons who are currently experiencing physical, social, or psychological harm from alcohol use but do not meet the criteria for dependence.

Alcohol dependence is a maladaptive pattern of alcohol use, leading to clinically significant impairment or distress, as manifested by three (or more) of the following, occurring at any time in the same 12-month period:

(a) tolerance, as defined by either of the following: a need for markedly increased amounts of alcohol to achieve intoxication or desired effect. markedly diminished effect with continued use of the same amount of alcohol. (b) withdrawal, as manifested by either of the following: the characteristic withdrawal syndrome for alcohol or the same (or a closely related) substance is taken to relieve or avoid symptoms. (c) alcohol is often taken in larger amounts or over a longer period than was intended. (d) there is a persistent desire or unsuccessful efforts to cut down or control alcohol use. (e) a great deal of time is spent in activities necessary to obtain the alcohol (e.g. driving long distances), use alcohol, or recover from its effects. (f) important social, occupational, or recreational activities are given up or reduced because of alcohol use. (g) alcohol use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by alcohol (e.g. continued drinking despite recognition that an ulcer was made worse by alcohol consumption).

Alcohol abuse are which that the symptoms have never met the criteria for alcohol dependence. It is a maladaptive pattern of alcohol use leading to clinically significant impairment or distress, as manifested by one (or more) of the following, occurring within a 12-month period:

(a) Recurrent alcohol use resulting in a failure to fulfill major role obligations at work, school, or home (e.g., repeated absences or poor work performance related to alcohol use; alcohol-related absences, suspensions or expulsions from school; neglect of children or household) (b) Recurrent alcohol use in situations in which it is physically hazardous (e.g., driving an automobile or operating a machine when impaired by alcohol use) (c) Recurrent alcohol-related legal problems (e.g., arrests for alcohol-related disorderly conduct) (d) Continued alcohol use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of alcohol (e.g., arguments with spouse about consequences of intoxication, physical fights)

Drinking limits: Criteria for men: >14 drinks/week; > 4 d; For Women > 7 drinks/week, or 3 > d; For anyone over 60yo > 7 drins/week, or 3 > d.
 * CAGE (feeling the need to Cut down, Annoyed by criticism, Guilty about drinking, and need and Eye-opening in the morning) is the most popular screening test for detecting alcohol abuse or dependence in primary care.

Substance abuse Hx: Which substances? How Much? How often? What Route? What consequences?
 * The Alcohol Use Disorders Identification Test (AUDIT) is the most studied screening tool for detecting alcohol-related problems in primary care settings. It is sensitive for detecting alcohol misuse and abuse or dependence and can be used alone or embedded in broader health risk or lifestyle assessments.

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