Spring

MARCH 3rd First Hour 1.	Describe key factors in making recommendations regarding preventive services, including role of resources, evidence and values in making recommendation. a.	Resources: Time, money, personnel b.	Evidence: expert recommendations Characteristics of the population c.	Value: Competing priorities (other screening/preventive tests) Monetary and human resources needed to carry out screening Overall public health versus individual benefit Screening test is: Population based Detect disease in individuals without signs or symptoms of disease. Identify disease early enabling earlier intervention A. Universal screening- all individuals in a certain category B. Case finding- smaller group of people based on the presence of risk factors Sensitivity= True Positives/ True Positives + False negatives Highly sensitive tests are good screening tests, cast a wide net and don’t miss 	cases but may include false positives Specificity = True negatives/ True negatives + False Positives Highly specificity tests confirm results of sensitive tests 2. Describe the factors that contribute to an effective screening test. The condition should be an important health problem. There should be a treatment for the condition. Facilities for diagnosis and treatment should be available. There should be a latent stage of the disease. There should be a test or examination for the condition. The test should be acceptable to the population. The natural history of the disease should be adequately understood. There should be an agreed policy on who to treat. The total cost of finding a case should be economically balanced in relation to 			medical expenditure as a whole. 3. Demonstrate application of knowledge Economics of screening Costs money up front to deliver preventive services Benefits occur over time Unclear if savings occur, and if so, when Some claim billions in savings with screening, some just the opposite Widely varied reasons for screening and prevention services True Prevention (flu shot) Precondition detection (colon polyp) Early detection (mammography	Modify risk factors (hepatitis C) 4. Describe the method the USPSTF uses to create its recommendations, and define the categories of recommendation Grade A: recommended, offer the service -high certainty that net benefit substantial. Grade B: recommended, offer the service- high certainty that net benefit is moderate or 	there is moderate certainty that the net benefit is moderate to substantial Grade C: recommend against routinely providing the service. -There may be 	considerations that support providing the service in an individual patient. 	There is at least moderate certainty that the net benefit is small. 	Offer or provide this service only if other considerations support the offering or 	providing the service in an individual patient Grade D: recommends against the service. -There is moderate or high certainty that the 	service has no net benefit or that the harms outweigh the benefits. Discourage the use of this service. Grade I- the current evidence is insufficient to assess the balance of benefits and harms 	of the service.Evidence is lacking, of poor quality, or conflicting, and the balance 	of benefits and harms cannot be determined.

March 3, 2010 2nd Hour Objectives 1. Define -pneumonia: Pneumonia is an infection of the pulmonary parenchyma. Typically classified as community-acquired, hospital-acquired, or ventilator-associated. -pleural effusion: Pleural effusion refers to any significant collection of fluid within the pleural space. May be asymptomatic; chest pain frequently seen in the setting of pleuritis, trauma, or infection; dyspnea is common with large effusions. Dullness to percussion and decreased breath sounds over the effusion. Radiographic evidence of pleural effusion. Diagnostic findings on thoracentesis. -empyema- Thoracic empyema is defined by a purulent pleural effusion. The most common causes are parapneumonic, but postsurgical or posttraumatic empyema also is common

2. Describe the pathophysiology of pneumonia. Pneumonia results from the proliferation of microbial pathogens at the alveolar level and the host's response to those pathogens. Microorganisms gain access to the lower respiratory tract by aspiration from the oropharynx, pathogens are inhaled as contaminated droplets., hematogenous spread. Alveolar macrophages initiate the inflammatory response. The host inflammatory response triggers the clinical syndrome of pneumonia. IL1 & TNF results in fever. IL-8 and granulocyte colony-stimulating factor, stimulate neutrophils 3. Describe the physical findings of pneumonia (consolidation), pleural effusion, and pneumothorax. Consolidation: The lung is normally resonant. As consolidation occurs its density increases to yield, successively, impaired resonance, dullness, and flatness. Tubular breath sounds. Increased tactile fremitus Pleural Effusion: Key Sign is dullness and diminished vibrations. Egophony "Eee" is changed to "Ay," This arises from compressed lung below a pleural effusion, Absence of fremitus. Pneumothorax: Key sign is hyperresonance. Air enters the pleural space separating the lung from the chest wall leading to failure of respiratory mechanics and lung collapse. 4. Describe the inheritance pattern of polycystic kidney disease. -Progressive expansion of numerous fluid-filled cysts and frequently causes kidney failure. Autosomal dominant polycystic kidney disease (ADPKD) is seen predominantly in adults (Variable penetrance), whereas autosomal recessive polycystic kidney disease (ARPKD) is mainly a disease of childhood.

March 10, 2010 Health Maintenance Assessment Describe preventive services that should be included in an organized approach to prevention, including how prevention services change depending on the targeted population. -Consider what diseases are most prevalent in the target population (i.e. HepC in IV drug abuser population) and what diseases would have the worst outcome in your population (i.e. TB outbreak in prison could be devastating). -Consider cost effectiveness. How expensive is the test? Can you afford to treat people if they screen positive for a disease (i.e. Interferon tx for 6 mo in HepC+ pts)? -Prevention services can change depending on the targeted population. (Ex. Probably don’t need to screen for HIV in a population of nuns. That might change if you’re working with a population of IV drug abusers.) Describe methods that can assist physicians in evaluating the effectiveness of clinical preventive services. (From Wiki) -Consult the USPSTF for grading recommendations. -Consider recommendations of societies like American Diabetes Association, etc. -Do your own literature search. March 10, 2010 Problem-Based Learning 2-B (Small Group Only) Develop skills in hypothesis-building and deductive problem solving: a.    List hypotheses for patients’ problems b.    Prioritize Hypotheses c.    Use hypotheses to direct information-gathering Develop skills in self-directed learning: a.    Identify knowledge gaps and answerable questions relevant to patient’s illness b.    Use various information resources to answer clinical questions Develop skills in explaining and/or sharing information with colleagues: a.    Present answers to assigned clinical problems to peers b.    Organize presentations using established principles of structuring information so that it is understood and retained Describe the physical findings of pneumonia (consolidation), pleural effusion, and pneumothorax. (From Mosby’s) Pneumonia - Pneumonia is an inflammatory response of the bronchioles and alveolar spaces to an infective agent. Exudates lead to lung consolidation, resulting in dyspnea, tachypnea, and crackles. Diminished breath sounds and dullness to percussion over the area of consolidation. Involvement of the right lower lobe can stimulate the 10th and 11th thoracic nerves to cause RLQ pain and simulate an abdominal process. Increased tactile fremitus (“toy”). On auscultation, you hear “A” when they say “E” (egophany). Pleural Effusion - Excessive nonpurulent fluid in the pleural space can result in permanent fibrotic thickening. The sources of fluid vary: infection, neoplasm, trauma, etc. The findings vary with severity and also with the position of the patient. Fluid is mobile; it will gravitate to the most dependent position. in the affected areas, breath sounds are muted and there will be dullness to percussion. Decreased tactile fremitus. Pneumothorax - The presence of air or gas in the pleural cavity may be the result of trauma or may occur spontaneously. There will be decreased breath sounds over pneumothorax and percussion will produce hyperressonance. Describe the inheritance pattern of polycystic kidney disease. Autosomal dominant PKD is seen primarily in adults, while autosomal recessive PKD is mainly a disease of childhood.

Preventive Services II - March 17, 2010    1:00 PM - 3:00 pm Describe the key factors in making recommendations regarding preventive services. 1) Resources: Cost-benefit addressed below 2) Evidence : “ “ 3) Values: Every adverse outcome of screening is iatrogenic and preventable •    Labeling, anxiety •     Harms of screening or treatments •     Burdens/costs on patient    Demonstrate application of these factors for a group of preventive services in a vulnerable population. WHO Principles of Screening 1.     condition should be an important health problem 2.     a treatment should be available, benefit to screening 3.     need to have facilities to treat (rural, undeveloped countries) 4.     the disease should have a latent stage to allow early intervention 5.     the test should be acceptable to the population (no brain biopsies!!) 6.     the natural history of the disease should be understood so that disease progression can be predicted 7.     need to have an agreed upon policy for who to treat (all, risk factors, etc.) 8.     total cost of finding a case should be balanced to medical expenditures as a whole (difficult in multiple payer systems where patients switch insurance) 9.    case finding is a continuous process, not a once and for all occurrence Demonstrate application of knowledge gained to arrive at a group recommendation in a simulated advisory committee setting. Group activity creating recommendations for inmate screening tests using above plus: USPSTF Cost Analysis Present Protocol

Recognition and Reporting of Child Abuse – March 17, 2010   3:00 PM - 5:00 PM Describe the signs and symptoms of abuse and neglect. - No history or changing history given by guardian - History inconsistent with developmental abilities - Mechanism inconsistent with history - Bruises/scars/old fractures/failure to thrive - Prior injuries Describe the common types of child abuse and their characteristic injury patterns. •    Limb twisting: - spiral fracture (can’t happen from a fall) •    Shaken baby Syndrome: -    subdural/arachnoid bilateral hemorrhages – break sagittal sinus veins -    Axonal injury -    Brain swelling -    Hypoxic ischemic injury -    Can be with or without discrete impact -    Figure 8-shaped acceleration and deceleration of shaking => diffuse injury -    Common rib fractures, most often on posterior aspect from squeezing (***most common fracture in child abuse) -    Retinal hemorrhages (only seen in abuse, motor vehicle accidents, crushing injuries) •    Abusive Head Trauma: - Discrete impact: skull fracture, brain contusions, bruises Describe the child and family characteristics for child abuse. Child Symptoms: lethargy, fussy, vomiting and poor feeding, seizures, death Child Characteristics: -    often males who are abused -    prematurity -    special needs children -    crying Family Characteristics: -    Young, single parents -    Poverty -    Isolation -    Unrelated adults in home -    Domestic violence -    Alcohol/drug abuse Perpetrators: mostly men, moms and female babysitters Describe common features of and distinguish between non-accidental injuries vs. accidental injuries. •    Clear impression marks, didn’t just graze an iron or cigarette butt •    Clear handprint, petechia on buttocks from spanking, implement imprints (belt buckle) •    Clear line of submersion into scalding liquids •    Lack of nutrition, failure to thrive Describe the historical, physical, and behavioral findings in deprivational syndromes. Historical: -    Lack of appropriate well child care including immunizations -    Lack of appropriate medical care of chronic illness -    Absence of necessary health aids such as eyeglasses, hearing aids, -    Absence of appropriate dental care Physical: Nutrition (lower percentile on growth charts) -    poor hygiene (sever diaper rash) -    developmental delay -    untreated medical condition -    rampant dental carries Behavioral: - Depression, anxiety, enuresis (no urine control), sleep disturbances, excessive masturbation, impaired interpersonal relationships (lack of cuddliness, gaze avoidance, preference for inanimate objects) - Discipline problems and aggressive behavior, poor school performance, roll reversal in which child assumes caretaker role, excessive household responsibilities, inadequate supervision, food, clothing, shelter or other basics for a child endangers or impairs a child’s physical, mental or emotional health and development. Describe appropriate interviewing techniques for a child suspected of being abused or a family suspected of being abusive. Child: -    attempt to obtain pertinent info from others prior to interview -    sit near child, not across a barrier, at child eye level -    make trusting relationship -    do interview in private without caretaker -    have interview done by most experienced professional available -    find out who else has questioned the child -    try to explain purpose of interview to the child -    use the child’s own words -    always ask if child has questions -    carefully explain the reasons for removal from the home if eminent -    ask child to explain words or terms that are unclear -    acknowledge that the situation must have been difficult for the child and that they are not at fault Adult: -    reserve judgment until all facts are known -    tell them reason for interview -    tell them of the physician’s legal obligation to report suspicion of abuse -    do the interview in private -    attempt to be objective -    reassure the caretaker of the physicians continued availability -    explain further actions required -    answer questions honestly Describe physician responsibilities with regard to reporting laws in Oregon. •    Mandatory reporting of reasonable suspicion, even off duty •    Protection from civil and criminal liability as long as the act is in good faith •    Can be fined up to $1000 for failure to report.
 * Delay in seeking care

March 31st PCM Objectives Well-Child Inoculation Describe the routine childhood immunization schedule. '4:3:1:3:3:1' is commonly used jargon for: 4+DTP, 3+Polio, 1+MMR, 2+Hib, 3+HepB, 1+Varicella. The exact schedule is available on the ACIP website in a nice grid. Direct link to schedule. Describe the flexibility and the nature of decisions each provider must make in order to make the schedule operational. Who decides: Advisor Committee on Immunization Practices (ACIP). 15 experts appointed by US Health and Human Services come to agreement. ACIP issues recommendations. States make laws about what is required to enter schools. They determine religious (48 states) and philosophical (~38 states, including Oregon) exemptions. Oregon law says you need a written statement for a medical exemption or a parental statement for religious/philosophical exemption. Link to Oregon vaccination law for schools Describe ways in which the schedule is likely to change in the future. §    In 1983, ACIP recommended that children received 8 inoculations before the age of 2. §    In 1995, ACIP recommended that children received 15 inoculations before the age of 2. §    In 2009, ACIP recommended that children received 26 inoculations before the age of 2. §    If the trend continues, we're likely to see more vaccines §    A focus on the safety of vaccine additives, could change the composition of the vaccines. Describe common barriers that prevent the delivery of age-appropriate immunizations. Rates are far below the 90% 4:3:1:3:3:1 goal §    Improper contraindications: kid has a cold so they don't get the vaccination at their checkup visit (they should get it; missed opportunity). §    Chronic diseased kids: docs treat the disease but routine preventive health maintainace is ignored §    Immigration and foster care: records are lost. §    Loss of access to care: no insurance, etc. (The feds will pay for vaccines but most people don't know it) §    Paper documentation: lost cards. (we're moving to electronic records). §    Concern about vaccinations Describe specific actions providers can take to increase the likelihood that their patients will be adequately immunized. Put patient on a delayed vaccination schedule (not recommended by everyone). Explain a scientific belief that there is no relationship between MMR, mercury, thimerosol and autism. Immunizations are unlikely to weaken the immune system. Our current vaccines are much more pure now so that immune responses aren't mounted to contaminants (which are responsible for the adverse event profile). In other words, "there's not a lot of other junk" in modern vaccines. Communication! Ask the patient where they are getting their information; understand the source of their concerns so you can engage them. You can't argue science with data. Taking a Developmental History Describe the 4 major categories of child development (i.e., physical growth, motor development, cognitive development and psychosocial development). 1.    Physical: height (v. length), head circumference, weight, more than 3 dysmophic features Height –Short stature •Weight –Obesity –Failure to thrive •Head circumference –Microcephaly –Macrocephaly 2.    Motor: age appropriate development, reflexes 3.    Cognitive: problem solving & language Manipulating objects to solve a problem •Often perceived as just play –Reaching for objects –Peek a boo –Banging toys together –Develops object permanence (looks for things) Age	Receptive	Expressive 0-2 months	Alerts to sound	Cries & coos 2-3 months	Regards speaker	Differentiated cry 3-6 months	Orients to voice	Babbling (reflex) 6-8 months	Orients to bell	Jargon (purpose) 8-12 months	Associates words with meanings (bye-bye) Looks for family	Echolalia 12-18 months	Follows commands Points	Identification language 18-24 months	Points to body parts	Anticipatory language 2-2 ½ years	2 step commands	Beginning sentences 4.    Psychosocial: interaction with parent and physician Age	Emotional	Social 1-3 months	Distress, enjoyment	Reciprocal smile 3-6 months	Anger, happiness, sadness	Spontaneous smile Parent attachment 6-9 months	Fear, personality	Discriminates emotional/ facial expressions 9-12 months	Assertive yet cautious	Intentional social interactions, separation anxiety 12-15 months	Shyness, self-comfort	Solitary play, forming attachment relationships, kisses 15-18 months	Shame/guilt, contempt	Self-conscious, coy, hugs 18-21 months	Begins to think about feelings	Initiates interaction by calling, self-attributes (good etc) 21-24 months	Socialization of emotional expression begins	Parallel play, imitates others to please them Demonstrate the ability to plot a child on the appropriate growth chart given age and growth parameters for weight, height and head circumference. Describe the progression of gross motor and fine motor development in a normal child. In general, gross motor development occurs in a cephalo-caudal direction §    Birth - 2 Mo: begin to lift their head §    4 Mo: Up on shoulders, roll front §    6 Mo: Sit, roll on back §    9 Mo: Crawl and pull up onto furniture §    12 Mo: Walk In general, fine motor skills develop from proximal to distal §    2-3 Mo: begin grasp objects §    5 Mo: grasp objects with thumb. §    Needs completion..... Estimate a child’s age based on developmental milestones. 2 years	3 years	4 years Understandability	25%	75%	100% Describe red flags/causes for concern in a child’s physical growth, motor development, cognitive development, and psychosocial development. §    Persistent fisting past 3 months. §    Maintains primitive reflexes like palmar, plantar, Moro reflexes past 6 months. §    Early milestones, ie rolling over at 2 months §    Hand dominance before 18 months usually demonstrates weakness or injury in the contralateral side. §    No words by age 2 (could mean a hearing or cognitive deficit) §    Delay in reciprocal smile (should happen at 1-3 Mo). §    Lack of social relationships (parallel playing beyond age 3 could be a sign of autism) §    Normal delayed growth on a growth chart §    Familiar macroencephaly §    Delayed walking (raises serious concern at 18 months) §    No rolling at 4 months §    Delayed speech due to hearing impairment, gender, or sibling issues Identify the most common type of developmental delay seen by pediatricians and other primary care providers. Cognitive development –Hearing impairment –**Delayed speech (gender and sibling issues) –Lack of adaptive skills Psychosocial development –Autism spectrum disorders §    Ask about "first", total number of words §    Ask about sleeping, crawling, playing, eating/breast feeding, talking, hygiene, diapers §    how do they communicate with parents? §    what do they like to play? §    how independent is the child with specified tasks like eating, dressing, etc. §     Any problem and concerns §    Engage the parents. How are the parents doing? §    Immunizations §    Use screening tools as objective assessments §    chart for height, weight, head circumference, etc. §     Ages & Stages questionnaire §    Plantar grasp: touch bottom of the foot --> toes curl (less than 8 Mo) §    Palmar grasp: touch ulnar side of palm --> strong grasp up to 2 Mo; disappears after more than 3 Mo. §    Moro reflex: Birth - 6 Mo. §    Red Reflex: shine ophthalmoscope into the eye at a 15-degree angle. Lack is suggestive of a retinal lesion. §    Placing: day 4 - variable disappearance. Touch dorsum of foot to table. Child will react as if steppping §    Stepping: (birth/8 weeks) - Hold infant in standing position, touch bottom of feet to the ground and simulate walking. observe for flexion/extension of muscles. §    Assymetric fencing: 2 Mo - 4 Mo., While supine. When head turns in one direction, the infant prevents itself from rolling over. Observe ipsolateral leg & arm extension with contralateral leg & arm flexion.
 * 1) words in sentence	2	3	4
 * absolute most common in general practice    Demonstrate the ability to take a developmental history for a child under 5 years of age, using a variety of techniques and using both directed (“Can your child do ___”) and open-ended (“Tell me about your child’s language”) questions.

April 7th Objectives Beyond the Individual Patient: Protecting the Public’s Health 1. Explain the reasons for reporting diseases to public health officials. Prevent spread of disease to contacts Detect outbreaks Moniter epidemiologic trends Guide public health programs Stimulate public health research 2. Describe the rules for reporting diseases to public health officials. Report disease and demographic to local public health department. 3.Describe the process that follows the report of diseases to the public health officials. all cases interviewed by local health department nurse (most in 1-3 days) disease-specific forms with common layout forms sent to state electronically or by fax Hypothesis-generating questionnaire used if there is a probably common-source outbreak, and routine information does not indicate source (30-min. questionnaire covering 400+ food sources and types) 4. Explain the physician’s role in disease surveillance Treat the patient Report to the County Health Dept.- This is where it all starts, the key component of investigation! Intro to Infant Exam 1. Perform a physical examination of an infant, adjusting the content, sequence and focus of the exam based on the infant’s age and developmental level. 2. Describe specific techniques the examiner can use when examining an infant, including modifying the location of the exam, use of playing and observing behavior, and helpful ways to incorporate parents into the examination. Undress down to diaper (if appropriate) Examine on table Examiner must be flexible, especially in the sequence of the exam Begin with the portions requiring a calm infant Save less tolerated portions for later Examine areas of complain at the end 3. Describe primitive reflexes in infants and when they can be expected to disappear. Moro Reflex: startle response, disappears at 2 mo. Rooting Reflex: turning head to anything that strokes his/her cheeks or mouth (assists in breast feeding), disappears at 4 mo. Palmar Grasp Reflex: disappears at 5-6 mo. Plantar Reflex: plantar flexion of the foot (toes curl down), disappears at 1 yr. Swimming Reflex: an infant placed face down in water will begin to paddle and kick in a swimming motion.

April 14th Advance Care Planning: 1.    Describe the informational needs, emotions, and concerns of patients who are participating in an advance care planning process: a.    Informational needs: Patients need to feel like they’re in control of their decisions and treatment. They need to understand the available choices for accepting different types and levels of medical care; that they can change their mind (and AD) about treatment and surrogate as time goes on; and that they will continue to make their own decisions, without having to defer to the AD, with the support of the medical team for as long as they are able. b.    Emotions and Concerns: Patients are fearful of: lingering death, becoming a burden, pain and suffering, and lack of control over their treatment 2.    Describe how and when to use Oregon’s advance directive and POLST: a.    Advance Directive: Remember: “The goal of Advance Care Planning: Allowing patients to retain control over the types of life-sustaining treatment they receive.” AD Limitations: This is a legal document, not one written as a medical order, and is not terribly specific about lots of medical situations. The AD has two main sections: i.    Appointment of a health care representative: allows a patient to name a person as his/her health care representative and states the boundaries that the representative has on certain decisions. ii. Health Care Instructions: Allows patients to give instructions for health care providers regarding life support, tube feeding, and any situations in which they do or don’t want these things. This section breaks down into the following situations: 1) Close to death 2) Permanently unconscious 3) Advanced progressive illness and 4) Extraordinary suffering. b.    When trying to initiate a conversation about AD, take advantage of situations in which the patient and family may be more receptive such as: Changes in diagnosis, Hospitalization, Family/Friend illness, Patient cues, and during Preventive Exams (but don’t wait until a patient is already terminally ill to have the conversation!) c.    POLST: Ask yourself the question, “Would I be surprised if the patient was dead within the next year?” If “no” then it’s time to fill out a POLST with the patient. POLSTs, unlike ADs, are for seriously ill patients. Unlike the AD, it states actionable medical orders from you, the health care provider. Fantastic summary slide from lecture: Advance Directive 	POLST For every adult	For seriously ill (all ages) Decisions about myriad among future treatments	Decision presented options Statement of preferences	Checking preferred boxes Needs to be retrieved	Stays with patient Requires interpretation	Actionable medical orders 3.    Identify how to determine the surrogate decision-maker for a patient who is not able to make their own health care decisions: See following hierarchy i.    Appointed surrogate/guardian ii. Spouse or civil union partner iii. Adult designated by others on the list (they must, of course, agree to it) iv. Majority of adult children v.    Parent vi. Majority of adult siblings vii. Adult relative or friend 4.    Describe the components of the POLST form: Bright pink piece of paper! It’s designed for seriously ill people with terminal illnesses, and can be completed by health care professionals (physician, nurse practitioner, or PA) as long as this health care professional signs it and assumes full responsibility. Depending on state regulations, the patient or patient’s legal representative also needs to sign it to make it valid- Oregon does not require this. a.    Cardiopulmonary Resuscitation: does the patient want CPR/defibrillation attempted, or are they a DNR? (Only applies to a situation where the patient has no pulse AND is not breathing) b.    Medical Interventions: (Only if the patient has a pulse and/or is breathing) i.    Comfort only: Use meds, positioning, wound care to relieve pain and suffering; clear airway for comfort; but DO NOT transfer the patient to the hospital unless comfort can’t be met at home ii. Limited additional interventions: Above, plus IV fluids, medical treatment, and cardiac monitor and less invasive airway support, but DO NOT intubate or mechanically ventilate or transfer to ICU iii. Full treatment: Do pretty much everything possible, including intubation and transfer to ICU c.    Antibiotics: i.    No antibiotics at all ii. Determined at the time of infection iii. Always use antibiotics when needed to prolong life d.    Artificially Administered Nutrition: (This only applies if the patient will not take food by mouth) i.    No tube feeding ii. Trial period of tube feeding iii. Long-term tube feeding. e.    Remember, YOU sign off on the POLST as a physician/PA/NP ordering this treatment. The patient has the option of providing the name of a health care representative (let’s just hope it’s the same name that’s on his/her Advance Directive). The POLST then sits on the patient’s fridge (usually) or somewhere out in the open in their home for people like EMT staff to utilize during a home visit, and a copy is scanned/copied into the patient’s medical record. POLSTs can be updated accordingly as a patient’s prognosis changes. Meyers Briggs: 1. Define terms to describe the 16 MBTI types and 4 temperament types The purpose of the Myers-Briggs Type Indicator® (MBTI) personality inventory is to make the theory of psychological types described by C. G. Jung understandable and useful in people’s lives. The essence of the theory is that much seemingly random variation in the behavior is actually quite orderly and consistent, being due to basic differences in the ways individuals prefer to use their perception and judgment. Favorite world: Do you prefer to focus on the outer world or on your own inner world? This is called Extraversion (E) or Introversion (I). Information: Do you prefer to focus on the basic information you take in or do you prefer to interpret and add meaning? This is called Sensing (S) or Intuition (N). Decisions: When making decisions, do you prefer to first look at logic and consistency or first look at the people and special circumstances? This is called Thinking (T) or Feeling (F). Structure: In dealing with the outside world, do you prefer to get things decided or do you prefer to stay open to new information and options? This is called Judging (J) or Perceiving (P). Your Personality Type: When you decide on your preference in each category, you have your own personality type, which can be expressed as a code with four letters. Type meanings: http://www.myersbriggs.org/my-mbti-personality-type/mbti-basics/the-16-mbti-types.asp 2. Describe how to cope with differences in people in a constructive way. All types are equal: The goal of knowing about personality type is to understand and appreciate differences between people. As all types are equal, there is no best type. The MBTI instrument sorts for preferences and does not measure trait, ability, or character. When you understand your type preferences, you can approach your own work in a manner that best suits your style, including how you manage your time, problem solving, best approaches to decision making, and dealing with stress. Knowledge of type can help you deal with the culture of the place you work, the development of new skills, understanding your participation on teams, and coping with change in the workplace. 3. Describe how MBTI can be used as a tool in deciding upon a medical specialty and/or work environment Work environments influence how comfortable you are at your job. Someone with a preference for Introversion, for example, who is required to do a lot of detail work or think through a problem, may find it disruptive to be in an environment that is too loud or where a lot of interaction is required. When you know this about yourself, you can make arrangements to do your work in a more suitable location or at a time when there is less activity and interference. When health care professionals understand personality type they have more resources for providing quality service to patients and their families. With a knowledge of the framework of the sixteen types, health care providers can adjust communication and create appropriate care programs that best suit the patient. Personality type can assist the professions in many ways including learning how to be flexible with patients, understanding their reactions to disease, appreciating how they experience stress, determining patient compliance with protocols, and knowing how best to deliver challenging medical news.

April 21st, 1pm-3pm: Refusal and Request for Treatment 1.     Describe ethical and legal aspects of decision-making capacity, competency, and selection and assessment of surrogate decision-makers. Decision making capacity is clinically determined, whereas competency is legally determined. If the patient does not have decision-making capacity, self-determination is preserved by the surrogate. Methods of clinically assessing decisional capacity identify several essential functional abilities, and are different from measures of mental status like the Mini-Mental State Exam. Decision-Making Capacity*Must be able to… nUnderstand basic information nAppreciate consequences nEvaluate information rationally nCommunicate decision Additional: Abilities are usually assessed hierarchically, proceeding from simple to more complex tasks. These abilities include: making and communicating a choice, understanding relevant information about the medical situation, appreciating that the relevant information about the medical situation, appreciating that the relevant information applies to oneself in the situation at hand as well as the future, engaging in rational deliberation about treatment options and being able to describe why a particular choice was made, rather than another, based on one’s own values. A bedside tool exists, but is seldom used. (From JAMA article “Refusal of Care”) 2.     Describe the clinician’s ethical responsibilities and practical guidelines for assessing and responding to a patient’s refusal of treatment or requests a specific medical intervention. The capable patient has the right to refuse treatment supported by the US Constitution and case law, but the physician can conscientiously object to being directly involved in care. Conscientious ObjectionOHSU Policy nNot required to be directly involved*in initiating a legally available, medically recognized intervention if contrary to beliefs nMay not refuse to be indirectly involved in legally available, medically recognized intervention An Approach – Above all, seek the meaning for the refusal. nOpportunity to discuss with patient nSeek and examine the reasons for refusal nIdentify patient-related factors (religion, culture, psychosocial, prior health care experience, family/friends) nConsistent with stated patient goals? nDetermine decision-making capacity nExplore if refusal and patient welfare reconcilable nValues conflict, conscientious objection Carrese JA. Refusal of Care: Patients’ well-being and physicians’ ethical obligations. JAMA. 2006;296(6):691-695. Reasons for Treatment Refusal Caused by the Professional §Use of jargon §Patients average 8thgrade reading level §Health care professionals use > 12thgrade §Hearing but not listening §Assuming patient understands §Does not appreciate value/cultural differences §Doesn’t appreciate the meaning to the patient Reasons for Refusal From the Patient §Can’t hear/see/read §Money/insurance coverage §Doesn’t indicate lack of understanding §Lacks decision-making capacity §Values (fixed belief)/cultural differences §Doesn’t share the meaning 3.    Describe common reactions of physicians to patients who refuse treatment or demand a specific medical intervention. There are many possible responses to a patient who refuses treatment recommendations. In particularly frustrating cases, some physicians are tempted to disengage and accept patients’ decisions out of resignation or anger. Although this approach may seem easier for the physician, it may not serve patients’ best interests. Alternatively, physicians may reject a patient’s refusal and attempt to impose treatment through whatever means available, including pursuit of legal options through the court….Another response to treatment refusal is to explain the physician’s perspective to the patient, attempting to persuade the patient to change their mind while avoiding manipulation or coercion (taken from April 21st JAMA article syllabus page 234). Objectives from 2nd Session: The Medical Write-Up I:  SOAP Format (Small groups only) 1.     Identify what types of information are considered subjective and objective. 2.    Demonstrate the organization of the written and oral presentation using the SOAP format. 3.    Develop skills in providing constructive critical feedback to and receiving feedback from peers. No answers provided.
 * Performing/assisting a procedure, writing or filling prescription, removing artificial ventilation. Facilitate referral, can’t abandon patient

Week 8, April 28 Objectives Session 1: Breaking Bad News 1.	Define bad news and describe situations that fall into “breaking bad news.” Bad news is anything the patient considers to be bad news. Can be anything from an ear infection to cancer or death. *The patient defines the bad in the news!!! 2.	Describe a systematic approach to breaking bad news (ABCDE) Systematic Approach: •	invest in the beginning ◦	know the facts, establish rapport, know patient’s name, optimize physical setting, prepare patient in advance •	 elicit parent/patient perspective ◦	ask open-ended questions about patient’s understanding of their illness ◦	ask how the patient would like to hear the news in terms of: how much detail, who should be present, over phone or in person ◦	explain what lead up to the bad news today ◦	take into account the patient perspective in terms of: expectations, knowledge, understanding and feelings •	 show empathy ◦	follow your heart, show empathy, adjust amount according to situation, remember that seemingly trivial news might be really bad to the patient, allow for silence •	 invest in the ending ◦	summarize how the patient got to this point, briefly summarize information that was discussed, lay out a plan for the next steps, ask if they have concerns that were not discussed

3.	Describe challenges and solutions to breaking bad news. Challenges – why it's so hard: •	not being aware that news are bad •	 fear of upsetting the patient •	 lack of systematic approach •	 dealing with our own emotions •	 unexpected bad news •	 not sure how to respond to patient’s reaction •	 feeling of helplessness •	 busy and not enough time •	 cultural barriers/language •	 afraid that patient will be angry at you •	 not really sure about the prognosis Solutions: Use systematic approach and remember your ABCDE's

4.	Set specific short and long term communication skill goals. Just do it.

ABCDE Approach:

4/28: Week 8 Session 2: Communication and the Electronic Health Record 1.	From the Lecture list ways that an EHR helps or hinders patient communication.

EHR improves patient communication by having clear documentation of each visit. This allows providers to be able to reference past medical experiences to enrich the current interaction. It also can facilitate more accurate patient records if recorded properly.

EHR hinders patient communication by putting a computer, literally, between the doctor and patient. Physician can be more focused on computer than patient. Patient may feel uncomfortable interacting this way. The full record can also lead to assumptions about past medical experiences which may have been inaccurately recorded.

2.	From the reading and the lecture describe strategies to overcome the problems an EHR creates with patient communication.

Alter the EHR visit flow: Efficient and Patient Inclusive. Including the EHR review as part of the visit to ensure accuracy and include patient.

Alter the EHR visit set-up: Remember to make a TRIANGLE between yourself, the patient, and computer. Allow the patient to see what you are typing as you do it: full transparency and patient involvement.

Extra Tips: Tell the patients your level of expertise with the system. Give patient permission to interrupt you. Practice taking a basic history and typing and talking. Type AND Talk –tell the patient what you are typing Summarize what you heard/typed to get clarifying information. Don‟t worry about typos in the room, just get an outline down. Briefly review the chart beforehand Familiarize yourself with the EHR system(s). There will be many types of systems, You will be confused/frustrated initially. Ask for help Avoid showing frustration in front of a patient. Use the System Prompts. Use the EHR to jog your memory. Before: Type questions that you will want to ask During: Type answers while you go. It is OK to abort (using the computer) to favor interacting with the patient

Ways to prevent EHR errors: Double check the patient name Independently verify information Have one chart open at a time READ what you write Include the TEAM in the care –empower others to correct you Include patients in their care –empower them to correct you

3.	From the reading and from lecture: Give examples of how an EHR improves patient safety and examples of other medical errors that can commonly occur because of EHR use. EHR improves patient safety by: Legible prescriptions and notes/instructions to patients (less errors in filling Rx) Automatically tells you allergies and drug interactions. Has all the info and charts in the EHR so there is no lost/missing charts, messages, results, etc.	Medical Errors due to  EHR : TMI Garbage In = Garbage Out Inter-System communication issues. Paper and Paperless don‟t mix well. People neglect to talk –They send messages. Computers need electricity. The more users, the less system flexibility 4.	From the lecture and small group, give examples of common errors created when using computerized documentation short cuts (“cut and paste”, standardized forms, “dot phrases”, etc). Errors: Typos Adding information to the wrong chart Selecting an erroneous item (diagnosis or medication) from a scroll-down list “Cut and Paste” errors (propagation of already wrong info) The Error Lives On 5.	From the internet resource, lecture, and small group identify characteristics of clear written communication with patients through an Electronic Health Record. 6.	From the internet resource, lecture and small group identify examples of poor written communication with patients.

Obj 5 and 6: Recommendations for written patient communication with the EHR „Common Sense‟ Recommendations: Keep comments professional at all times. E-communication should not be used to send jokes or messages of a personal nature. Statements of affection, cute nicknames, and the use of the word “love” are inappropriate. Patients should know the turn-around time. Not for urgent matters. Some issues should be dealt with in person (Sensitive? Fearful? Complex?) Inform patients about privacy issues. Others will need to read e-messages. Avoid anger, sarcasm, and criticism Document all messages Use short, simple wording. Surprise! Clinicians use jargon terms (Castro et al, 2007) Research shows that allpatients prefer simple health information If you can‟t avoid jargon, then define or explain the term, phrase, or concept

5.5.10 Living with Life-Threatening Illness: The Patient Experience 1. Describe the 3 key tasks of the dying role: practical, relational, and personal. •    Practical = physical-medical and logistical features •    Relational = characteristic patterns of negotiated transitions, especially in relationship to the coexisting roles •    Personal = contribute to the person’s self-definition (identity) Practical Tasks	Relational Tasks	Personal Tasks Financial legacy	Coexistence with other roles	Adjustment to loss End-of-life planning	Teaching the dying role	Reaching closure Caring for dependents	Passing the mantle	Existential tasks Last good-byes	Giving permission	Final growth phase Placing a legacy capstone	Last right of passage 2. Describe your own attitudes and experiences towards death. 100% personal and 100% un-testable 3. Describe how a Palliative Care Team can address the needs of the dying patient. Palliative care defined by WHO as: an approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual. While hospice only provides services to patients who have opted out of curative treatments, palliative care services can be provided at any stage of advanced or life-limiting illness. Palliative care addresses the needs of the dying patient by: •    Providing evidence-based symptom palliation and psychological support provided by an interdisciplinary team. This usually includes formulation of a care plan that meets the goals of the patient and appropriately monitors the plan, anticipation and prevention of problems, education of patient and family regarding treatment interventions, routine patient and family conferences, and around the clock services. •    Promoting shared decision making and patient choice in care, with support of the family and caregivers. •    Treating patient with dignity and respect for cultural values. •    Attending to the needs of the patient and family for practical, financial and legal assistance. •    Coordinating care across health care settings and disease trajectory. 4. Describe the importance of effective communication skills for an experienced palliative care physician. Palliative care physicians are interacting with patients and their families at extremely vulnerable times. Good communication skills can foster better therapeutic interventions in the context of patient’s values and symptoms and promote a good dying process. History Taking and Presentation Skills Practice A written history should include: •    CC/ID •    HPI •    Review of Systems •    Past Medical Hx •     Surgical Hx •     Medications •    Allergies •    Family Hx •     Social Hx •     Habits •    Physical Exam •    Database •    Assessment and Plan Remember: PMHx is a compilation of all the patient’s medical problems prior to this encounter, whereas the problem list is a compilation of all the active medical problems during this encounter. An oral history should cover the same topics, but focus on what is relevant, which is usually the HPI and Assessment and Plan. •    CC/ID/HPI – similar to written •    PMHx – additional history is summarized with only necessary details •    Medications and Allergies – always relevant •    ROX/FHx/SocHx – briefly reviewed or skipped based on relevance •    PE – pertinent positives and negatives •    Database – all abnormals, compare with previous, normals when relevant •    A&P – Focuses on principal unresolved issue at time of presentation (DDx, diagnostic plan, treatment plan)

Objectives May 12, 2010 Caring for Patients with Life-Threatening Illness: The professional’s Experience 1-3pm       *From OHSU Wiki 1.) Describe common reactions, including powerful and moving emotions, we all have to death. Denial, numbness, and shock •    This serves to protect the individual from experiencing the intensity of the loss. •     Numbness is a normal reaction to an immediate loss and should not be confused with "lack of caring". •     Denial and disbelief will diminish as the individual slowly acknowledges the impact of this loss and accompanying feelings. Bargaining •     At times, individuals may ruminate about what could have been done to prevent the loss. •     Individuals can become preoccupied about ways that things could have been better, imagining all the things that will never be. •     This reaction can provide insight into the impact of the loss; however, if not properly resolved, intense feelings of remorse or guilt may hinder the healing process. Depression •     After recognizing the true extent of the loss, some individuals may experience depressive symptoms. •    Sleep and appetite disturbance, lack of energy and concentration, and crying spells are some typical symptoms. •    Feelings of loneliness, emptiness, isolation, and self-pity can also surface during this phase, contributing to this reactive depression. •    For many, this phase must be experienced in order to begin reorganizing one’s life. Anger •    This reaction usually occurs when an individual feels helpless and powerless. •    Anger may result from feeling abandoned, occurring in cases of loss through death. •    Feelings of resentment may occur toward one’s higher power or toward life in general for the injustice of this loss. •    After an individual acknowledges anger, guilt may surface due to expressing these negative feelings. •    Again, these feelings are natural and should be honored to resolve the grief. Acceptance •    Time allows the individual an opportunity to resolve the range of feelings that surface. •    The grieving process supports the individual. That is, healing occurs when the loss becomes integrated into the individual’s set of life experiences. •    Individuals may return to some of the earlier feelings throughout one’s lifetime. •    There is no time limit to the grieving process. Each individual should define one’s own healing process. 2.) Identify the key role and responsibility of the Palliative Care Team and how the team can help the student in future patient care. •    A Pallative Care Team can provide enhanced communication between a patient, their family and their medical team. They help in making difficult medical decisions at any stage of illness, and with emotional and spiritual support. •     The provide expert treatment of symptoms, including:   * Pain, shortness of breath, constipation, nausea, trouble sleeping, loss of appetite 3.) Describe how personal experiences with death (family, friends) may influence a professionals response to dying patients and their families, as modeled by Palliative Care Team members. Personal experience with loss may enable a medical professional to be more empathetic and help them find the appropriate words to comfort dying patients and their families. Personal experiences might also have the effect of over-sensitizing professionals, causing them to have a very emotional response which may not always be appropriate for the dying patients and their families. A medical professional must achieve a balance by demonstrating empathy without allowing his or her emotional response to take precedence in the situation. 4.) Describe active steps a physician might take to work through his/her own issues with death in order to give better care to patients. A physician could take the time to think about what death means to them, and what it is that they might fear about it. If the physician has never personally dealt with death among their loved ones, they might take the time to think about how that would impact them and what they would feel and do in that situation. Seeking help from a counselor or therapist to work through the issues is always a good option that physicians should consider. History Taking and Presentation Skills Practice 3:00-5:00pm Objectives May 12, 2010 1.) Demonstrate data gathering skills using both open and close-ended questions. Remember open-ended questions allow the patient to come up with their own answer rather than “leading” them to an answer or giving them only a yes or no answer choice. For example, instead of saying “Is the pain burning?” you could phrase the question as: “can you describe your pain to me?” 2.) Demonstrate oral presentation of HPI and PMHx Just remember that pertinent past medical history having to do with the chief complaint should go in HPI, not in PMHx. 3.) Demonstrate written presentation of HPI and PMHx 4.) Describe common mistakes made by the novice in interviewing and presentation skills. Remember that when you are asking ROS questions, be thinking of your differential diagnoses and what possible symptoms you would want to know about. When you are presenting, be sure to present pertinent negatives as well as pertinent negatives in physical findings and ROS. 5.) Demonstrate giving formative feedback to a peer.

May 19th – Living with a Life Threatening Illness: The Family’s Experience 1. Describe the experiences of the dying patient’s family before and after death. There are stages of grief that most people go through, although the pattern of grief is different for every person. The stages include: Numbness Yearning Disorganization Reorganization Another way of looking at the stages of grief is in the reading (Stroebe p 347). It focuses on the “tasks” of grieving. Accepting the reality of the loss Experiencing the pain of grief Adjusting to the environment without the deceased Relocating the deceased emotionally and moving on Generally, the psychological symptoms of bereavement happen early following the loss. These include loneliness, social withdrawal, loss of meaning, spiritual questions, anxiety, suicidal thoughts, depression, guilt, difficulty concentrating, etc. See reading for a more complete list (p 347). Many also suffer from problems with their physical health. They may have insomnia, headaches, dizziness, chest pain, go to the doctor more often, or start using drugs or alcohol. 2. Describe the needs of the family throughout their experience of loss. TIME Patient support from friends/family Maybe grief counseling Services of a chaplain or spiritual leader Opportunities to reminisce about loved one Care from a health provider 3. Describe the symptoms of grief, differentiating normal grief from depression. GRIEF Physical symptoms: Tight chest, hollow stomach, hypersensitivity to noise, SOB, lack of energy, dry mouth Psychological symptoms: Things don’t seem real, social withdrawal, loss of meaning, confusion, spiritual questioning COMPLICATED GRIEF – depression, PTSD Defined in the reading (p 348) as a “deviation from the normal grief experience in either time course, intensity, or both, entailing a chronic and more intense emotional experience or an inhibited response, which either lacks the usual symptoms or in which onset of symptoms is delayed.” Time has stopped for the grieving person. Depression is a normal part of grief, but it is temporary. When it persists for an extensive period of time, it becomes unhealthy. 4. Describe the physician’s role in assisting grieving friends and family of dying patients. Be aware of the emotions and physical symptoms of grief, as well as the risk factors for health. ASK the bereaved how they are doing and LISTEN to their response. Identify unhealthy behaviors and try to encourage them to seek another way to deal with their grief. Maybe refer to grief counseling services. Physical Exam Applied 1. Describe common heart murmurs using the 6 characteristics of the murmur. Aortic Stenosis	Aortic insufficiency (regurgitation)	Mitral regurgitation	Tricuspid regurgitation	Mitral stenosis Intensity Timing	Systolic	Diastolic	Systolic	Systolic	Late diastole Shape	Crescendo-decrescendo	Decrescendo	Holosystolic	Holosystolic Location	Right upper sternal border	Left lower sternal border	Apex	Left lower sternal border	Apex Pitch	High	High	High -	High	Low Radiation	Right side of neck and down sternal border toward apex	None	Left Axilla	A few cm to the left	None 2. Distinguish aortic stenosis from mitral regurgitation Both are systolic murmurs, but they have different shapes and occur in different locations. They also radiate to different places. 3. Describe the characteristics of aortic regurgitation. See chart 4. Differentiate between S3 and S4. S3 occurs in early diastole, so that it comes right after S2. Caused by rapidly filling the left ventricle against high pressure. S4 occurs in late diastole, so that it comes right before S1. Caused by atrial contraction against a high pressure/non-compliant ventricle. 5. Describe the characteristics of a pericardial rub. Inflammation of the pericardial pleura; creates a rubbing sound that is heard throughout the entire cardiac cycle and can distort S1 and S2. 6. Describe the findings of lung consolidation. Dullness to percussion, tubular breath sounds, increased tactile fremitus, crackles, egophay 7. Describe the characteristics of a pleural rub. According to Mosby’s – “A palpable, course, grating vibration, usually on inspiration…leather rubbing on leather.” 8. Describe the findings of a pleural effusion. Dullness to percussion, diminished breath sounds, decreased tactile fremitus, crackles in area superior to effusion, egophany; fluid-air line on chest Xray.

5.26.10 1:00-3:00pm Care, Not Cure: Exploring Care Options for the Elderly 1.    Demonstrate understanding of the emotions involved when families need to transition elderly relatives to more structured care. Elderly relatives may see the transition as signifying a loss familiarity, personal possessions, health, privacy, self-esteem, and independence. It can cause the older person and their family to experience sadness, anger, guilt, grief, hopelessness and fear. 2.    Define the physician’s role in functional assessment and in helping families recognize and deal with the need for structured care. Top goals of elder patient care: cure & death prevention Assessing placement: •    Cognitive assessment – does PT remember to take meds? Do they get lost? •    Home safety assessment – ramps, railings, bars by toilets, lighting, stairs •    Functional independence – cooking, shopping, bathing, OT evaluation •    Support structure – family, friends, neighbors, emergency contacts 3.    Describe potential methods of physician support for elderly patients and family members and potential resources for physicians. 4.    Describe differences between various care options available and note how patient management techniques and care philosophies vary from facility to facility.

Continuing Care Retirement Community	Residential Care & Assisted Living Facility	Adult Foster Care	Skilled Nursing Facility Space	Studio & 1 or 2 BR	Studio & 1 or 2 BR	Private/Shared	Usually shared Setting	Total independent living	Feel independent, but assistance available	Home-like, no more than 5 residents	Institutional environment, frail residents Meals	1 full meals included option of cooking for self	3 meals/day Limited cooking for self	3 meals/day Special diets	3 meals/day Special diets Excursions	Scheduled bus outings	Transport arranged for appointments	NOT provided	NOT provided Professional Staff	No med monitoring … unless pay extra $$$	LAW REQUIRES med/chart monitoring. RN on call, consult w/ doc	LAW REQ. med/chart monitoring. Some have RN on call	LAW REQ. med/chart monitoring. RN avail 24 hrs/day. House doc on call Mobility	NO wheelchairs/ electric carts	Must be able to get to dining room, but wheelchairs / electric carts are allowed	Some are wheelchair accessible. Usually not more than 1 person/ home. Walkers are fine	Wheelchairs/ electric carts are fine. Therapies	Arranged w/ outside provider	Arranged w/ outside provider	Arranged w/ outside provider	PROVIDED Assistance	Short term illness can arrange for extra $$$	Assistance w/ daily tasks (bathing, dressing)	Assistance w/ daily tasks requires Level 3 license	Assisted w/ ALL daily living tasks Introduction to Functional Assessment 5.26.10 3:00-5:00pm 1.    Describe the importance of functional abilities in health care assessment. •    Vision/ Hearing/ Oral •    Mobility (arms & legs) Cognitive •    Nutrition •    Elimination •    IADL & ADL function (see below) •    Medication/ Habits •    Social Support 2.    Describe the limits of the standard history and physical in detecting functional deficits. It takes time and patients may not be honest, especially if they are fearful. 3.    Describe the components of Activities of Daily Living (ADL). ADL – the basic activites required for most adults to live independent •    Bathing •    Ambulation •    Transfers •    Toileting (continence) •    Eating •    Dressing 4.    Describe the components of Instrumental Activites of Daily Living (IADL) and discriminate between these and “ADL” activities. IADL – more sophisticated measure of active individuals living in a community •    Writing •    Reading •    Cooking •    Cleaning •    Shopping •    Doing laundry •    Going up stairs •    Outside activities •    Managing meds •    Managing $ •    Transportation •    Using the phone 5.    Describe the elements of a mobility evaluation. Upper Extremities: •    Touch palms to back of head •    Reach up over head •    Touch hands behind back Lower Extremities: - the “get up and go” test •    Ask the patient to get out of the seat, walk in a straight line, turn 180 degrees and return o    Did the patient use their arms to get out of the chair? o    Did the patient move steadily and turn w/o difficulty? •    Ask the patient to sit down and touch opposite toes •    Ask the patient to stand for a few seconds w/o support o    Did they sway? •    Push lightly on the patients sternum o    Does the patient resist w/o losing balance? 6.    Describe the movement components of “gait.” (see #5) An abnormal gait is correlated w/ an increased risk of falling. 7.    Demonstrate assessment of ADL’s, IADL’s, gait, and balance. (see #3-#5) 8.    Demonstrate a functional evaluation of geriatric patient. (small group activity)

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