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    Clinical Skills Study Guide

    Uploaded by

    Angelica Mae Dela Cruz
    This document provides guidance on developing clinical skills such as professionalism, conducting patient encounters, writing SOAP notes, and building patient-physician relationships. Some key points covered include: 1) The importance of first impressions, maintaining professional appearance and conduct, and using clear communication. 2) Elements of a thorough patient encounter including introductions, hand hygiene, avoiding interruptions and medical jargon. 3) Components of the SOAP note format including subjective history, objective exam findings, assessments, and treatment plans. 4) Factors in an effective patient-physician relationship and dealing with differing emotions and values sensitively.

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    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd

    Clinical Skills Study Guide

    Uploaded by

    Angelica Mae Dela Cruz
    192 views58 pages
    This document provides guidance on developing clinical skills such as professionalism, conducting patient encounters, writing SOAP notes, and building patient-physician relationships. Some key points covered include: 1) The importance of first impressions, maintaining professional appearance and conduct, and using clear communication. 2) Elements of a thorough patient encounter including introductions, hand hygiene, avoiding interruptions and medical jargon. 3) Components of the SOAP note format including subjective history, objective exam findings, assessments, and treatment plans. 4) Factors in an effective patient-physician relationship and dealing with differing emotions and values sensitively.

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    This document provides guidance on developing clinical skills such as professionalism, conducting patient encounters, writing SOAP notes, and building patient-physician relationships. Some key points covered include: 1) The importance of first impressions, maintaining professional appearance and conduct, and using clear communication. 2) Elements of a thorough patient encounter including introductions, hand hygiene, avoiding interruptions and medical jargon. 3) Components of the SOAP note format including subjective history, objective exam findings, assessments, and treatment plans. 4) Factors in an effective patient-physician relationship and dealing with differing emotions and values sensitively.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    192 views58 pages

    Clinical Skills Study Guide

    Uploaded by

    Angelica Mae Dela Cruz
    This document provides guidance on developing clinical skills such as professionalism, conducting patient encounters, writing SOAP notes, and building patient-physician relationships. Some key points covered include: 1) The importance of first impressions, maintaining professional appearance and conduct, and using clear communication. 2) Elements of a thorough patient encounter including introductions, hand hygiene, avoiding interruptions and medical jargon. 3) Components of the SOAP note format including subjective history, objective exam findings, assessments, and treatment plans. 4) Factors in an effective patient-physician relationship and dealing with differing emotions and values sensitively.

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    © All Rights Reserved
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    At a glance
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    The documents discuss topics related to clinical skills including professionalism, patient encounters, communication, documentation using SOAP notes, common lab tests and values, and various imaging modalities and their uses.

    The main elements of a SOAP note are S (subjective), O (objective), A (assessment), and P (plan). S includes the patient's history and chief complaint. O is the physical exam findings. A lists potential diagnoses. P shows the treatment plan.

    Common lab tests mentioned include complete blood count (CBC), basic metabolic panel, lipid panel, thyroid panel, urinalysis, and others. The CBC and its components (WBC, RBC, etc.) test the blood cells and values. The basic metabolic panel and comprehensive metabolic panel test electrolytes, kidney and liver function.

    Clinical Skills Study Guide

    Professionalism - Dr. Olek

    1. Gain an appreciation of the importance of making a good first impression


    1. Importance of first impressions
    1. Sets the tone for the visit relationship and beyond
    2. Tone includes speech, body language and appearance
    3. A good start makes the rest of the encounter productive
    4. It is difficult to reverse a “bad” first impression
    5. People form an instant emotional opinion so be POSITIVE
    2. Know the main factors in making good first impressions
    1. Smiling and being positive
    2. Using a firm handshake
    3. Good eye contact
    4. Speak clear and understandable English
    5. Appearance
    1. Dressing professionally
    3. What are the first steps in the patient encounter?
    1. Always knock before entering
    2. Ask if you may come in the room
    3. Enter the room and introduce yourself as student doctor X with a smile and
    good eye contact
    4. Apologize for their wait while you wash your hands
    5. Ask them “How would you like to be addressed?”
    4. When should you wash your hands?
    1. ALWAYS wash hands before touching patients
    5. When is it ok to interrupt? How many questions can you ask in a row?
    1. Almost NEVER
    6. When is it ok to use medical jargon with speaking to patients?
    1. NEVER on the OSCE or COMLEX 2-PE exam!!
    2. Use “lay people” terms
    7. How to end the patient encounter
    1. Sum up the encounter in the last 2 minutes
    1. Significant history and findings from the exam
    2. Include 4 or more assessments
    3. Include your plan
    4. Educate/instructional skills
    5. Thank them before leaving
    8. Know the aspects and importance of professionalism
    1. Habitual and judicious use of:
    1. Communication
    2. Knowledge
    3. Technical skills
    4. Clinical reasoning
    5. Emotions
    6. Values
    7. Reflection in daily practice
    Clinical Skills Study Guide

    2. Principles
    1. Primacy of Patient Welfare
    1. Primum Non Nocere
    2. Accountability
    3. Excellence
    4. Honor
    5. Respect
    Intro to SOAP and H/P – Dr. Hedger

    1. Review and understand the elements of a proper SOAP note.


    1. The elements of a SOAP note include
    1. S = subjective (patient history and chief complaint)
    1. Family History
    2. Past Medical History
    3. Past Surgical History
    4. Social History
    5. Current Meds
    6. Allergies
    2. O = objective (physical exam)
    1. HEENT (Head, eyes, ears, nose and throat)
    2. Neck
    3. Heart
    4. Lungs
    5. Abdomen
    6. Musculo-skeletal
    7. Neuro
    8. Vital Signs
    3. A = assessment
    1. List of potential diagnoses based on the S and O
    2. Around 3 or more potentials should be included
    4. P = Plan
    1. Shows other’s your action plan
    2. Can include imaging, labs, additional testing, medication,
    education, referrals, follow up plans with number of days
    listed.
    2. Know and be able to discuss the “Five Simple Steps to Effective Communication”
    3. Be able to list the pertinent positives and pertinent negatives for a patient’s complaint in
    Subjective HPI and in Objective Physical examination.
    1. You need to physically ask ALL patients if they have every been told that
    they have:
    1. Diabetes
    2. Heart disease
    3. Lung disease
    4. Thyroid conditions
    5. G.I. issues
    6. Cancer
    Clinical Skills Study Guide

    2. Objective Physical examination:


    1. Neck: Check for lymph nodes, thyroid enlargement and carotid bruit
    presence bilaterally.
    2. Heart: Listen to the heart at all 4 listening posts. (RRR neg. murmur,
    neg. S3, neg. S4)
    3. Lungs: Listen to two spots anteriorly (infraclavicular bilaterally) and 4-6
    areas posteriorly. (CTA, neg. rales, neg. wheeze, neg. rales)
    4. Abdomen: Soft/rigid? Check for bowel sounds in all 4 quadrants, is there
    any tenderness, mid-line bruit (AAA), hepatosplenomegaly, rebound,
    McBurney point tenderness. Must list positives and negatives.
    5. Neuro: Alert and Oriented X3. DTR to upper and lower extremities.
    Strength in upper and lower extremities. Cranial nerves, alert and oriented
    (A&O X3). Sensation of left side of body compared to right. Check
    patient’s gait and coordination.
    6. Genitalia: This examine is NOT done during the OSCE course or is it
    done on the PE exam. In actual practice, you will need to check girls for
    breast bud development, and boys for inguinal hernias and if both testicles
    have descended and aren’t suffering from cryptorchism (undescended
    testicles). This as well as pap smears, rectal exams and breast exams are
    done with an assistant in the room.
    4. Know what makes up a limited physical exam and the proper way to write it on a SOAP
    note.
    1. Patient’s may present to the office for a “well-physical” or “general check-
    up.”
    2. Questions to ask for well-physical subjective
    1. Explore the patient, their lifestyle, normal activities, occupation, and
    general fitness, unusual fatigue, weight gain/loss, sexual issues,
    urinary and bowel habits (have they changed). How is the patient’s
    diet, exercise, sexual activity (monogamous or multiple partners and
    do they use protection).
    2. Pertinent positives and negatives are above.
    3. Ask the patient about tobacco use, alcohol use (how much per day).
    Illicit drug use (including marijuana). Document by each, positive or
    negative and how much of each they use. If they don’t use any of
    these you must indicate neg. tobacco, neg. alcohol, neg. illicit drug use.
    4. Ask about surgical history, Family history, allergies, and current
    medications.
    5. Ask patient how long has it been since their last physical exam. Age
    appropriate: when was your last colonoscopy? Mammogram/Pap
    smear, breast exam for females, prostate exam for males. When was
    your last comprehensive blood test? EKG?
    3. Objective / Physical Examination
    1. Do a system by system check
    1. HEENT
    2. Neck
    3. Heart
    Clinical Skills Study Guide

    4. Lungs
    5. Abdomen
    6. Musculo-skeletal
    7. Neuro
    8. Vital Signs
    4. Assessment
    1. For a well physical you can write Well physical / Well exam as your
    first assessment
    2. Look for hints in the history about poor diet, no exercise, nicotine
    addiction, illicit drug use, unsafe sexual practices to include as the rest
    of your assessment.
    5. Plan
    1. Includes:
    1. Lab work
    2. Imaging
    3. Pain control
    4. Routine physical workup
    1. EKG
    2. Complete metabolic profile
    3. CBC
    4. UA
    5. Age / sex appropriate tests:
    1. Colonoscopy
    2. Mammogram
    3. Pap smear
    4. Prostate/rectal exam
    6. Lifestyle change counseling
    7. OMM
    8. Date for follow up or patient disposition
    5. Know what does and does not make up an appropriate Assessment and how to write it on
    your SOAP note.
    1. List at least 3 or more possible diagnoses.
    2. List the patients complaint at the top
    1. Thoroughly examine the patient’s area of complain
    6. Know what does and does not make up an appropriate Plan and how to write it on your
    SOAP note.
    1. See above notes.
    7. Know and be able to list the appropriate examination for a “Well/General Physical
    Exam”
    1. See above notes.

    Patient Physician Relationship – Dr. Harris

    1. Understand Dealing with differing values and emotions and potential effect upon patient
    encounters
    a. Dealing with emotions can be difficult due to:
    Clinical Skills Study Guide

    i. Intimate information
    1. Patient’s often share intimate information with clinicians
    about family difficulties, sexual relationships, and fears about
    disability and death.
    2. Dealing with this information should include identifying
    faculty, peers, or significant others with whom to discuss
    feelings.
    ii. Lack of legitimacy
    1. Students may feel that they are “playing” at becoming doctors
    and that patients with whom they work might just as well
    share intimate information with the person in the next bed
    2. Managing this includes
    a. Explaining your stage of training and level of
    responsibility.
    b. Developing confidence about data collection skills and
    an awareness that new and important information may
    be discovered.
    iii. Conflict between education and patient care
    1. Students may feel tension between attaining educational
    objectives and providing patient care and may be concerned
    that they are “using patients” when they repeat examinations
    that are clinically unnecessary.
    2. Note that:
    a. You may discover something new and important
    b. Most patients are pleased to that they have something
    worthwhile to teach students.
    c. Many patients appreciate the extra attention
    iv. Patients with self-inflicted problems
    1. Patients with “self-inflicted” problems may engender feelings
    of anger or frustration
    2. Managing this is developing the ability to suspend your moral
    or personal judgement about the patient’s behavior, to set
    aside your negative feelings (if present) and work in the
    patient’s best interest
    a. Unconditional positive regard
    v. Patients with terminal illness
    vi. Regimentation and loss of sense of self
    2. How to hand and deal with Self Inflicted Patient Issues
    a. See above.
    3. Know the definition of Unconditional Positive Regard
    a. See above.
    4. Necessity of demonstrating respect and diversity
    a. Respect means to value an individual’s traits and beliefs despite your own
    personal feelings about them and to see patients’ feelings and behavior as a
    valid adaptation to their illness or life circumstances.
    i. How to demonstrate
    Clinical Skills Study Guide

    1. Clear introductions
    2. Using the patient’s full name
    3. Arranging for patient’s comfort during the course of the
    encounter
    4. Warning the patient of unexpected or painful procedures
    5. Respond to your patient in a way that shows you have heard
    what they have said

    Greeting/CC/HPI – Dr. Olek

    1. Learn how to greet a patient


    i. Dress appropriately
    ii. Knock and ask to enter
    iii. Introduce yourself and make eye contact
    iv. Apologize for the wait and ask how they would like to be addressed
    v. Wash hands then shake hands then ask to sit
    vi. Remember the general recommendations (eye level, empathy, do not
    interrupt, etc.)
    vii. Now you are ready to ask about their chief complaint
    2. Learn how to obtain a chief complaint
    i. What is bringing the patient in today?
    1. Should be in the patient’s own words
    2. Should be brief and focused
    3. No more than one sentence
    4. Should not include a diagnosis
    3. How to obtain a history of present illness (HPI)
    i. History of Present Illness should start with patient’s:
    1. Name
    2. Age
    3. Gender
    4. Handedness (right/left/ambidexterous)
    5. Race
    6. Gravida (total number of confirmed pregnancies)
    7. Para (Number of births that a woman has had after 20 weeks
    gestation)
    ii. The HPI can be obtained through the following mnemonic:
    1. OPQRST
    a. Onset
    i. Questions about the timeframe of the illness
    b. Palliative/Provocative Factors
    i. Questions about what the patient does to alleviate the
    symptoms.
    c. Quality
    i. Description of the pain
    1. Cramp
    2. Wave of pain
    Clinical Skills Study Guide

    3. Twisting
    4. Pressure
    5. Stabbing
    6. Dull ache
    d. Region / Radiation
    i. Location of the pain and if it travels to different points
    on the body
    e. Severity
    i. Pain scales (i.e. 1-10; mild, moderate or severe)
    f. Timing
    i. Duration of the pain
    4. Suggested order for writing clinical notes
    i. C/C-Chief Complaint
    ii. HPI-History of Present Illness
    iii. PMH-Past Medical History
    iv. PSH-Past Surgical History
    v. MEDS-Medications
    vi. ALL-Allergies
    vii. SH (Social History)/OH (Occupational History)/Sexual Hx
    viii. FH-Family History
    ix. ROS-Review of Systems

    Mental Status Examination – Dr. Olek

    1. To learn about different causes of cognitive impairment


    i. Neurocognitive disorders result primarily from primary or secondary
    abnormalities of the central nervous system that affects:
    1. Memory
    2. Orientation
    3. Attention
    4. Judgment
    2. To know the different testing options available
    i. Mini mental state examination
    ii. AD8 (differentiating aging and dementia)
    iii. Modified mini-mental examination (3MS)
    iv. The Montreal Cognitive Assessment – MOCA
    v. The mini-cog test
    vi. The brief cognitive assessment tool – BCAT
    vii. Saint Louis University Mental Status test – SLUMS
    3. Learn how to administer the MMSE
    i. Brief, structured mental status examination
    ii. 10-15 minutes to administer
    iii. Scores range from 0-30
    iv. Steps in administering the MMSE:
    1. Greet patient, introduce yourself and confirm the patient
    2. Take a good history and examination
    Clinical Skills Study Guide

    3. Always include care givers


    4. It is advisable to administer AD8 to family members before MMSE
    screening (this can be done with the help of the assistant)
    5. Explain the test briefly and obtain consent
    6. Go ahead to administer MMSE (as in our setting) or the MINI – COG
    7. Explain the result to the patient
    8. Answer patients questions and clarify issues that are confusing
    9. Thank patient after test, continue with other investigations, conduct
    other more sensitive tests, refer if indicated and give F/U appointment

    4. To learn the risk factors for neuro-cognitive disorders


    i. Risk factors of neurocognitive disorders include
    1. Dyslipidemia
    2. Cerebrovascular disease
    3. Hypertension
    4. Type II DM
    5. Obesity
    6. Depression
    7. Chronic psychological stress
    8. Traumatic brain injury
    9. Down’s syndrome
    10. Smoking
    5. To learn about modifiable risk factors for dementia
    i. Reversible: Due to medical conditions
    1. Drugs
    2. Endocrine disorder
    3. Metabolic
    4. Nutritional (B12 deficiency)
    5. Tumor
    Clinical Skills Study Guide

    6. Trauma
    7. Infection (tertiary syphilis)

    PMH, PSH Medication – Dr. Meeks

    1. What are the components of the Past Medical History? What conditions should you ask
    about?
    a. You should always ask about:
    i. Current medical problems (i.e. do you have any chronic health
    problems?)
    ii. Do you have diabetes, HTN, Heart disease, or you can ask about any
    2-3 specific conditions
    b. Both of the above components are necessary for a proper PMH
    2. What is a Differential Diagnosis?
    a. A mental list of different disease possibilities created by the clinician as they
    “work up” the patient and attempt to discover what disease is causing the
    chief complaint
    3. What are Pertinent positives and Pertinent Negatives?
    a. These are “symptoms” that are related to the Chief Complaint and History
    of Present Illness
    4. Describe the components of the Past Surgical History.
    a. Components
    i. Have you had any surgeries?
    1. If pertinent, ask if the surgery was recent
    2. Cosmetic surgeries we usually don’t need to know unless they
    are pertinent
    5. List the components of the Medication history. When should you detail the dosages and
    frequency?
    a. Components:
    i. What medications are you currently taking?
    1. List them including
    a. Dosage
    b. Frequency
    i. There is often not enough time during
    COMLEX-2 to do so
    ii. If the medication may be affecting the CC or
    Ddx you should get the specific dosage and
    frequency
    6. What are the components of the “allergy” history? What should you determine about a
    positive history of medicine allergies?
    a. Mostly we should be concerned about allergies to medications, NOT
    environmental
    i. If they answer yes to having allergies to medications
    1. Record what reaction they had
    Clinical Skills Study Guide

    b. If the patient is suffering from possible environmental or food allergies, you


    would want to inquire about a history to those

    CAGE, EtOH, TOB, Illegal Drugs and FH, Travel, Sexual Hx, Immunizations – Dr.
    Hedger

    1. Understand the importance of talking to all patients about alcohol use.


    2. Define CAGE
    • It is a combination of 4 simple questions that can be used for the screening of
    patients for alcoholism
    • Designed to be a SCREENING tool NOT DIAGNOSTIC
    • Questions include:
    • Have you ever felt you should CUT down on your drinking?
    • Have people ANNOYED you by criticizing your drinking?
    • Have you ever felt bad or GUILTY about your drinking?
    • Have you ever had a drink first thing in the morning or to get rid of a
    hangover? (EYE-OPENER)
    3. Be able to utilize the CAGE questionnaire effectively and in the correct situations
    • To effectively ask patient questions in CAGE:
    • Inquire about symptoms and sometimes press the patient who seems
    evasive about answering questions about substance abuse
    • Remember that when asking a patient about how much they drink it
    usually leads to an estimate much lower in quantity.
    • This questionnaire should be completed as part of the medical history
    • 2 affirmative responses to CAGE questionnaire is probable diagnosis of
    alcoholism.
    • Questions are asked in regards to the whole life of the patient.
    • Validity of the CAGE questionnaire decreases if it is asked after asking
    about the amount of alcohol ingested regularly.
    • Know the Alcohol Conversion Chart
    • 1 shot liquor: ½ ounce = 1 drink
    • 1 glass of wine: 5 ounce = 1 drink
    • 1 bottle of beer: 12 ounce = 1 drink
    • Appropriate situations to ask CAGE:
    • Routine physical exam
    • Patient presenting with any of the following symptoms / CC / issues
    • Chronic dizziness, fatigue
    • Anxiety or depression issues
    • Anger issues
    • Sleep disorder
    • Chronic stomach or bowel issues
    • Patients that you can smell alcohol on their breath
    • Patient with newly diagnosed pregnancy
    Clinical Skills Study Guide

    4. Understand when the CAGE questionnaire is not appropriate to use


    • For drug/substance use
    • For anxiety / depression
    • Smoking
    • Don’t use the CAGE Questionnaire for anything other than alcohol
    5. Understand and be able to perform an effective Review of Systems (ROS) during a
    patient encounter/history and physical
    • Unable to answer this based on the PowerPoint provided
    6. Define pertinent positives and pertinent negatives and be able to elicit appropriate
    pertinent positives/negatives during a patient encounter
    • Unable to answer this based on the PowerPoint provided

    Ethic and Drug Abuse – Dr. Hedger

    1. Understand the severity of substance abuse among health care professionals


    a. A 2013 study in the Journal of Addiction Medicine stated that 69% of
    doctors abused prescription medication as a means of relief from emotional
    distress or general stress.
    b. The American Nurses Association reports that 10% of nurses may be
    impaired or in recovery from drug or alcohol addiction.
    2. Recognize the warning signs of early substance abuse in yourself or colleagues.
    a. Starting to use a benzodiazepine “now and then” to help you cope with stress
    or help you get to sleep
    b. Starting to utilize opioids to get rid of a stress headache or relieve you neck
    or back pain from over work or another medical condition
    c. Drinking alcohol to calm down at the end of the day or before you start your
    day
    d. Feeling as if you need to take something to help you make it through each
    day
    e. Not being able to complete your day’s work. More often when you use to be
    able to handle the load fine
    f. Starting to get more frustrated with co-workers/colleagues and “lashing out”
    at them
    3. Know the importance of intervening to help prevent health issues.
    a. Remember that we are all humans with needs and concerns
    b. Don’t be afraid to ask for help
    c. Remember that we have a duty to serve our patients with the highest of
    moral character and high standard of medical care
    d. Remember that we also have a duty to keep ourselves healthy, strong, and
    emotionally stable and well balanced
    i. When these break down you. Have broken the standard of care and
    your ethical obligation to yourself, your family and your patients
    4. Know that state licensing boards are very receptive and proactive to substance
    abuse and treatment of health care professionals.
    5. Understand the importance of intervening in yourself or a colleague for their benefit as
    well as patient population safety.
    Clinical Skills Study Guide

    a. See question 3.

    Humanism: Patient Centered Questioning – Dr. Zacharias

    1. Be familiar with the difference between illness and disease


    a. Disease implies a disruption in normal biologic function
    i. Disease is objective:
    1. You can see disease processes under a microscope and in
    abnormal laboratory or imaging tests
    b. Illness is subjective
    i. People feel a sense of “dis-ease”
    ii. They identify themselves as sick
    iii. They behave in accordance with the way they feel
    1. Different from how they act when they feel healthy
    c. Example: A patient can have a disease without illness
    i. Hypertension, but no symptoms
    d. Most patients who seek medical care have both disease and illness in varying.
    Degrees
    e. We cure diseases with medications, surgery and biotechnology
    f. We heal illnesses mainly through our words and the therapeutic
    relationships we. Establish with our patients
    2. Be familiar with the different types of open ended skills: non focusing and focusing. Be
    able to use them in an interview
    a. Non-focusing
    i. Silence: eye contact and welcoming body posture
    ii. Nonverbal encouragement: nods, leaning forward or hand motion
    iii. Neutral utterances: brief non-committal statements (e.g. “I see,”
    “Yes,”, or “Mmm”)
    1. Avoid using slang (e.g. “That’s cool”)
    iv. Used throughout the entire interview
    b. Focusing
    i. Echoing: repeating a word or phrase that was just said so that the
    patient can proceed or focus more on the echoed word/phrase
    ii. Open-ended requests: “Tell me more” or “Go on”. Allows the patient
    to feel that you are listening and would like more info.
    iii. Summary: Summarizing allows the patient to focus on the material
    summarized and express deeper levels of their story.
    iv. Needed to help interviewer restore structure to patients narrative
    3. Be familiar with the four concepts of indirect inquiry of emotion seeking skills
    a. Inquiring about impact: how the illness or other situation in question has
    affected the life of the patient or family member.
    Clinical Skills Study Guide

    b. Eliciting beliefs/attributions: asking what the patient thinks caused the


    problem is not only helpful for understanding the patient’s medical
    explanatory model but it may also uncover an underlying feeling or emotion
    c. Demonstrating understanding through self-disclosure: Sharing how you or
    others might feel in similar circumstances can help the patient identify her or
    his own emotions and feelings.
    d. Triggers: Determining why the patient is seeking care at this precise time,
    especially if the problem has been present for more than a few days.
    4. Be familiar with NURS
    a. Empathy Skill
    i. Naming: name the feeling or emotion
    ii. Understanding: acknowledging that the patient’s emotional reaction
    is reasonable
    iii. Respecting: verbal respect appreciates the patient, clearly
    acknowledges how difficult things have been, or praises the patient’s
    efforts
    iv. Supporting: supporting statements signal to the patient thata you are
    prepared to work together
    5. Be familiar on how to end interview
    a. Conclude a patient interview by
    i. Explain Diagnostic and/or Prognostic Information
    ii. Incorporate Patient's Informational Needs: this will vary for each
    patient. Use laymen terms and give enough information until the
    patients has general understanding.
    iii. You could ask for permission before sharing information.
    iv. Invite the patient to participate in shared decision making.
    v. Explain testing and/or treatment options.

    LGBTQA – Dr. Lockhart

    1. Demonstrate how to collect the two-step gender and sex differentiation questions, using
    appropriate language
    a. Two-step Gender and Sex Questions
    i. What is your current gender identity?
    ii. What sex were you assigned at birth?
    iii. What are your preferred pronouns?
    2. Demonstrate the use of appropriate language to explain to all patients why they are being
    asked separate question about their gender and sex
    a. Some may not understand and a short explanation of sex and gender may be
    needed
    i. The response should be short and explain that there are patients who
    were assigned one sex at birth and identify as another gender now.
    3. State at least three reasons why the two-step gender an sex method is important
    a. See below.
    4. Describe at least three ways in which cultural competence in transgender care affects
    health outcomes for this population
    Clinical Skills Study Guide

    a. Asking the correct questions can


    i. Improve the long term health of the transgender population
    ii. Make data gathered more accurate and providers will be better able
    to respond to transgender patient’s health care needs
    iii. Asking these questions can increase awareness of transgender
    experience and these patients will feel more comfortable discussing
    health care needs
    iv. Funding and medical reimbursement will improve for the transgender
    community

    Medical Malpractice – Dr. Havins

    Key Points:

    U.S. Tort System Goals


    1. Compensate
    a. Past and future medical costs
    b. Past and future wages
    c. Noneconomic damages
    i. (Special damages = 1a + 1b; General damages = 1c
    2. Punish
    a. Compensatory damages
    b. Punitive damages – limits
    3. Deter
    Why do Patients Sue Doctors?
    1. Prevent similar incidents
    2. Honest and clear answers
    3. Accountability for action
    4. Financial motivation
    Other Causes of Medical Malpractice Actions
    1. Wrongful death
    2. Loss of a chance of recovery or survival
    3. Res Ipsa Loquitur. (The Thing Speaks for Itself)
    a. The plaintiff could not have contributed to injury
    4. Battery and Assault
    5. Lack of Consent (Battery)
    6. Lack of Informed Consent (Negligence)
    7. Abandonment
    8. Breach of Privacy & Confidentiality
    9. Breach of Contract or Warranty to Cure
    10. Products Liability for Drugs and Medical Devices
    11. Vicarious Liability for Act of Others
    12. Loss of Consortium
    13. Negligent Referral or Consult
    Four C’s of Medical Malpractice Avoidance
    1. Compassion
    Clinical Skills Study Guide

    2. Competence
    3. Charting
    4. Communication

    General Survey and Vital Signs – Dr. Zacharias

    1. Become familiar with techniques of obtaining values for


    a. Blood pressure
    b. Respirations
    c. Pulse
    d. Temperature
    2. Differentiate between comprehensive and focused exam
    a. Comprehensive exam
    i. Typically for wellness visits
    ii. Review of systems
    b. Problem focused
    i. Examination starts with the problem area and radiates outward from
    their
    3. Become familiar with pain and different origins
    a. Pain is the 5th vital sign
    b. Evaluated on a scale from 1 to 10
    c. Types of pain include:
    i. Somatic (nociceptive): tissue damage pain
    ii. Neuropathic: injury to the central or peripheral nervous system.
    iii. Psychogenic: psychiatric conditions
    iv. Idiopathic: unidentifiable etiology
    4. Be able to understand the application and limitations of BMI
    a. BMI useful for assessing whether the patient has a healthy level of body fat
    in proportion to their height and weight
    b. NOT useful for very athletic or heavily muscled individuals
    5. Define normal values for
    a. Blood pressure
    i. Normal: <120 systolic and <80 diastolic
    b. Body temperature
    i. Normal is 98.6 F or 37 C
    c. Respiration rate
    i. Normal around 10-20 respirations per minute
    d. Pulse
    i. Normal pulse rate is 60-100 BPM
    6. Define use of the following terms in relationship to blood pressure understanding
    a. Pulse Pressure
    b. MAP/ SO/ SVR/ CO
    Clinical Skills Study Guide

    i. MAP (mean arterial pressure) = CO (cardiac output) + SVR (systemic


    vascular resistance)
    1. MAP = SV x HR x SVR
    ii. CO = SV (stroke volume) x HR (heart rate)
    c. EF/EDV
    i. SV = EF (ejection fraction) x EDV (end diastolic volume)
    7. Define Auscultatory gap
    a. Silence caused by disappearance of Korotkoff sounds with subsequent
    appearance
    b. Usually caused by decreased flow
    8. Understand five Korotkoff sounds
    a. Phase 1: sharp thuds, start at systolic blood pressure.
    b. Phase 2: blowing sound; may disappear entirely (the auscultatory gap )
    c. Phase 3: crisp thud, a bit quieter than phase 1.
    d. Phase 4: sounds become muffled.
    e. Phase 5: end of sounds -- ends at diastolic blood pressure.

    9. Understand arterial wave fluid dynamics


    Clinical Skills Study Guide

    10. Be familiar with long term complications for lack of treatment for hypertension
    a. Hypertension has a devastating effect on “end organs” including the:
    i. Brain: atherosclerosis leading to impaired circulation, embolic,
    thrombotic and hemorrhagic stroke
    ii. Eyes: hypertensive retinopathy with impaired blood supply and infarcts
    iii. Heart: left ventricular hypertrophy (enlarged heart) and valvular disease
    leading to myocardial infarction and congestive heart failure
    iv. Arteries: hypertensive vascular lesions including atherosclerosis,
    atheroma, thrombus formation and ultimate stenosis and dissection
    v. Kidneys: hypertensive nephropathy glomerular sclerosis and renal failure
    11. Be familiar with JNC 8 recommendations

    Comlex 2-PE Intro and Review – Dr. Meeks

    1. Have a basic understanding of the components of the Comlex Level-2 PE exam.


    1. Components
    1. Humanistic Domain: measures a students skills in
    1. Communication
    2. Empathy
    Clinical Skills Study Guide

    3. Respect
    4. Physician-Patient Communication
    5. Interpersonal skills
    6. Professionalism
    2. Biomedical/Biomechanical domain: measures the 3 following areas
    1. OMM – osteopathic principles and osteopathic manipulative
    treatment
    2. Medical history – Taking and Physical Examination skills
    3. SOAP note – including synthesis of clinical findings, integrated
    differential diagnosis, and formulation of a diagnostic and
    treatment plan
    2. Be familiar with basic aspects/keys of the Humanistic domain.
    1. Dress professionally. Clean white coats (ironed), socks for men, well-
    groomed.
    2. Start with open-ended question (How can I help you today? What brings
    you in today?)
    3. Don’t interrupt
    4. Show and express empathy by addressing pain early and compassion to sad
    situations (deaths, etc).
    5. If you cannot give them some immediate pain relief with positioning, state
    that you will relieve pain ASAP.
    6. Ask permission, especially when: examining the chest, untying gown and
    doing OMM
    7. Describe OMT, get permission, ask if its hurting or helping while performing
    and after. Document consent obtained, technique and response to Rx.
    8. Assist patient up and down.
    9. Help patient tie the gowns’ neck tie in back after heart and lung exams.
    10. Use the foot rest/table foot extension when the patient is lying down.
    11. Don’t ask more than one question at once
    12. Don’t use medical jargon
    13. Try to “connect” with the patient
    14. When finished, ask patient if they have any questions?
    3. Understand the importance of doing a thorough History and Physical.
    1. Compilation of historical information that is necessary to create and “fine
    tune” a differential diagnosis
    2. Gathering information regarding the patient’s history which aids the
    clinician in making recommendations.
    4. Know the proper order of questioning when obtaining the history
    1. Chief complaint – the reason the pt comes to you
    2. OPQRST – details regarding the CC
    3. Pertinent positives and negatives – questions to investigate the differential
    diagnosis
    4. PMH – ask generally, then ask about 2 specific diseases
    5. PSH - straightforward
    6. Fam Hx – ask generally, then ask about 2 specific diseases
    7. Meds
    Clinical Skills Study Guide

    8. All – ask about the allergic reaction


    9. Soc Hx – ask about smoking, drinking, drug use, work, sexual hx
    10. Review of Systems (ROS) – if doing a complete history and physical
    5. Know all the components of a proper history
    1. See above
    6. Begin learning how to set up your paper for OSCE encounters.

    Documentation of the Physical Exam – Dr. Meeks

    1. What is a Complete Exam versus a Problem Focused exam? When should you perform
    one or the other?
    • The chief complaint will usually determine whether we will do a complete vs
    a problem focused exam
    • A wellness visit is a prime example of when to utilize a complete exam format
    • Focused exams involve focusing on the area of complaint and moving
    outward from there
    • Include every positive finding that helps to confirm the most likely
    diagnosis
    • Include negative findings that helps to exclude other items in the
    differential diagnosis
    2. Know what areas of the body should be examined by the physician for each particular
    complaint
    • See above
    • Note that every exam should include
    • A review of all the vital signs
    • A heart and lung exam
    3. What are the acceptable abbreviations for the Physical Exam?
    Clinical Skills Study Guide

    • Abbreviations that are nationally accepted based on the NBOME list


    • Examples:
    • Lungs: clear to auscultation bilaterally = LCTAB
    • Heart: regular rate and rhythm = HRRR
    • Abdomen:: soft, positive bowel sounds x 4 quadrants. Non-
    tender, no guarding, rebound or rigidity = Abd soft, + BS x 4.
    NT. -g/r/r
    4. What is the standard order for documenting the physical exam?
    • Vitals: transfer vital signs from the patient data sheet and include later in
    plan that you will repeat/or address a specific abnormal vital sign
    • General: general features that you feel are pertinent
    • Example: Alert. Well nourished. Pleasant__old female/male in no.
    acute distress
    • HEENT
    • Heart
    • Lungs
    • Abd
    • Ext
    • Neuro
    5. What is “academic dishonesty” in documenting the physical exam and what are the
    repercussions?
    • One must NEVER, EVER, document anything in your physical exam that
    you did not actually perform. This is an automatic failure.
    • The Objective area is restricted to current factual information
    • Any statements in the documentation that cannot be confirmed by the
    standardized patient or by reviewing the candidate’s video are considered
    irregular behavior and could result in the entire test being disqualified,
    resulting in failure of the examination.

    Building SOAP Notes – Dr. Hedger

    See previous SOAP lecture with Dr. Hedger. No lecture slides.

    Upper Extremity - Dr. Harris

    1. In the Upper Extremity


    a. Identify pertinent anatomy
    1. Bicipital groove (between greater and lesser tuberosity of the
    humerus)
    2. Deltopectoral groove
    3. AC joint
    4. Acromion process
    5. Coracoid process
    6. Greater and lesser tuberosity of the humerus
    7. Clavicle
    8. Olecranon
    Clinical Skills Study Guide

    9. Medial epicondyle (ulnar nerve found posteriorly, lymph node


    palpation)
    10. Lateral epicondyle (radial head; will reveal even minor
    effusions or mild synovitis)
    11. Glenohumeral joint
    12. Rotator cuff muscles
    a. SITS
    i. Supraspinatus
    ii. Infraspinatus
    iii. Teres minor
    iv. Subscapularis
    13. Thenar and Hypothenar eminences
    14. Flexor Tendons
    15. Radial styloid
    16. Ulnar styloid
    17. Carpal bones
    a. Hook of Hamate
    b. Pisiform
    c. Scaphoid
    18. Anatomical snuffbox
    b. Recognize anatomical landmarks
    i. Necessary for physical examination and for performance of
    procedures
    c. Know and perform common physical exam techniques
    i. Correlate them to potential pathology
    1. Muscle testing
    a. Range of “normal” muscle strength
    b. Test to overcome patient
    c. Compare bilaterally
    d. Grade from 0-5
    2. Glenohumeral Motion: Apley Scratch
    a. Tests ROM of glenohumeral joint
    i. External rotation and Abduction (should reach
    C7)
    ii. Internal rotation and Adduction
    b. Cross arm test shows AC joint pathology
    3. External rotation test
    a. Pain or weakness indicative of infraspinatus or teres
    tear
    4. Infraspinatus Test / Teres Minor
    a. Resistance to external rotation
    b. External rotation lag sign
    i. Passively place in external rotation and have
    patient hold position
    5. Shoulder Impingement
    a. See picture
    Clinical Skills Study Guide

    6. Empty beer can test


    a. Weakness / pain on symptomatic side implies
    supraspinatus tear
    7. Bicipital Groove
    8. GH Instability
    a. Apprehension Test
    i. Patient abducted 90 degrees and Externally
    rotated and applies anterior pressure to humerus
    ii. Test is positive when the patient feels the
    shoulder is going to “pop out” or has pain
    9. Biceps Tendonitis
    a. Yergason’s Test
    i. Evaluate biceps in bicipital groove
    ii. Patient flexes elbow to 90 degrees
    iii. Physician grasps the elbow with. One hand and
    the wrist with the other
    iv. Examiner resists as the patient attempts to
    supinate and flex the elbow
    v. Test is positive is pain is elicited at the biceps
    tendon or bicipital groove
    10. The Drop Arm Test
    a. Test to determine if there are tears in the rotator cuff
    b. Test is positive if the patient is unable to lower his arm
    slowly to his side
    11. Subscapularis damage
    a. Gerber Lift Off Test
    i. Adduction with internal rotation
    ii. The patient attempts to press the palm
    posteriorly
    12. GH Instability
    a. O’Brien’s Test
    i. Shoulder at 90 degrees of forward flexion, 30 to
    45 degrees of horizontal adduction and maximal
    internal rotation (thumb pointed down)
    ii. Patient resists downward pressure
    iii. Rotate to supination and resist flexion
    iv. Test is positive if pain alleviated in palm-up
    position
    v. Pain on maneuver implies superior labral
    anterior to posterior tear
    13. Elbow
    a. Tinel’s sign
    i. Eliciting paresthesia in the territory of the ulnar
    nerve allows an assessment of the likely site of
    compression
    14. Speed’s Test
    Clinical Skills Study Guide

    a. Biceps Tendon
    b. Arm extension
    c. Supination of arm
    d. Pt pushes up against doctors hand
    e. Positive if there is pain or tenderness in the bicipital
    groove
    15. Finkelstein’s Test
    a. Brace wrist in ulnar deviation
    b. Passive stretching of extensor thumb tendons by flexing
    thumb across palm
    c. Positive if there is pain over the tendon
    i. Sensitive for tenosynovitis of abductor pollicis
    longus and extensor pollicis brevis
    16. Tinel’s sign
    a. Percuss median nerve at the carpal tunnel in wrist
    17. Phalen’s
    a. Inverse praying position

    Assessment and Plan – Dr. Hedger

    Summary:
    - Write C/C on top of Assessment section
    - Decide whether the complaint is
    o Acute and life threatening
    o Acute and non-life threatening
    - Assessment vs Differential
    o Assessment = what is wrong with the patient
    o Differential = what could be wrong with the patient
    - Plan
    o Based on your subjective history (CC and HPI) as well as your examination
    findings AND your Assessment, what do you need to do with the patient to
    prove your assessment, make the patient comfortable, and correct the
    problem the patient presented with? As well as what are you going to do to
    address the patient’s other medical/health issues that presented themselves
    during your history with the patient?

    Hip and Knee Exam – Dr. Havins

    1. Appreciate the gross anatomy of the hip and knee


    2. Know the surface anatomy of the hip and knee
    a. Anterior superior iliac spine (ASIS)
    b. SI joints
    c. Greater Trochanter
    d. Lumbar spinous processes
    e. Gluteal muscles
    3. Know the ROM of the hip and knee
    Clinical Skills Study Guide

    4. Know the common tests (provocative maneuvers) used to assess the hip and knee
    a. Special Tests (Hip)
    i. Ober’s Test
    1. Patient in lateral recumbent, leg abducted and extended, leg is
    then allowed to gently fall toward the table
    2. Tests for IT band inflexibility (common cause of runner’s
    knee)
    ii. Modified Thomas Test
    1. Patient sits on edge of exam table, pulls opposite knee to chest
    and then lies supine
    2. Test is positive if the thigh rises off the exam table or the knee
    passively extends past 90 degrees
    3. Suggestive of iliopsoas contracture, rectus femoris contracture
    or quadriceps inflexibility
    iii. FABER Test
    1. Flexion, Abduction, External Rotation
    2. Test is positive if the ipsilateral SI joint hurts
    3. Test is for SI joint dysfunction
    b. Special Tests (Knee)

    GenuGenu Genu VarusValgus


    Recurvatum

    “Bow Legs” “Knock Knees” “Back Knee”


    Clinical Skills Study Guide

    i. Bulge Sign
    1. Small amounts of synovial fluid in and around the synovial
    joint of the knee
    ii. Baker’s cyst
    1. Popliteal palpation
    iii. Pes Anserine bursitis
    1. Sartorius, gracilis, semitendinosus
    a. Attachment at medial tibia
    iv. Patellar J sign and patellar grind
    1. Patellar J: Patient leg straight, apply resistance to the superior
    pole of the patellae with the thenar space and ask patient to
    flex quadriceps
    a. Positive if the patella moves medially or laterally before
    moving caudally or if pain occurs
    b. Suggestive of patellar femoral pain syndrome
    2. Patellar Grind: leg in extension, compress the patella against
    the femur longitudinally and transversely
    a. Suggestive of patellar femoral pain syndrome
    v. Patellar apprehension
    1. Patient supine, relaxed quadriceps, knee flexed 30-45 degrees,
    press against the medial border of the patella
    a. Test positive if the patella begins to sublux. Patient will
    feel as if their patella is about to dislocate
    2. Suggestive of a patellar retinaculum disruption / patellar
    instability
    vi. Lachman’s Test
    1. Knee flexed to 30 degrees, hands placed on distal thigh and
    proximal tibia with the thumb on the tibial crest, attempt
    anterior translation with the distal hand
    2. Test is positive if endpoint is not detected or excessive anterior
    translation occurs
    3. Suggestive of ACL injury
    vii. Anterior and Posterior Drawer
    1. Knee flexed at 90 degrees, both hands placed on the tibia,
    anterior and posterior translation is transmitted through the
    joint
    2. Test is positive if endpoints are not detected or if excessive
    anterior translation occurs.
    3. Anterior drawer = ACL
    4. Posterior drawer = PCL
    viii. Varus and Valgus Stress
    1. Knee flexed at 30 degress, stabilize femur and apply varus and
    valgus stress to the knee
    a. Varum = rum between legs knees outward (lateral /
    LCL)
    Clinical Skills Study Guide

    b. Valgum = gum between legs, knees stuck together


    (medial / MCL)
    ix. Apley’s Grind
    1. Patient prone with knee flexed to 90 degrees examiner pushes
    straight down on the foot while rotating the tibia and partially
    flexing and extending the knee.
    2. Test is positive if there is pain over the medial joint line during
    external tibial rotation or over the lateral join line during
    internal tibial rotation
    3. Suggestive of medial or lateral meniscal injury
    x. Thessaly’s Test
    1. Patient standing on affected limb, flexed 20-30 degrees, patient
    rotates their body weight on the knee
    2. Test is positive if there is pain with rotational movement on the
    medial or lateral joint line
    3. Suggestive of medial or lateral meniscal injury
    xi. McMurray Test for Medial Meniscal Tears
    Clinical Skills Study Guide

    xii. Apley’s Compression/ Distraction Test (Meniscal tear)

    xiii. Thessaly’s Test – Meniscal Pathology – The “Twist and Shout”


    Clinical Skills Study Guide

    Evidence Based Medicine – Dr. Olek

    Summary:
    - Definition:
    o Systematically developed statements to assist practitioner and patient
    decisions about appropriate health care for specific clinical circumstances
    - 3 dimensions of EBM:
    o Clinician training and experience
    o Judicious integration of science
    o Patient references and values
    - Steps for Implementing EBM
    o Assess: Your patient
    o Ask: Clinical questions
    o Acquire: The Best Evidence
    o Appraise: The Evidence
    o Apply: The evidence to patient care
    Type of Question Suggested Best Type of Study

    Therapy RCT > Cohort > Case control > Case series
    Diagnosis Prospective, Blind comparison to a gold standard
    Etiology/Harm RCT > Cohort > Case control > Case series
    Prognosis Cohort study > Case control > Case series
    Prevention RCT > Cohort > Case control > Case series
    Clinical exam Prospective, Blind comparison to gold standard
    Cost Economic analysis

    Skin – Dr. Manthei


    1. Discuss the key questions that make up a dermatologic history
    a. In general the questions should go as follows:
    i. History of Present Illness (HPI)
    ii. When did it start?
    iii. Does it itch, burn, or hurt?
    iv. When was the first episode?
    v. Where on the body did it start?
    vi. How has it spread (pattern of spread)?
    vii. How have individual lesions changed (evolution)?
    viii. What has made it worse or triggered it?
    ix. What have you tried for it? Did it help?
    x. Have you seen another medical professional for this?
    Clinical Skills Study Guide

    xi. Has the rash been biopsied?


    2. Explain the indications for a total body skin exam
    a. Reasons for TBSE
    i. To identify potentially harmful lesions, of which the patient is unaware,
    including:
    1. skin cancers, such as basal and squamous cell carcinoma, and
    melanoma
    2. pre-malignant lesions (actinic keratoses)
    ii. To reveal hidden clues to diagnosis
    1. e.g. psoriatic plaques on the buttocks or gluteal cleft
    iii. To inform your counseling to the patient on sun protective measures
    1. e.g. lentigines are a sign of sun damage and suggest the need for
    improved sun protection
    b. Indications for a TBSE
    i. Personal history of skin cancer
    ii. History of significant sun exposure or blistering sunburns
    iii. Increased risk for melanoma, such as
    iv. Two first-degree relatives with melanoma • Over 100 nevi (moles)
    • Red hair, skin phototype I
    v. Patient with concerning or changing growth
    vi. New rash on body
    vii. New patient with undiagnosed skin condition
    viii. Follow-up patients with extensive eruption such as psoriasis
    3. Recognize the need for patient comfort and modesty during this examination
    a. Undressed patients feel very vulnerable
    b. Avoid keeping them waiting too long while undressed
    c. Offer a second gown or blanket if it is cold
    d. Before untying a gown or moving it, ask permission
    e. Ask the patient to expose the area being examined, and cover the area after it
    has been examined
    f. Say out loud what part of the body you want to examine next
    i. e.g., “Okay, now let’s look at your chest and abdomen”
    ii. The patient will usually move the gown accordingly
    4. Develop a systematic approach to the total body skin exam
    a. Can also be integrated into a ROS exam during a wellness exam
    i. HEENT
    ii. Cardiac
    iii. Pulmonary
    iv. Abdomen
    v. Pelvic/Genitourinary exam
    vi. Extremities
    b. Systemic order approach (sitting/standing or lying down)
    i. Head and Neck
    1. Front and back
    Clinical Skills Study Guide

    ii. Arms
    1. Fingernails, palms, underarms
    iii. Chest
    iv. Abdomen
    v. Genital area
    vi. Legs
    1. Buttocks
    vii. Feet
    5. List the tools that can improve the quality of your skin examination
    a. Tools to use:
    i. Ruler: accurately records the size of a lesion on successive examinations
    ii. Handheld light: detects atrophy and fine wrinkling
    1. Distinguishes
    a. Flat from raised lesion
    b. Whether lesions are solid or fluid-filled
    c. Helps look inside the mouth
    iii. Magnification: may help detect fine details
    6. Quiz Questions and Answers (Double Check these for me please)*
    a. Which of the following is an indication for a total body skin exam?
    i. New patient with a wart on her right index finger
    b. Which of the following is true regarding patient modesty during skin exams?
    i. C. Doctors should ask permission before moving the gown to examine
    the next body part
    c. Which of the following is true regarding the order in which you perform a skin
    exam?
    i. C. You may use any order you want, but it’s better to do it in the same
    order each time
    d. What is the best way to examine the skin of a 5 year old?
    i. Perform the exam with the child sitting on the parent’s lap
    e. What is the best way to improve your skills with performing the skin exam?
    i. Perform full body skin exams on as many patients as possible during
    training

    Public Health I – Dr. Harris

    1. Understand just what is “Health” and how stressors affect it.


    a. Health is a state of complete physical, mental, and social well-being and not
    merely the absence of disease – WHO
    b. Eustress = helpful
    c. Distress = harmful
    2. What is Public Health and Preventive Medicine?
    a. Medicine
    i. Concern in the patient
    ii. Goal to heal the sick
    Clinical Skills Study Guide

    b. Public Health
    i. The public is the patient
    ii. Goal is preventing illness
    iii. Definition:
    1. “The science and art of preventing disease, prolonging life, and
    promoting physical health and efficiency through organized
    community efforts for the sanitation of the environment, the
    control of community infections, the education of the individual
    in the principles of personal hygiene, the organization of medical
    and nursing services for the early diagnosis and preventative
    treatment of disease, and the development of the social
    machinery which will ensure to every individual in the
    community a standard of living adequate for the maintenance of
    health.”
    c. Core Functions
    i. Assessment
    1. Epidemiology and statistics
    2. Social/ Behavioral sciences
    3. Environmental Sciences
    ii. Policy Development
    1. Social/behavioral sciences
    2. Environmental Sciences
    iii. Assurance
    1. Health policy management/ health administration
    d. Its impact upon Society
    i. Saves money and lives
    ii. Contributes more to the health of a population than medicine does
    e. Governmental role
    i. Role is determined by law
    ii. All states have public health mandates to promote the general welfare
    of their population
    3. Know the 5 Steps of Public Health intervention.
    a. Define
    i. The health problem
    b. Identify
    i. The risk factors associated with the problem
    c. Develop
    i. And test community level interventions to control/prevent the cause
    d. Implement
    i. Interventions to improve the health of the population
    e. Monitor
    i. Those interventions and reassess
    4. Understand the Natural History of Disease and Stages of Disease and how interventions
    fit within a Public Health/Disease Prevention framework.
    Clinical Skills Study Guide

    a. The Natural History is a disease course if NO INTERVENTION is taken at any


    time
    i. Predisease Stage
    1. Possessing various factors for risk of the disease
    ii. Latent (Hidden) Stage
    1. Disease process underway without symptoms
    iii. Symptomatic Stage
    1. Producing clinical manifestations
    b. Prevention types:
    i. Primary:
    1. Prevents an illness/injury from occurring by preventing risk
    factor exposure
    a. Modifying risk factors through
    i. Health promotion
    ii. Specific Protection
    ii. Secondary:
    1. Minimize the severity of illness after the exposure/development
    of illness
    a. Presymptomatic screening
    b. Case Finding programs
    iii. Tertiary:
    1. Minimize disability by providing medical care and rehabilitation
    a. Symptoms have occurred
    i. Disability management
    ii. Rehabilitation

    Biostatistics and Epidemiology – Dr. Olek

    1. Identify and describe variables:


    a. Independent vs dependent
    i. Independent variable = experimenter’s preference
    ii. Dependent variable = response variable
    b. Types of data (NOIR)
    i. Nominal (names only):
    1. Order not meaningful
    2. Dichotomous (Nominal with 2 levels)
    a. Example: personal biodata
    ii. Ordinal (Categories - names or numbers) with order:
    1. Intervals not consistent
    2. Example:
    a. How satisfied were you with your service?
    i. Very satisfied
    ii. Satisfied
    iii. Indifferent
    Clinical Skills Study Guide

    iv. Dissatisfied
    v. Very dissatisfied
    iii. Interval (numbers with order):
    1. Intervals are consistent but no true zero
    a. Examples:
    i. Temperature
    ii. Time
    iii. IQ test
    2. Ratio (numeric variables with consistent intervals):
    a. Examples:
    i. Multiple choice questions
    ii. Surveys
    c. Assess descriptive statistics (LoSR: Location, Spread, Relationships)
    i. Location (i.e. central tendency)
    1. Mean, median, mode, percent or count of a sample
    ii. Spread (i.e. variability around the location)
    1. Variance, standard deviation (SD), standard error (SE),
    interquartile range (IQR), range (maximum and minimum)
    iii. Relationships (among variables)
    1. Correlation coefficients (Pearson, Spearman, Point Bi-serial)
    2. Slope and intercept
    3. Contingency table
    2. Experiment types
    a. MoVeRS BLIND?
    i. Meaningful treatments and control
    ii. Variables:
    1. What are they?
    2. What kind?
    3. How many?
    4. Within or between people?
    iii. Randomized
    iv. Sample size
    v. Blinding
    b. Common experiment types (SMART CoCCCS)
    i. SMART:
    1. Series
    2. Systematic Review
    3. Meta-Analysis
    4. Randomized controlled Trial
    ii. CoCCCS
    1. Cohort
    2. Case Controlled
    3. Case Study
    3. Use inferential statistics to look for differences (UHTC)
    Clinical Skills Study Guide

    a. Understand the independent and dependent variables


    b. Hypothesize based on descriptive statistics
    c. Test to compare groups or find relationnships
    d. Conclude
    4. Understand the relationships among p-values, alpha, beta, and power
    a. P-value: P (your data if null hypothesis is true)
    i. P = 0.99: your data are verly likely when null hypothesis is true
    ii. P= 0.05: your data are quite unusual when null is true (GOOD)
    iii. P=0.0001: your data are extremely unusual when null is true (VERY
    GOOD)
    b. Type I error (alpha) – claiming an effect when none exists “false positive”
    c. Type II error (beta) – failing to find an effect which exists “false negative”
    Reality
    Ho true Ho false
    Statistics

    Ho true Correct Type II error (b) Real effect was missed

    Correct
    Ho false Type I error (a)
    (power)

    Statistical power
    Claim effect when none
    exists.

    d. Power = P(rejecting null | null false) = 1-beta


    i. What are your chances of seeing an effect which actually exists?
    1. Often set at 80%
    ii. Increase power by:
    1. Increasing alpha (Type I error)
    2. Lowering variation in the data
    3. Increasing effect size
    4. Increasing sample size

    Public Health II – Dr. Harris


    Clinical Skills Study Guide

    1. Know the 3 levels of prevention methods and examples of achieving them.


    a. See Public Health I for these definitions
    i. Primary
    1. 3 major goals
    a. Prevention of Specific disease: vaccinations, antimicrobial
    prophylaxis
    b. Prevention of Specific Deficiency States: iodized salt,
    fluoride in water
    c. Prevention of Specific Injuries and Toxic Exposure:
    Motorcycle helmet, goggles, ventilation filter
    ii. Secondary
    iii. Tertiary
    2. Understand indications and contraindications to vaccinations
    a. Not contraindication to vaccinations
    i. Previous mild reaction to DTP or DTaP (redness/swelling at site)
    ii. Temp. <105 F
    iii. Presence of nonspecific allergies
    iv. Mild illness/diarrhea with low grade fever in an otherwise healthy child
    who is scheduled for vaccination
    v. Current antibiotic use
    vi. Breastfeeding infant
    vii. Household contact who is pregnant
    3. Understand types of immunity.
    a. Passive: protection against an infectious agent provided by circulating
    antibodies made in another organism
    i. Maternal antibody
    ii. Human immunoglobulin
    iii. Antitoxin
    b. Sources:
    i. Blood or blood products
    ii. Homologous
    1. Pooled human antibody
    2. Human hyperimmune globulin
    iii. Heterologous hyperimmune serum (antitoxin)
    c. Active:
    i. vaccines confer active immunity by stimulating the production of
    humoral (blood) antibodies or by eliciting cell mediated immunity (NK
    cells)
    ii. Herd immunity
    4. Understand case finding vs. screening.
    a. Screening
    i. Process of identifying a subgroup of people in whom there is a high
    probability of finding symptomatic disease or risk factor for disease or.
    Injury (e.g. community screening)
    Clinical Skills Study Guide

    1. Positive test must be followed up with a more confirmatory test


    b. Case finding
    i. The process of searching for asymptomatic diseases or risk factors
    among people in a clinical setting.
    1. Example: preoperative chest x-ray
    5. Requirements for screening and recommendations and use of the US Preventative
    Services Task Force Guidelines.
    a. Minimum requirements for a community screening program
    i. Disease requirements
    1. Must be serious
    2. Must have effective therapy if detected
    3. Knowledge of the Natural History of the Illness
    4. Must not be too rare or too common
    ii. Screening test requirements
    1. Test must be reasonably quick, easy, inexpensive
    2. Test must be safe and acceptable to person being screened and
    the clinicians
    3. Sensitivity, specificity, positive predictive value and other
    operating characteristics must be known and acceptable.
    iii. Health care system requirements
    1. Follow up must be available for positive results
    2. Treatment must be available for known positives before
    screening
    3. Treatment for newly diagnosed
    4. Treatment is acceptable
    5. Clearly defined population being screened
    6. Who is responsible for the screening

    Epilepsy – Dr. Olek

    1. Be familiar with the epidemiology/etiology of seizures and epilepsy.


    a. Seizures: Transient disruption of brain cells due to abnormal and excessive
    electrical discharges in brain cells
    i. Provoked seizures (NOT considered epilepsy)
    1. Examples:
    a. Head trauma
    b. Drug/alcohol intoxication
    c. Metabolic disturbances such as hypo/hyperglycemia
    d. Stroke
    e. Fever
    ii. Epidemiology:
    1. Incidence: 80 / 100,000 per year
    2. Lifetime prevalence: 9%
    3. 30-70% recurrence rate over 3 years after a single seizure
    Clinical Skills Study Guide

    b. Epilepsy: disease of the brain that predisposes a person to recurrent


    UNprovoked seizures.
    i. Must have 2 or more UNprovoked
    ii. Third most common neurological disease
    iii. Incidence: 35.5-71/100,000 cases/year
    iv. Prevalence:: 5-8.4 per 1000 (1.2% of the population)
    2. Be familiar with the various type of epilepsies, their presentation, symptoms, diagnosis
    and treatment.
    a. See below.
    3. Know how seizures are classified.
    a. Partial
    i. Simple
    1. No loss of awareness
    2. May be followed by postictal depression
    a. Focal weakness
    b. Numbness
    3. Reversible neurologic deficits are collectively referred to as:
    a. Todd’s paralysis
    ii. Complex
    1. Starts focally in the brain and causes impaired consciousness
    a. Impaired consciousness/level of awareness (staring)
    2. Produces unresponsiveness
    3. Automatisms (manual, oral)
    a. Repetitive purposeless complex movements
    4. Amnesia for event
    b. Generalized
    i. Primary
    1. General tonic-Clonic (Formerly Grand Mal)
    2. Absence (Formerly Petit Mal)
    a. Brief staring
    3. Myoclonic:
    a. Brief shock-like muscle contractions
    b. Consciousness preserved
    c. Precipitated by awakening or falling asleep
    4. Atonic
    ii. Secondary generalized
    4. Know how to distinguish partial seizures from generalized seizures.
    a. See above
    5. Be familiar with the management of status epilepticus.
    a. A seizure that lasts greater than 5 minutes or 2 seizures close together that do
    not recover between seizure
    b. Status can be either convulsive or non-convulsive
    Clinical Skills Study Guide

    Art and Medicine – Dr. Olek

    Summary:

    1. Art can teach medical students observational skills


    2. The goal of bringing the arts into medical education is to improve the students visual
    diagnostic skills as well as their empathetic skills
    3. The arts program also helps students process the human tragedies they are exposed to in
    medical school

    Medical Jurisprudence – Dr. Havins

    Summary:
    Clinical Skills Study Guide

    1. HIPAA Basic Rule


    a. Protected Health Information may not be used or disclosed without authorization
    of the individual or the individuals personal legal representative.
    2. Health Information (HI):
    a. Created or received by a health provider
    b. Relates to the past, present, or future physical or mental health 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.
    3. Individually Identifiable Health Information (IIHI)
    a. Any HI where there is a reasonable basis to believe that it can be used to identify
    an individual.
    4. Protected Health Information (PHI)
    a. Individually IIHI which is or has been transmitted or maintained by a Covered
    entity.
    5. Covered Entities
    a. Health care providers
    b. Health plans
    c. Healthcare Clearinghouses
    6. HIPAA Privacy Rule
    a. Must disclose PHI in two situations (no authorization needed)
    i. to individuals (or the individual’s legal representative) when they request
    access to, or accounting of disclosures of, their PHI
    ii. to HHS when undertaking a compliance investigation or review of an
    enforcement action.
    b. Minimum necessary Requirement
    i. Unless authorized by the individual or otherwise required by law,
    disclosures or uses must be limited to those “minimally necessary” to
    accomplish to necessary function
    1. Example: billing information
    7. Violation Categories
    a. Did Not Know
    b. Reasonable Cause
    c. Willful Neglect, Corrected
    d. Willful Neglect, Not Corrected

    Endocrinology – Dr. Olek

    1. To learn how to recognize a patient with endocrine issues


    Clinical Skills Study Guide

    § May have a vague chief complaint


    § Fatigue
    § Not feeling well
    § May have multiple symptoms
    § May have a strong family history of an endocrine issue
    § May have multiple assessments/diagnoses
    § Will need a concrete plan with labs and follow up
    2. To list the main symptoms of hypo- or hyper-thryoidism
    § Higher/lower BMI (Body Mass Index)
    § Skin tenting
    § Dry skin
    § Thinning hair
    § Loss of lateral eyebrow
    § Slow/fast reflexes
    § Slow or fast heart rate
    § Blunted affect/anxious
    § Irregular menstruation
    § High cholesterol
    § High blood pressure
    3. To list the main symptoms of diabetes
    § Polydipsia
    § Polyphagia
    § Polyuria
    § Other:
    § Fatigue
    § Weight loss
    § Loss of muscle
    § Weakness
    § Dizzy
    § Excessive thirst
    § Frequent urination
    § Getting up at night to urinate
    § Slow healing
    § Frequent infections
    § Dizzy
    § Hunger
    § Yeast infections
    § Numbness
    § Pain in feet
    § Erectile dysfunction
    § Nausea/vomiting
    § Stool changes
    4. To introduce the physical exam findings
    § Vitals: Temp, BP, HR, RR, BMI
    Clinical Skills Study Guide

    § General
    § HEENT
    § Neck/thyroid
    § Cardiovascular
    § Pulmonary
    § GI
    § MSK
    § Neuro
    § Skin
    5. To review appropriate assessment
    § Example from slides:
    § Fatigue – possibly low thyroid
    § Dry Skin – possibly low thyroid
    § Constipation – possibly low thyroid
    § Cold intolerance – possibly low thyroid
    § History of depression
    § Family history of High Blood Pressure
    § Family History of Colon Cancer
    § Tobacco use
    § Elevated Blood Pressure
    § Low heart rate (bradycardia)
    § Thyromegaly
    6. To deduce an appropriate plan
    § Example from slides
    § 1. Labs
    § 2. Imaging – ultrasound
    § 3. Cardiac evaluation
    § 4. GI evaluation
    § 5. Blood pressure medication
    § 6. Smoking cessation counseling
    § 7. Follow up after labs

    Cardiac Palpation and Auscultation – Dr. Kalekas

    1. Prepare the student for clerkships and COMLEX/USMLE


    Clinical Skills Study Guide

    2. Understand the surface anatomy of the precordium and the cardiac cycle

    1st heart 2nd heart sound


    sound

    3. Understand depolarization and repolarization as it relates to systole and diastole and


    the ECG
    a. EKG measures electrical stimulation of the heart
    Clinical Skills Study Guide

    b. Depolarization: spread of electrical stimulation through the heart


    c. Repolarization: return of stimulated heart cells to resting state

    P wave – atrial depolarization


    (contraction)
    QRS – complex – ventricular
    depolarization (contraction)
    ST segment and T wave – ventricular
    repolarization (recovery)

    4. Be able to describe the heart as


    a pump
    a. Preload: volume of
    blood that stretches the
    ventricle before
    contraction (end
    diastolic volume).
    Preload is increased by
    blood volume expansion
    b. Afterload: degree of vascular resistance to ventricular contraction. Resistance is
    reflected by tone of the arterial walls and volume of blood in the vascular tree.
    c. Myocardial contractility: ability of the cardiac muscle (myocardium) to shorten
    (contract) when given a load.
    5. Estimate CVP from JVP measurements and observe venous pulsations of the internal
    jugular vein
    a. Venous pressure is also determined by blood volume and RV contractility and
    reflects Central Venous Pressure (CVP)
    b. Normal CVP (JVP): is 5-9 mm Hg or 0-4 cm above the sternal angle
    6. Evaluate the carotid pulse and differentiate it from jugular venous pulses. Auscultate for
    bruits.
    a. Internal jugular
    i. Rarely palpable
    ii. Soft, undulating, diphasic
    iii. Pulsations eliminated by light pressure
    iv. Level of pulsations positional
    v. Pulsations descend with inspiration
    b. Carotid
    i. Palpable
    ii. Firm, single component
    iii. Pulsations not eliminated with pressure
    iv. Pulsations unchanged with position
    v. Level unaffected by inspiration
    7. Palpate and auscultate the heart at the 4 cardinal posts
    Clinical Skills Study Guide

    a.
    8. Understand arterial impulses in terms of diameter, amplitude, and duration
    a. Diameter: measure the diameter of the impulse. Normal apical impulse is 2.5
    cm.
    b. Amplitude: the height, or strength of the impulse.
    c. Duration: how long during the cardiac cycle is the impulse. Normal apical
    impulse lasts 2/3rds of systole and does not continue to the second heart sound.
    9. Know basics of extra cardiac sounds and murmurs.
    a. Heart sounds S1 and S2 represent the closing of valves
    b. Closure of AV valves (tricuspid & mitral) produce the first heart sound (S1)
    c. Closure of semilunar valves (aortic & pulmonic) produce the second heart sound
    (S2)
    d. Splitting of S1
    i. Mitral component is louder than the tricuspid component
    ii. Heard best at tricuspid listening point
    iii. Does not vary with respiration
    iv. Is not pathological
    e. Splitting of S2
    i. Detected in 2nd or 3rd L interspace
    ii. Accentuated with inspiration, disappears with expiration
    iii. Normal finding
    f. Extra Heart Sounds
    i. S3 represents ventricular filling pathology and is caused by volume
    overload (Kentucky )
    ii. S4 represents atrial contraction and is caused by a pathologically stiff
    left ventricle (Tennessee)
    iii. Presence of an S3 or S4 creates a cadence like the gallop of a horse
    therefore are called gallop rhythms. A summation gallop signifies an S3
    and S4
    g. Other Heart Sounds
    Clinical Skills Study Guide

    i. Ejection sound (click): opening sound of the aortic or pulmonic valve due
    to pathology. High pitched sound heard best with the diaphragm in early
    systole
    ii. Systolic click: midsystolic click due to mitral valve prolapse. High pitched
    sound heard with the diaphragm at LLSB or apex, frequently followed by
    a ejection murmur
    iii. Opening snap: opening sound of mitral valve (rarely tricuspid) indicating
    pathology. High pitched sound heard best with the diaphragm in early
    diastole
    h. Murmurs
    i. Evaluated in:
    1. Timing
    a. Diastole
    b. Systole
    2. Shape
    a. Crescendo
    b. Decrescendo
    c. Crescendo-decrescendo
    d. Plateau
    3. Quality
    a. Blowing
    b. Harsh
    c. Rumble
    4. Radiation
    a. Traveling of murmurs to different areas
    5. Intensity
    a. Grade 1-6
    10. Learn how to record a normal cardiac exam
    a. Example cardiac exam recording
    i. The JVP is 3 cms above the sternal angle (CVP=8 mm Hg) with the head
    of the bead at 30 degrees. The jugular pulsations are diphasic and
    normal. The right and left ventricular impulses are normal in amplitude
    without heaves, lifts, or thrills. The PMI is tapping and just medial to the
    midclavicular line in the 5th intercostal space.
    ii. Heart is regular rate and rhythm without murmurs or ectopy. There are
    no extra heart sounds.

    Head and Neck – Dr. Olek

    1. Be familiar with the various causes of Headaches and be able to diagnose and treat each
    type.
    a. Headache
    i. Mnemonic: VOMIT
    Clinical Skills Study Guide

    1. Vascular: SAH (subarachnoid hemorrhage) , SDH (subdural


    hematoma), EDH (epidural hematoma), Temporal arteries
    2. Other causes: Malignant HTN, postlumbar HA,
    pheochromocytoma, pseudotumor cerebri
    3. Medications/drugs: nitrates, EtOH withdrawal, opioid
    abuse/medication overuse
    4. Infection: meningitis, encephalitis, abscess, sinusitis, zoster, fever
    5. Tumor
    ii. Mnemonic: VINDICATUM-P
    1. Vascular
    2. Infectious
    3. Neuro/Neoplasm
    4. Drugs
    5. Idiopathic
    6. Congenital
    7. Autoimmune
    8. Trauma
    9. Unknown
    10. Metabolic
    11. Psych
    iii. Caused by irritation of pain-sensitive structures
    1. Intracranial pain sensitive structures
    2. Extracranial pain sensitive structureS
    3. Important
    a. Neck pain can cause headaches!
    2. Be able to differentiate between the various types of headaches.
    a. Primary Headache Syndromes:
    i. Migraine Headaches
    1. Causes:
    a. Genetic predisposition
    b. Hormonal factors
    c. Stress
    2. Clinical features
    a. Recurrent
    b. Episodic
    c. Auras
    d. Pain***
    i. Usually gradual in onset.
    ii. Dull, deep, steady-when mild-moderate
    iii. Throbbing or Pulsating-when severe
    iv. Unilateral
    v. Frontotemporal
    vi. Accompanied by anorexia, nausea & vomiting
    Clinical Skills Study Guide

    vii. Photophobia(may be present). May seek a dark


    room.
    viii. Phonophobia (intolerant to sound)?
    ix. Olfactophobia (intolerant to odors)?
    ii. Tension-Type Headaches
    1. Most common type of headache
    2. Symptoms
    a. Steady diffuse pain
    b. Vicelike pressure
    c. Bilateral
    d. Frequently located in the neck
    e. Lasts for long periods
    f. No sensitivity to light or sound
    3. Treatment
    a. Thorough evaluation for anxiety or depression.
    b. Treat underlying cause.
    c. Symptomatic relief w/ NSAIDs, Tylenol, Relaxation.
    d. Improving posture, trigger point injections, OMM, etc.
    e. Tricyclic antidepressant drugs in low doses have proved
    the most useful for prevention.
    f. Massage, physiotherapy, acupuncture, Muscle relaxers
    g. Intramuscular botulinum toxin injections have been used
    successfully in both migraine and tension-type HA’s.
    iii. Trigeminal Autonomic Cephalgias
    1. Cluster Headaches***
    a. Epidemiology
    i. Relatively uncommon. Less than 10% of all
    headaches.
    ii. More common in men than women (unlike
    migraines).
    iii. Onset is usually in adults
    iv. One of many Trigeminal Autonomic Cephalgias.
    v. Extreme intensity!!
    vi. Precipitated by alcohol.
    2. Symptoms
    a. Ocular symptoms that are similar to Horner’s Syndrom
    i. Ptosis (littler eye)
    ii. Miosis (little pupil)
    iii. Anhidrosis (little sweat)
    iv. Intense pain
    v. Localized behind the eye (retro-orbitally)
    vi. Unilateral
    vii. Nasal congestion
    viii. Conjunctival injection (red, watery eye)
    Clinical Skills Study Guide

    b. Not relieved with resting in a dark environment


    c. Reoccurs frequently
    3. Diagnosis
    a. Thorough history and exam
    b. CT brain
    c. Spinal tap
    4. Treatment
    a. Preventative
    i. Beta blockers
    ii. Anticonvulsants
    iii. TCA’s
    iv. Calcium channel blockers
    b. Abortive
    i. Oxygen
    ii. Sumatriptan
    iv. Other Primary Headache disorders
    1. Note: There are NO structural or metabolic abnormalities with
    these types of HA
    b. Secondary Headache Syndromes:
    i. HA due to head/neck trauma
    ii. HA due to cranial/cervical vascular disorder
    iii. HA due to non-vascular intracranial disorder
    iv. HA due to substance or withdrawal
    v. HA due to infection
    vi. HA due to disorder of homeostasis
    vii. HA due to disorder of cranium, neck, ears, eyes, nose, sinuses, teeth,
    mouth or other facial or cranial structure
    viii. HA due to psychiatric disorder
    ix. Painful cranial neuropathies and other facial pain (Trigeminal,
    Glossopharyngeal, Occipital, Painful Optic Neuritis, et al)
    x. Other Headache Disorders not elsewhere classified or unspecified
    c. Additional Info Must Know Based on Lecture Slides
    i. Headaches may be found in all forms of cerebrovascular disease:
    infarction, TIA, ICB, SAH.
    1. Subarachnoid HA-”worst HA of my life”
    2. Meningitis-HA, fever, Neck stiffness.
    a. +Brudzinski’s (flexion at the hips when the head is flexed
    chin to chest).
    b. +Kernig’s signs (neck pain induced on attempted knee
    extension with hips flexed.)
    ii. Idiopathic intracranial HTN
    1. Benign Intracranial HTN or Pseudotumor Cerebri
    2. Population affected typically obese women
    iii. Giant-Cell Arteritis
    Clinical Skills Study Guide

    1. Diagnosis:
    a. ESR is elevated. Often > 100mm/hr.
    b. Anemia
    c. Temporal artery biopsy confirms dx.
    2. Treatment:
    a. IV Steroids (Prednisone) given promptly! Even before
    biopsy is done
    iv. Trigeminal Neuralgia
    1. Also known as Tic Douloureux.
    2. Caused by vascular compression of the trigeminal nerve root.
    (Which artery?)
    3. Paroxysmal, excruciating brief episodes of facial pain
    4. Unilateral in one of the divisions (2nd and 3rd) of the Trigeminal
    nerve.
    5. Lasts seconds but may occur many times a day for weeks.
    6. More common in women in middle to later life
    v. Postherpetic Neuralgia
    1. Follows Herpes Zoster
    2. Big key: Burning pain
    d. Questions out of this lecture (Review slides)

    Peripheral Vascular System – Dr. Zacharias

    1. Describe and classify the venous and arterial system of upper and lower extremity

    Arterial Pulses:
    o Brachial
    o Radial
    o Ulnar
    - Arterial vs Venous Anatomy
    Clinical Skills Study Guide

    Arteries (highlighted):
    - Intima: synthesizes thrombosis regulators
    - Media: dilate or constrict to accommodate blood pressure and flow
    - Adventitia: Comprised of connective tissue
    Veins:
    - Intima: thinner than in arteries
    - Media: thinner than in arteries
    - Adventitia: larger and thicker
    - Have valves
    2. Discuss differences of structure between arteries and veins
    a. See above.
    3. Discuss and grade edema
    a. Fair amount of pressure
    b. Pretibial
    c. Distal ankle
    d. Top of foot over bone
    4. Understand evolution of atherosclerosis and PAD
    a. An atheroma begins in the intima as lipid filled ‘foam cells’ (macrophages)
    b. The plaque progresses as smooth muscle cells migrate over the lesion causing
    ‘fatty streaks’
    Clinical Skills Study Guide

    c. At this point endothelial dysfunction has occurred as normal intimal functions


    are impaired
    d. The plaque may remain stable, forming a fibrous cap of smooth muscle cells
    and progress to a complex atheroma that remodels the vessel wall eventually
    narrowing the lumen
    e. Or the plaque may rupture and cause distal thrombosis or embolization

    5. Understand ABI testing and the values


    a. Evaluates difference in systolic pressures of the ankle and brachial blood
    pressure
    b. Patient is supine. Use Doppler
    c. Ankle systolic pressure over the brachial systolic pressure
    Clinical Skills Study Guide

    d. 0.9 or greater = normal


    e. <0.89 to >0.60 = mild PAD
    f. <0.59 to >0.40 = moderate PAD
    g. <0.39 = severe PAD
    h. 95% specific for lower extremity PAD
    6. Understand Virchow triad and signs of Deep Venous Thrombosis

    a. Homan’s sign for DVT***


    i. Unilateral swelling
    ii. Elevation improves symptoms
    iii. Dorsiflexion of the foot produces pain in the calf
    iv. Knee should be flexed
    v. Indicative of DVT
    vi. Note:
    1. Swelling, tenderness, Homan’s sign and postphlebitic syndrome
    or post-thrombotic syndrome: (Pain (aching or cramping),
    itching or tingling, swelling (edema), varicose veins, brownish or
    Clinical Skills Study Guide

    reddish skin discoloration, ulcer, stasis dermatitis. Occurs in up


    to 60% post DVT. Increased risk for PE.
    7. Understand evolution of varicose veins and post-thrombotic syndrome

    8. Understand evolution of arterial dissection

    9. Identify types of arterial dissection


    a. See above.
    10. Discuss and differentiate between pathological arterial pulse waves and their clinical
    significance
    a. Pulsus parvus et tardus
    Clinical Skills Study Guide

    i. Low amplitude with slow upstroke secondary to aortic stenosis


    b. Pulsus Alternans
    i. Beat to beat alternation in amplitude and intensity of pulse wave
    ii. A loud Korotkoff then soft
    iii. Left ventricular systolic dysfunction
    c. Pulsus paradoxus
    i. Loss of pulse during inspiration
    ii. Increase in negative intrathoracic pressure
    iii. i.e. cardiac tamponade, constrictive pericarditis or severe lung disease
    d. Water hammer pulse
    i. Bounding 4+ pulse followed by immediate collapse of vessel (wide pulse
    pressure) from aortic regurgitation

    Preventative Medicine – Dr. Olek

    1. Encourage Focus on Prevention


    1. Prevention is Better than a Cure
    2. Levels
    1. Primordial
    1. Alter societal structures
    2. Primary
    1. Avoidance/Prevention of disease or injury
    3. Secondary
    1. Early detection and treatment
    4. Teritary
    1. Reduction of disability and prompt rehabilitation
    2. Identify Basic Health Screening Principles::
    1. Principles
    1. Perform Disease Screening (BP, CHOL, GLU, Colonoscopy, HIV and other
    STD’s, Mammography, Pap test, Bone Density Scan for osteoporosis,
    Certain genetic testing [Breast or Ovarian CA])
    2. Identify Risk Factors
    3. Discuss Healthy Diet
    4. Discuss Exercise
    5. Stay Up To Date with Immunizations
    2. All Ages (Annually):
    1. HTN screen
    2. Diabetes screen
    3. Cognitive Health screen
    3. Age 20+ Cervical Cancer Screening (Every 3-5 years)
    1. Women 21-29: Pap test every 3 years
    2. Women 30-65: Pap and HIV every 5 years
    3. Women 65+: Consider screen based on medical history
    4. Age 40+ Mammogram (Every 1-2 years)
    Clinical Skills Study Guide

    1. Women 45-54: Annual screening mammogram


    2. Women 55+: Mammogram every other year if no history of symptoms
    5. Age 50+ Lung and Colon Cancer Screening (Annual for Smokers)(Colon screen
    every 10 years)
    1. Men and Women 55-80 who smoke or quit within the past 15 years: CT
    scan
    2. Men and Women 50-75: Average risk patient should have colonoscopy
    every 10 years
    6. Age 65+ Osteoporosis Screening (Every 2 years)
    1. Women under 65: Talk to physician about risk factors
    2. Women 65+: Bone density scan every 2 years
    3. Discuss the role of EBM
    1. See Evidence Based medicine lecture for role
    4. Define the USPSTF grading system
    1. Uses EBM to give grades to guide preventative services
    1. Grade A-Strongly recommend
    2. Grade B-Recommend
    3. Grade C-Recommends selectively
    4. Grade D-Recommend against
    5. Grade I-Insufficient evidence
    5. Implement Wellness Intervention
    1. Five modes of Intervention
    1. Health Promotion
    2. Specific Protection
    3. Early Diagnosis and Treatment
    4. Disability Limitation
    5. Rehabilitation
    6. Discuss counseling and delivery to the patient (EPA #8)
    1. Give or receive a patient handover or transition of care responsibly #8 of the
    Core Entrustable Professional Activities.
    7. Describe New Federal Initiatives
    1. Could not find in lecture slides.
    8. Demonstrate USPSTF-related Resources (EPA #13)
    1. Identify system failure and contribute to a culture of safety and improvement
    (EPA #13)
    2. USPSTF-related resources
    i. www.ahrq.gov/clinic/pocketgd.htm
    ii. www.epss.ahrq.gov
    iii. www.uspreventiveservicetaskforce.org

    Review of routine Normative Medical Data – Dr. Olek

    1. Review basic laboratory examination


    a. Serological Testing
    Clinical Skills Study Guide

    i. CBC
    1. WBC
    2. RBC
    3. HGB
    4. HCT
    5. PLT
    ii. CBC with Differential
    1. Neutrophils
    2. Lymphocytes
    3. Monocytes
    4. Eosinophils
    5. Basophils
    iii. CHEM-8 or Basic Metabolic Panel
    1. Sodium
    2. Potassium
    3. CO2
    4. Chloride
    5. BUN
    6. Creatinine
    7. Glucose
    8. Calcium
    iv. CHEM-14 or Comprehensive Metabolic Panel
    1. BMP Plus
    a. Albumin
    b. Total protein
    c. ALP
    d. ALT
    e. AST
    f. Bilirubin
    v. Lipid Panel
    1. Tot. Cholesterol
    2. HDL
    3. LDL
    4. Triglycerides
    5. VLDL
    vi. Urinary Testing
    vii. Thyroid Panel
    1. TSH
    viii. Arterial Blood Gas
    1. pH
    2. PaO2
    3. PaCO2
    4. O2 Saturation
    5. O2 Content
    Clinical Skills Study Guide

    6. HCO3
    7. Base excess/deficit
    ix. Routine CSF
    2. Review basic imaging techniques
    a. CXR
    i. PA
    ii. AP
    b. CT
    c. MRI
    d. Ultrasound
    3. Review basic diagnostic tests
    a. ECG / EKG
    4. Review basic ancillary tests
    a. Spirometry
    5. Identify when to order certain tests
    a. Chest CT with Contrast Indications
    i. Aortic Aneurysms
    ii. Aortic Dissection
    iii. AVM
    iv. Superior Vena Cava Syndrome
    v. PE
    b. Brain CT Indications
    i. Trauma-Head CT without contrast
    ii. Stroke-Head CT without contrast first, if NEG may go to MRI
    iii. NPH/hydrocephalous-head CT without contract
    iv. Metastatic Lesions-Head CT with contrast
    v. Infection-head CT with contrast
    c. Spine Imaging Indications (CT)
    i. Low back pain or degenerative disease-MRI is best
    ii. Disease of osteophytes or presurgical planning-CT is best
    iii. Spondylosis/Pars defect-stress fx
    iv. Can use CT but MRI is better
    d. Cranial Imaging Indications (MRI)
    i. Vascular (ischemic and hemorrhagic stroke, AVM, aneurysm, venous
    thrombosis)
    ii. Tumor (primary CNS and metastatic)
    iii. Infection (abscess, cerebritis, encephalitis, meningitis)
    iv. Inflammatory/Demyelinating Lesions (multiple sclerosis, sarcoidosis,
    etc.)
    v. Trauma (epidural hematoma, subdural hematoma, contusion)
    vi. Hydrocephalus
    vii. Congenital Malformations
    e. Pelvic and Abdominal Pathology (Ultrasound)
    Clinical Skills Study Guide

    i. Useful in the evaluation of masses in the: Liver, Spleen, Pancreas and


    Pelvis
    ii. Excellent for the evaluation of the biliary tract
    iii. Also good for detecting ascites
    iv. Useful in pregnancy-No radiation
    v. Can be used for those who cannot tolerate IV contrast
    f. See summary table below
    Modality Terminology Contrast Radiation Prep Contraindications/
    medium Problems

    X-ray Opacity vs Lucency Iodine (e.g. IV Yes None Pregnancy (relative)


    pyelogram)

    CT Attenuation/Density Iodine Yes Hydration Renal impairment, Pregnancy


    (low eGFR) (relative)

    MRI Signal intensity Gadolinium No Remove Metals, Electronics,


    piercings Claustrophobia

    Ultrasound Echogenicity Air No Full bladder Body habitus, Operator skill


    (‘microbubbles’) (gynae scans)

    Nuclear Uptake Radioactive Yes None Pregnancy, Breastfeeding


    labelled ‘tracer’

    Fluoroscopy Filling defect Barium/Air/ Yes NBM/Bowel Poor mobility


    Gastrografin prep

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