Download Block 6 Standardized Patient Study Guide

Block 6 Standardized Patient Study Guide
Subjective: think OLDCARTS, SMASH-FM (FEDTACOS) and ROS (i.e. what the patient tells you)
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History of Present Illness (HPI) = think OLDCARTS
o Onset – How did this happen?
o Location – Where is the pain/discomfort/lesion?
o Duration – How long has this been going on?
o Characteristics – What does it feel like (burning, itching, painful, etc.)?
o Aggravating/Alleviating
 What makes it better?
 What makes it worse?
o Radiate – Where does the pain/discomfort spread to?
o Temporal – What time of day does this bother you more?
o Severity
 On a scale of 1 to 10, with 10 being the worst pain/discomfort you’ve ever felt in
your life and 1 being you notice it but can still go about your day to day
activities, how would you classify it right now? At its worst?
o NOTE:
 When asking these questions, be sure to phrase them in an OPEN-ENDED
format
 Depending on what the patient’s chief complaint is for this SP, you may be able
to get away with skipping this and thus save time for later
 Ex.) patient may be coming in for a well-exam and may mention to you
interest in starting or switching their current form of birth
control/contraception
Patient History = think SMASH-FM and FEDTACOS
o Social Hx
 Food – What is your diet like?
 Exercise – What is your current exercise regimen?
 Drugs – Do you currently use any illicit drugs or medications not prescribed to
you?
 Tobacco – Do you use tobacco? If so how often do you smoke?
 Have you ever considered cutting back or stopping?
o If so we have some materials that we could provide you with to
help in this.
 Alcohol – Do you consume alcohol? If so how much would you say you drink?
 Have you ever considered cutting back or stopping?
o If so we can provide you with some educational materials that
may be useful.
 Caffeine – Do you drink caffeine, such as coffee or tea? If so how much?
 Occupation – What do you do for a living?
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Sexual History – Are you sexually active? Monogamous?
 To be continued later on in the interview
Medical Hx – What medical conditions do you have that I should be aware of?
Allergies – What are you allergic to? What happens when you take/are exposed to this?
Surgical Hx – What surgeries have you had? When was this? Were there any
complications from this?
Hospitalization Hx – What have you been hospitalized for? When was this?
Family Hx – What medical conditions run in your family, if any? Are mom and dad still
living?
Medications – What medications are you currently taking (both Rx and OTC)? Verify
what medications are used for if unsure?
Sexual and Relationship History (This part is new!)
 Current sexual status
 Are you sexually active? Are you monogamous (both them and their
current partner(s) ) ?
o Same as for S in FEDTACOS
 Are you heterosexual, homosexual or bisexual?
 Activity type
 What form of sexual intercourse do you engage in?
o Vaginal, Anal, Oral, etc.
 Frequency
 How often do you engage in intercourse?
 Complaints with current sexual status?
 Do you experience pain with sex (dyspareunia)?
 Do you notice any bleeding during or after sex?
Female Reproductive and Obstetric History (This part is new!)
 Chronologically review ALL prior pregnancies
 Including any losses or any positive pregnancy test
 G and P status
 GPTPAL
o G (gravidity)
 Have you ever been pregnant? How many times?
o P (parity)
 Have you ever given birth? How many times?
 Term – how many births were term deliveries?
o Term – after 37 wks gestation
 Pre-Term – how many births were pre-term?
o Pre-Term – between 20 and 37 wks
gestation
 Abortions – how many were abortions?
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Abortion – any loss before 20 wks
gestation (regardless of how: voluntary,
miscarriage, etc.)
 Living – how many are still living?
 Dates and gestational age at birth
 What day(s) did you deliver?
o How far along was the child?
 Type of delivery
 What type of delivery was it?
o Vaginal? C-section?
 Gender
 Was it a boy or girl?
 Birth Weight
 How much did they weigh?
 Pregnancy complications
 Were there any complications during the course of the pregnancy?
o Ex.) HTN, gestational diabetes, preeclampsia, eclampisa, preterm, etc.
Other Histories (not specifically mentioned in the objectives but who knows?)
o Menstrual History
 Age of menarche (first menses)
 When was your first menstrual cycle?
o Average – 12-13 yrs old
 Interval between periods
 How long do each of your menstrual cycles last?
o Range: 21-35 days
 Average: 28 days
 Duration of menses
 How many days do you menstruate?
o Average: 5 days
 Character of bleeding
 How would describe your menstrual flow?
o Light, heavy, clots present, bleeding between periods, etc.
 Associated pain (dysmenorrhea)
 Do you experience any pain with your menstrual cycle?
o How would you describe it?
 ALWAYS ASK AND DOCUMENT THE LAST MENSTRUAL PERIOD!!!!
o Pap History
 When was your last pap smear?
 What were the results of this?
 Have you ever had an abnormal pap smear?
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 When was this?
 What was abnormal about it (what did the doctor say)?
 What treatment did you receive for this?
 How have your pap smears been since this incidence?
o Contraceptive History
 Type/Duration of prior contraceptive methods
 What forms of contraception have you used in the past?
o Name, dosage, frequency, etc.
 How well did each method work, in regards to:
 Pregnancy prevention
o Did you become pregnant while on the contraception?
 Menstrual regularity
o What changes (if any) did you note in your menstrual cycle?
 Bleeding profile
o What changes (if any) did you notice during menstruation?
 Complications
o What complications did you experience while on the
contraception?
 Examples include:
 Unintended pregnancy
 Infection
o Especially if using IUD or implantable
device
 Thrombotic events (DVT, PE, etc.)
Review of Systems
o General
 Have you experienced any unexpected weight loss/gain? Fever? Chills?
o MSK
 Have you noticed any unusual muscle or joint pain?
o Cardiac
 Have you experienced any recent chest pains? Any palpitations (explain that this
is the sensation of your heart beating out of your chest)?
o Pulmonary
 Have you noticed any shortness of breath?
o GI
 Have you experienced any nausea, vomiting or diarrhea?
 Have you been aware of any abdominal pain or discomfort?
o GU/Reproductive
 Female
 Have you noticed any abnormal vaginal bleeding or discharge?
 Male
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Have you noticed any discharge or bleeding from the penis?
Objective: think physical exam findings (what you discover in the course of the encounter)
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Discuss patient’s vital signs (which you got from the door note)
o Vital signs:
 Temperature
 Normal (oral): 98.6 F
 True fever: 100.5 F or higher
 Blood pressure
 Normal: 120/80 or below
 HTN: 140/90 or above
 Respiratory rate
 Normal: 12-20 breaths/minute
 Heart rate (pulse)
 Normal: 60-100 beats per minute
Cardiac/Pulmonary Exam
o Inspection:
 Lower patient gown to expose chest and back
 Examine ANTERIORLY and POSTERIORLY
 Note any scars, moles, asymmetry, abnormal hair patterns, rashes,
masses, bruising, etc.
o Auscultation
 Heart = 5 listening posts
 Stand to the RIGHT of the patient
 Two heart sounds:
o S1 = due to CLOSURE of tricuspid and mitral valves (lub)
o S2 = due to CLOSURE of aortic and pulmonary semilunar valves
(dub)
 Listening posts: (right and left refer to PATIENT’S right and left)
o Aortic = right 2nd intercostal space
o Pulmonic = left 2nd intercostal space
o Tricuspid = 5th intercostal space along left sternal border
o Mitral = 5th intercostal space along mid-clavicular line
 Erb’s Point:
o Where S2 heart sound is the LOUDEST
o Place stethoscope in the left 3rd intercostal space next to the
sternum
 Note for any murmurs/rubs/clicks or RRR (regular rate and rhythm)
 Lungs
 Stand to RIGHT of patient
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Auscultate using the DIAPHRAGM of your stethoscope and tell your
patient to open their mouth and take deep, quiet breaths in and out
Listen to two positions anteriorly (and bilaterally)
o First spot should be at the apices of the lungs (above the
clavicles)
Listen to two positions laterally (and bilaterally)
Listen to three positions posteriorly (and bilaterally)
Note any:
o Wheezes:
 High-pitched, musical sound
 Inspiration or expiration
 Think asthma, chronic bronchitis
o Rhonchi:
 Deep, bubbling sounds due to secretions/airway
narrowing
 Expiration, clears w/coughing
 Think bronchitis or other diseases that generate
secretions
o Rales/crackles:
 Rice crispy treats, hair rolled between fingers
 Inspiration
 Think CHF, pulmonary fibrosis, chronic bronchitis, etc.
o Stridor:
 Think croup, epiglottitis, foreign bodies, trauma, etc.
 Follow up with X-ray
Abdominal Exam
o Inspection
 Look for:
 Bruising, erythema, scars, masses, jaundice, distended veins, hernias
 Abdomen: asymmetry, distension, peristaltic waves, ascites, striae
o Auscultation (do BEFORE percussion and palpation)
 Listen in ALL 4 QUADRANTS for bowel sounds
 Normal: high pitched sounds heard every 5-10 seconds
 Borborygmi: low pitched rumbling sounds due to gas moving through
intestines
 Listen over epigastric region for bruits
 May indicated renal artery stenosis
o Percussion
 Listen for resultant sounds in ALL 4 QUADRANTS
 Distinguish between
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Tympanitic = drum like sounds produced by percussing over AIR filled
structures
 Dull = dull sounds heard over SOLID structures or FLUID over percussed
area (ascites)
 Pain with percussion = inflammation
o Palpation
 Light and deep palpation in ALL 4 QUADRANTS
 Light palpation
o Identify muscle spasm and tenderness
o Use flat part of hand or finger PADS (not tips)
 Deep palpation
o Estimate organ size, detect masses
o Use flat part of bottom hand with upper hand exerting force
with finger tips
 Rigidity
o INVOLUNTARY spasm of abdominal wall
 Think diffuse/localized peritoneal irritation
 Guarding
o VOLUNTARY or INVOLUNTARY muscle spasm
 Rebound tenderness
o Deep/slow palpation in area AWAY from pain site, remove
palpating hand and painful sensation is elicited at pain site
 Think peritoneal irritation
Osteopathic Exam
o During palpation, you can note any TART changes:
 T = tissue texture change
 A = asymmetry
 R = restricted range of motion
 T = tenderness
o Palpate anteriorly and posteriorly for Chapman’s Points:
 Chapman’s Points:
 Smooth, small, firm, discretely palpable nodules
 Pinpoint, non-radiating, sharp, fairly distressing pain that is elicited
upon palpation
 Anterior Chapman’s Points:
 Cardiac:
o 2nd and 3rd intercostal spaces (bilaterally)
 Next to sternum
 Pulmonary: (also next to sternum)
o 2nd intercostal space = bronchus
o 3rd intercostal space = upper lung
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o 4th intercostal space = lower lung
 Posterior Chapman’s Points:
 Cardiac:
o Transverse process of T2 and T3
 Remember to distinguish C7 from T1:
 Find first prominent bump on back of neck
 Have pt flex/extend neck
 C7 will disappear, T1 will not
 Pulmonary:
o T2 transverse process = bronchus
o T3 transverse process = upper lung
o T4 transverse process = lower lung
 GI Chapman’s Points
 Proximal stomach
o Acidity = left 5th intercostal space
o Peristalsis = left 6th intercostal space
 Pyloric sphincter = center portion of sternum
 Liver = right 5th/6th intercostal space
 Gallbladder =right 6th intercostal space
 Pancreas = right 7th intercostal space
 Small intestines = medial 8th-10th intercostal spaces
 Appendix = distal tip of right 12th rib
 Colon = iliotibial bands
o Remember it’s like the colon was flipped out of the body
 Superior colon is low on IT band
 Inferior colon is high on IT band
 Celiac ganglion = right underneath the xiphoid process
o Innervates foregut
 Superior mesenteric ganglion = halfway between xiphoid process and
umbilicus
o Innervates midgut
 Inferior mesenteric ganglion = right above umbilicus
o Innervates hindgut
Discuss and document deferral of intimate exams (this is new!)
o Female = pelvic and breast exams
o Male = urogenital and rectal
o Example:
 At this time, normally I would go ahead and perform …. but given the nature of
your visit I think it’s okay to defer that until a future visit.
Assessment
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Primary Diagnosis
o Either Health Maintenance or Well Visit
Secondary Diagnosis
o Examples:
 Smoking, DM, HTN, asthma, obesity, etc.
Plan
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Medications:
o Should the patient continue their current medications and/or do you give them new
meds?
 Include name, dosage, route, frequency
o As of right now Mr/Mrs. Smith, I think we should continue you on your current
medications, as long as you aren’t having any problems.
OMM
o What is OMT? Is it indicated in this patient or can it be deferred? If indicated, what
would you do?
o Now as osteopathic physicians we do have at our disposal some manipulative medicine
techniques called OMT. Are you familiar with this? No well it’s a series of tissue/joint
manipulations that are designed to help get your body in proper alignment and
orientation so that it can better aid in the healing process.
 However given that this is just a well exam, I don’t think it is necessary at this
time. But if you are interested in the future, we can come up with a treatment
regimen for you depending on your complaint.
Tests
o Includes imaging AND labs
 Should be age appropriate and relative to the patient’s complaint (which in this
setting of a well exam are probably not necessary)
o Example:
 Pregnancy test before starting contraception
 Now Mrs. Smith, what we typically like to do before starting any female
on contraceptive therapy is to get a pregnancy test. We do this just to
have documentation on record that you aren’t pregnant before starting
you on a new form of birth control or changing your existing regimen.
 HIV test? STD tests (chlamydia, gonorrhea, syphilis, etc.)?
Holistic
o Ask if patient agrees/is compliant with the recommended course of treatment. Ask if
they have any questions/concerns about what you’ve discussed with them today. Check
and see if they have a support system they can rely on. Ask if they require a note for
work or school.
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Does this seem like a suitable course of action with you? Do you have questions
or concerns about what we’ve discussed here today? Do you have somebody at
home that can help/assist you should you need it? Do you need a note for work
or school?
Education
o Counsel patient about diet, exercise, smoking/alcohol/drug cessation based on results
from earlier interview
o Three forms of birth control (this is new!) Include: method, fail rates,
AE/complications
o Discuss Safe Sex Practices (this is new!)
Forms of Birth Control
o Typical vs Perfect Use
 Perfect Use
 % of pregnancies that occur with correct and consistent use
 Typical Use
 % of pregnancies that occur in couples that use the method correctly
and consistently PLUS those couples who do not
o Oral Contraceptive Pill (OCP)
 Advantages:
 Effects are reversible, decreased pain with ovulation/menses
(dysmenorrhea)
 Decreased menstrual flow
 Decreased risk of ovarian/endometrial cancer
 Disadvantages:
 Lack of protection against sexually transmitted infections (STIs)
 Headaches, nausea/vomiting
 Hypercoagulable state
o Increased risk of VTE (DVT, PE)
 Contraindications:
 DVT/PE, CAD/CVA, DM w/vascular disease, breast cancer, liver
adenoma/hepatitis/cirrhosis
 Migraine HA w/aura
 Over 35 yrs old and a heavy smoker
o If younger than 35 use LOW DOSE estrogen (20 mcg)
 BP > 160/100
 Surgery w/prolonged immobilization
 Failure Rates
 Perfect Use: 0.3%
 Typical Use: 9%
 If you go with OCP, use MONOPHASIC
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Constant dose of estrogen & progesterone for 21 days followed by a 4or 7-day pill free
 Less complicated, more flexible
 Easier to identify and rectify side effects
 Example: ethinyl estradiol + levonogestrel
 Take OCP at the SAME TIME EVERY DAY
 Warn them that AEs may occur during the first three months/cycles but
should decrease after that
Condoms
 Advantages:
 STD prevention
 Inexpensive/over the counter
 Non-hormonal
 Disadvantages:
 Reported decreased sensation
 Latex allergy (not as big a deal b/c they now make latex-free)
 Tear, break, slip
 Outer ring can be cumbersome
 Insertion skill
 Failure Rates:
 Perfect Use: 2%
 Typical Use: 17%
 Complications:
 Allergic reaction (if allergic to latex and using a latex condom)
 Unintended pregnancy (if condom breaks, tears or slips)
The Patch
 Norelgestromin + ethinyl estradiol
 Apply one patch per week for 3 weeks, then a patch-free week
 Application sites: upper arm, buttocks, lower abdomen and upper torso (not
breasts)
 Disadvantages/AEs:
 Spotting highest in the 1st two months
 Adhesive intolerance
 2.8% partially detached
 1.8% completely detached
 Breast discomfort (18.7% v 5.8% w/OCP)
 Dysmenorrhea (13.3% v 9.6% w/OCP)
 Average estrogen concentration 60% higher than common oral
contraceptives
o may increase the risk of adverse events, including venous
thromboembolism (VTE)
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Same precautions and contraindications as for OCP
Failure Rates:
 Perfect Use: <1%
 Typical Use: 8%
o Mirena IUD (intrauterine device)
 Releases 20 mcg per day of levonorgestrel
 Advantages:
 Compliance not an issue
 Good for 5 years, low failure rate
 Shorter, lighter periods (amenorrhea rates of 20% at one year)
 Disadvantages:
 Cost, professional insertion
 Irregular bleeding, dysmenorrhea
 Possible increase in PID (<1%)
 If pregnancy occurs, 25-40% ectopic
 Failure Rates:
 Perfect Use: 0.1%
 Typical Use: 0.1%
Safe Sex Practices
o If you are a female and use NO FORM of contraception, you have an 85% chance of
becoming pregnant
o Regardless of what form of contraception you use, condoms or other means of barrier
contraception should be used as an adjunct since they are the only form of
contraception shown to decrease risk of STDs, HPV, HIV, etc.
o The greater the number of sexual partners you have, the higher your risk of acquiring an
STI
 This also goes along with the number of times you engage in intercourse
without barrier contraception
o Should you or your partner contract an STI, the other partner should also be assessed
and treated for the STI as well
o The two biggest risk factors for PID (pelvic inflammatory disease) are infections with
chylamidia and gonorrhea
Referral
o Potential referral to OBGYN
 At this time, I believe that we can take care of your situation here at our office
and that we don’t need to refer you to an OBGYN. Should things change, we can
always refer you to them at a later time.
Return to visit/Follow up
o Discuss when you want the patient to return for follow-up. What they should do in the
meantime if they have any questions or concerns or if their symptoms should worsen.
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Okay then Mrs. Smith I’d like to see you back in about a month. At that point we can go
ahead and assess how things are going and what changes if any need to be made. In the
meantime if you have any questions or concerns, feel free to call the office or come
back in. If for some reason you can’t reach us and you develop symptoms or concerns,
go ahead and go to the emergency room.
Recheck to make sure the patient has no comments/questions/concerns and conclude the
encounter