Introduction Learning Objectives Students will practice skills they need for office-based clinical rotations 1. Focused history and physical exam 2. Oral presentation to preceptor Students will practice giving and receiving feedback Students will have fun in a setting that is supportive and familiar
What will you do this afternoon? Form into groups of 4-5 students and interact with 4 cases in the Assessment Center Rotate the tasks within your group so everyone can learn Each case takes 30 minutes. There is a rest break after the first 2 cases Everyone gather in the Assessment Center classroom for a brief summary session after last case Division of Labor in the Groups In station number 1, student A will ask a history and if necessary, perform a focused exam. Student B will give feedback to student A. Student C will present the case to the faculty preceptor. Student D will act as a timekeeper. In station 2, student B will now take the history, while student C gives the feedback and so on. Approximate Schedule for Each Case Each station is allotted 30 minutes. The timekeeper should help keep track of the time. We assume that the history (and physical if indicated) will take no more than 15 minutes, student feedback 2-3 minutes, faculty and/or SP feedback 2-3 minutes, the presentation 3 minutes, and more faculty feedback to complete the time. General Approach to the Interview
Greet the patient and establish rapport Invite the patients story Establish the agenda for the interview Generate and test hypotheses about the nature of the problem(s) by expanding and clarifying the patients story Create a shared understanding of the problem(s) Negotiate a plan (i.e., diagnostics, treatment, education) Plan for follow-up and close the interview
What are the cases about? Adolescent with weight gain Adolescent soccer player with knee pain Young adult with alcohol overuse Older adult with newly diagnosed diabetes How should I approach the interviews? Read the door chart first and plan it out Use your existing interview skills and the cheat sheets distributed before lunch today Next 4 slides show the 4 cases and the approach to each case Adolescent soccer player with knee pain
Location. Where is it? Does it radiate? Quality: what is it like? Quantity or severity: how bad is it? Timing: when did it start? How long does it last? How often does it come? The setting in which occurs What makes it better or worse? Associated manifestations
Adolescent with weight gain
HEADDS Home: Where do you live? Who lives with you at home? If the teen lives with one parent: How often do you see the parent who does not live with you? What do you do together? What types of responsibilities do you have at home? Education: What year in school are you? What kind of grades do you make? How are you doing in school? How often do you miss school? What do you want to do when you finish school? Activities: What do you like to do when you are not in class or working? What do you do for fun? What kind of exercise or organized sports do you do? Have you been injured in sports? How much time each week do you spend watching television or videos? Playing video games? Surfing the Net? Do you work? How many hours per week? Diet: How do you feel about your weight? Are you trying to change your weight? Have you gained or lost weight recently? Drugs: Do you take any nonprescription drugs, vitamins, supplements, or health foods? Do you use any alternative medicine treatments (e.g., herbs, acupuncture, massage)? Do any of your friends smoke cigarettes or chew tobacco? Do any of your friends drink alcohol? Have they tried other drugs? Have you ever tried smoking cigarettes? Do you still smoke? Have you drunk alcohol in the past month? What is the most you have ever had to drink at one time? Have you ever done anything you later regretted after drinking? Do you use other drugs? How often? Have you ever been in a car where the driver was drinking or on drugs? Have your friends ever tried to pressure you to do things that you dont want to do? How did you handle that? Are you worried about any friends or family members and how much they drink or use drugs? Sex: Do you date? Are you thinking about going out with men, women, or both? Do you have a steady partner? Are you happy with dating/this relationship? Do you have any worries or questions about sex or sexual orientation? Have you ever had sex before? On what will you/do you base your decision to have sex? Have you ever been pregnant (or gotten someone pregnant?)? Have you ever had a sexually transmitted infection? Do you use any kind of birth control? Did you use a condom the last time you had sex? Has anyone ever touched you in a way you didnt like? Forced you to have sex? Suicide: What do you do make yourself feel better when you are down or upset? Do you ever feel really down and depressed? Have you ever thought about hurting yourself or killing yourself? Do you sometimes think life isnt worth living anymore?
Young Adult with Overuse of Alcohol Screening question: For females, how many times in the past year have you had 4 or more drinks in a single day? For males, how many times in the past year have you had 5 or more drinks in a single day? Never (0) Once (1) More than once (2) Scores of >1 lead to follow-up with AUDIT 10
AUDIT 10
How often do you have a drink containing alcohol? Never (0);Monthly or less (1);2-4 times per month (2);2-3 times per week (3);4 or more times week (4) How many drinks containing alcohol do you have on a typical day when you are drinking? 1 or 2 (0);3 or 4 (1);5 or 6 (2);7 to 9 (3);10 or more (4) How often do you have six or more drinks on one occasion? Never (0);Less than monthly (1);Monthly (2);Weekly (3);Daily or almost daily (4) How often during the last year have you found that you were not able to stop drinking once you had started? Never (0);Less than monthly (1);Monthly (2);Weekly (3);Daily or almost daily (4) How often during the last year have you failed to do what was normally expected of you because of drinking? Never (0);Less than monthly (1);Monthly (2);Weekly (3);Daily or almost daily (4) How often during the last year have you needed a drink first thing in the morning to get yourself going after a heavy drinking session? Never (0);Less than monthly (1);Monthly (2);Weekly (3);Daily or almost daily (4) How often during the last year have you had a feeling of guilt or remorse after drinking? Never (0);Less than monthly (1);Monthly (2);Weekly (3);Daily or almost daily (4) How often during the last year have you been unable to remember what happened the night before because of your drinking? Never (0);Less than monthly (1);Monthly (2);Weekly (3);Daily or almost daily (4) Have you or someone else been injured because of your drinking? No (0);Yes, but not in the past year (2);Yes, during past year (4) Has a relative, friend, doctor, or other health care worker been concerned about your drinking or suggested you cut down? No (0);Yes, but not in the past year (2);Yes, during past year (4)
Low Risk (0-7 points) You probably do not have a problem with alcohol. Continue drinking in moderation or not at all. Medium Risk (8-15 points) You may drink too much on occasion. This may put you or others at risk. Try to cut down on alcohol or stop drinking completely. High Risk (16-19 points) Your drinking could lead to harm, if it hasn't already. It's important that you cut down on alcohol or stop drinking completely. Ask your doctor or nurse for advice on how best to cut down. Addiction Likely (20+ points) It is likely that your drinking is causing harm. Speak to your doctor or nurse, or an addiction specialist. Ask about medications and counseling that can help you stop drinking. If you are dependent on alcohol, do not stop drinking without the help of a healthcare professional.
Older adult with newly diagnosed diabetes Glycemic control usually measured 2 ways. (a) By patient performing home glucose monitoring daily (b) By physician ordering hemoglobin A1C levels every 3-6 months as a measure of average glycemic level (goal is < 7.0%). Many physicians start new Type 2 Diabetics on metformin along with or immediately after an initial trial of lifestyle modification. Blood Pressure Control (goal is < 140/90 per JNC 8 guidelines, 140/80 per ADA 2013 guidelines). If pharmacotherapy needed ACE inhibitors are used first to lower BP because of renal protective effects. Lipid control - Moderate intensity statin therapy recommended along with lifestyle modification (ACC/AHA 2013). Microalbuminuria - (goal is urine albumin/creatinine ratio < 30). ACE inhibitor added if needed. Monitoring for microvascular complications: (a) refer for dilated eye/retinal exam annually (b) examine feet each visit and perform monofilament exam every 12 months to monitor for peripheral neuropathy/ refer to podiatrist as necessary. Immunizations: (a) 23 valent pneumococcal vaccine at time of diagnosis (b) annual influenza vaccine Lifestyle changes/diabetic education various approaches including written handouts, group sessions, reinforcement at each office visit.. Almost all patients benefit from initial consultation with a dietitian or a certified diabetes educator (available at most hospitals/outpatient endocrinology clinics). CDEs also instruct patients in use of home glucose monitors (in some offices experienced nurses perform this function) Follow-up initially diabetic patients are seen monthly, but most settle into a plan for follow-up every 3-6 months depending on the degree of control of the above parameters and patients co-morbidities
Suggestions on Feedback Ask how the student thought the interaction went? Tell the student 2 things that went well in the H&P and 1 thing that could be improved Ask the student what they would do differently next time What goes into the presentation? The focused presentation follows the focused history and physical. The components include: chief complaint history of present illness pertinent review of systems pertinent past medical history general appearance vital signs pertinent physical examination findings assessment and plan
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