Podcast
Questions and Answers
A patient presents with knee pain. Which of the following questions is MOST appropriate to include directly in the HPI (History of Present Illness)?
A patient presents with knee pain. Which of the following questions is MOST appropriate to include directly in the HPI (History of Present Illness)?
- Any recent unprotected sex?
- Does the patient have any chronic medical problems?
- Has the patient had any prior knee surgeries? (correct)
- Does the patient have a family history of arthritis?
When constructing a differential diagnosis, what is the MINIMUM number of conditions that should be included on the differential diagnosis list?
When constructing a differential diagnosis, what is the MINIMUM number of conditions that should be included on the differential diagnosis list?
- Three
- Five (correct)
- Six
- Four
Which category of the 'VINDICATE' mnemonic encompasses conditions resulting from medical intervention or exposure to toxic substances?
Which category of the 'VINDICATE' mnemonic encompasses conditions resulting from medical intervention or exposure to toxic substances?
- Iatrogenic/Intoxication (correct)
- Traumatic
- Infectious
- Vascular
In a comprehensive patient note, which four systems should ALWAYS be included in the Review of Systems (ROS) regardless of the chief complaint?
In a comprehensive patient note, which four systems should ALWAYS be included in the Review of Systems (ROS) regardless of the chief complaint?
Where should you document the results of labs/diagnostics?
Where should you document the results of labs/diagnostics?
In the context of a focused note, where should the SINGLE paragraph of information be included?
In the context of a focused note, where should the SINGLE paragraph of information be included?
Within the Assessment section of a patient note, what is the purpose of 'clustering information'?
Within the Assessment section of a patient note, what is the purpose of 'clustering information'?
During a female genital exam, what specific actions should be taken to ensure patient empowerment and comfort?
During a female genital exam, what specific actions should be taken to ensure patient empowerment and comfort?
When inspecting the labia majora during a female genital examination, which of the following findings would require palpation for further evaluation?
When inspecting the labia majora during a female genital examination, which of the following findings would require palpation for further evaluation?
When palpating the Bartholin glands, what anatomical positions are most appropriate for assessment?
When palpating the Bartholin glands, what anatomical positions are most appropriate for assessment?
A patient who is primigravida is currently in labor at 39 weeks gestation. She previously had one abortion performed at 10 weeks gestation. Using the GTPAL system, how would you document her obstetrical history?
A patient who is primigravida is currently in labor at 39 weeks gestation. She previously had one abortion performed at 10 weeks gestation. Using the GTPAL system, how would you document her obstetrical history?
In what manner should the speculum be prepared for insertion during a vaginal examination to ensure both patient comfort and the integrity of subsequent diagnostic tests?
In what manner should the speculum be prepared for insertion during a vaginal examination to ensure both patient comfort and the integrity of subsequent diagnostic tests?
In a focused note, what information is considered subjective?
In a focused note, what information is considered subjective?
Which of the following is the MOST important component to include in the chief complaint (CC)?
Which of the following is the MOST important component to include in the chief complaint (CC)?
What does the mnemonic OLDCARTS stand for in the context of history of present illness (HPI)?
What does the mnemonic OLDCARTS stand for in the context of history of present illness (HPI)?
A patient's chart indicates 'G3 T1 P1 A0 L2'. Which of the following is the most accurate interpretation of this GTPAL score?
A patient's chart indicates 'G3 T1 P1 A0 L2'. Which of the following is the most accurate interpretation of this GTPAL score?
In which section of a focused note should pre-morbid conditions and harmful habits be documented?
In which section of a focused note should pre-morbid conditions and harmful habits be documented?
In the context of a focused note, what is the primary purpose of documenting pertinent negatives within the History of Present Illness (HPI)?
In the context of a focused note, what is the primary purpose of documenting pertinent negatives within the History of Present Illness (HPI)?
Which of the following best describes the significance of documenting the 'Plan' component in a focused note?
Which of the following best describes the significance of documenting the 'Plan' component in a focused note?
A patient presents with a cough. Which of the following is the MOST appropriate way to document the chief complaint?
A patient presents with a cough. Which of the following is the MOST appropriate way to document the chief complaint?
Which element of a patient's history, gathered using the 'OLDCARTS' mnemonic, BEST helps determine the impact of the problem on the patient's daily life?
Which element of a patient's history, gathered using the 'OLDCARTS' mnemonic, BEST helps determine the impact of the problem on the patient's daily life?
During a female genital exam, after swabbing the cervix, no discharge is visible in the cervical os. How must this be documented?
During a female genital exam, after swabbing the cervix, no discharge is visible in the cervical os. How must this be documented?
A patient's EKG results are documented in which section of the focused note?
A patient's EKG results are documented in which section of the focused note?
Why is the meticulous documentation of medical encounters paramount?
Why is the meticulous documentation of medical encounters paramount?
In the 'Plan' section of a focused note, what is the MOST important element to include?
In the 'Plan' section of a focused note, what is the MOST important element to include?
During a pelvic exam, which of the following instruments is used to collect a sample of cells from the cervix?
During a pelvic exam, which of the following instruments is used to collect a sample of cells from the cervix?
What is the definition of metrorrhagia?
What is the definition of metrorrhagia?
Which question directly assesses the 'C' in OLDCARTS for a patient presenting with abdominal pain?
Which question directly assesses the 'C' in OLDCARTS for a patient presenting with abdominal pain?
A 30-year-old female presents for her annual exam. Her history includes one full-term pregnancy, one spontaneous abortion, and twins who were born prematurely. She also has one living child from a previous relationship. How would you document her GTPAL?
A 30-year-old female presents for her annual exam. Her history includes one full-term pregnancy, one spontaneous abortion, and twins who were born prematurely. She also has one living child from a previous relationship. How would you document her GTPAL?
According to the guidelines, at what age should cervical cancer screening typically begin?
According to the guidelines, at what age should cervical cancer screening typically begin?
Why should lubricant be used sparingly, or not at all, during a Pap smear?
Why should lubricant be used sparingly, or not at all, during a Pap smear?
A patient presents with menorrhagia and a history of anovulatory cycles. Her GTPAL is G2 T1 P0 A1 L1. Which element of the patient's history is least relevant to the differential diagnosis?
A patient presents with menorrhagia and a history of anovulatory cycles. Her GTPAL is G2 T1 P0 A1 L1. Which element of the patient's history is least relevant to the differential diagnosis?
A patient has had three pregnancies. The first resulted in a single term birth, the second in twins born prematurely, and the third was a miscarriage. What is her GTPAL?
A patient has had three pregnancies. The first resulted in a single term birth, the second in twins born prematurely, and the third was a miscarriage. What is her GTPAL?
Which of the following historical elements is MOST relevant to include in a focused note, given the provided options?
Which of the following historical elements is MOST relevant to include in a focused note, given the provided options?
When is it MOST appropriate to perform a pelvic exam on a patient younger than 21 years old?
When is it MOST appropriate to perform a pelvic exam on a patient younger than 21 years old?
Which action is MOST important to ensure patient comfort during a pelvic exam?
Which action is MOST important to ensure patient comfort during a pelvic exam?
What is the PRIMARY reason for ensuring that a female examiner is accompanied by a chaperone during a female genitalia exam?
What is the PRIMARY reason for ensuring that a female examiner is accompanied by a chaperone during a female genitalia exam?
A G2P1001 patient is currently 36 weeks pregnant. How many living children does she have?
A G2P1001 patient is currently 36 weeks pregnant. How many living children does she have?
Which of the following findings on the skin would be MOST relevant to include in a focused note for a patient presenting with dyspnea (difficulty breathing)?
Which of the following findings on the skin would be MOST relevant to include in a focused note for a patient presenting with dyspnea (difficulty breathing)?
During the preparation phase for a pelvic exam, which of the following is LEAST crucial to have immediately available?
During the preparation phase for a pelvic exam, which of the following is LEAST crucial to have immediately available?
A patient’s GTPAL is G5 T2 P1 A1 L3. If she is currently pregnant, what will her GTPAL be after a full-term delivery of a single child?
A patient’s GTPAL is G5 T2 P1 A1 L3. If she is currently pregnant, what will her GTPAL be after a full-term delivery of a single child?
A 25-year-old patient (G0) is undergoing a routine physical exam. She reports no menstrual irregularities, pain, or unusual discharge. According to guidelines, what is the MOST appropriate course of action regarding a pelvic exam?
A 25-year-old patient (G0) is undergoing a routine physical exam. She reports no menstrual irregularities, pain, or unusual discharge. According to guidelines, what is the MOST appropriate course of action regarding a pelvic exam?
During a female genital examination, which statement MOST accurately describes the recommended positioning of the patient's hips?
During a female genital examination, which statement MOST accurately describes the recommended positioning of the patient's hips?
If a patient during a female genital exam has discharge emanating from the duct opening of the Bartholin gland, what is the MOST appropriate next step?
If a patient during a female genital exam has discharge emanating from the duct opening of the Bartholin gland, what is the MOST appropriate next step?
When communicating with a patient prior to initiating a female genitalia examination, which of the following statements is MOST aligned with empowering the patient?
When communicating with a patient prior to initiating a female genitalia examination, which of the following statements is MOST aligned with empowering the patient?
During palpation of the Bartholin glands, at which anatomical positions should the examination be performed to MOST accurately assess for abnormalities?
During palpation of the Bartholin glands, at which anatomical positions should the examination be performed to MOST accurately assess for abnormalities?
A 28-year-old patient (G3 T1 P1 A1 L2) presents to the clinic. Upon speculum examination, there's a small amount of clear discharge visualized at the os. Which step is MOST appropriate?
A 28-year-old patient (G3 T1 P1 A1 L2) presents to the clinic. Upon speculum examination, there's a small amount of clear discharge visualized at the os. Which step is MOST appropriate?
A patient has been pregnant twice. The first pregnancy resulted in the live birth of triplets at term. The second pregnancy was a miscarriage at 8 weeks. How should her obstetrical history be documented using the GTPAL system?
A patient has been pregnant twice. The first pregnancy resulted in the live birth of triplets at term. The second pregnancy was a miscarriage at 8 weeks. How should her obstetrical history be documented using the GTPAL system?
In a standard comprehensive patient history, which of the following Review of Systems (ROS) categories are explicitly mentioned as essential in the provided content?
In a standard comprehensive patient history, which of the following Review of Systems (ROS) categories are explicitly mentioned as essential in the provided content?
According to the provided information, which of the following components is included in the Physical Exam?
According to the provided information, which of the following components is included in the Physical Exam?
A 20-year-old patient with no significant past medical history requests a routine annual physical exam. She reports no menstrual irregularities, pain, or unusual discharge. Based on the provided guidelines, what is the MOST appropriate course of action regarding a pelvic exam?
A 20-year-old patient with no significant past medical history requests a routine annual physical exam. She reports no menstrual irregularities, pain, or unusual discharge. Based on the provided guidelines, what is the MOST appropriate course of action regarding a pelvic exam?
In the context of a female genitalia exam, under what specific circumstance is it explicitly recommended that a pelvic exam be performed on a patient younger than 21 years old, according to the provided guidelines?
In the context of a female genitalia exam, under what specific circumstance is it explicitly recommended that a pelvic exam be performed on a patient younger than 21 years old, according to the provided guidelines?
When documenting the Review of Systems (ROS) in a focused note, what is the minimum number of systems that should be included regardless of the chief complaint?
When documenting the Review of Systems (ROS) in a focused note, what is the minimum number of systems that should be included regardless of the chief complaint?
In the context of a patient presenting with dyspnea, which historical element, if present, would be MOST relevant to include in a focused note?
In the context of a patient presenting with dyspnea, which historical element, if present, would be MOST relevant to include in a focused note?
Regarding chaperones during a female genitalia exam, which statement BEST reflects the recommendation based on the provided text?
Regarding chaperones during a female genitalia exam, which statement BEST reflects the recommendation based on the provided text?
A patient (G4 T2 P1 A0 L3) is currently pregnant. She carries to term and delivers twins. What is the patient's updated GTPAL?
A patient (G4 T2 P1 A0 L3) is currently pregnant. She carries to term and delivers twins. What is the patient's updated GTPAL?
When preparing for a pelvic exam, which of the following is the MOST crucial piece of equipment to have readily available to facilitate a Pap smear, if indicated?
When preparing for a pelvic exam, which of the following is the MOST crucial piece of equipment to have readily available to facilitate a Pap smear, if indicated?
When using the 'VINDICATE' mnemonic to generate a differential diagnosis, which category would MOST appropriately classify a condition resulting from prolonged use of corticosteroids leading to Cushing's syndrome?
When using the 'VINDICATE' mnemonic to generate a differential diagnosis, which category would MOST appropriately classify a condition resulting from prolonged use of corticosteroids leading to Cushing's syndrome?
To ensure patient comfort and minimize anxiety during the pelvic exam, what specific instruction should be given to the patient regarding their position on the examination table?
To ensure patient comfort and minimize anxiety during the pelvic exam, what specific instruction should be given to the patient regarding their position on the examination table?
A patient's obstetrical history is documented as G3 T2 P1 A0 L3. She is currently pregnant with twins. If both twins are delivered at term and are living, what will her GTPAL be updated to after this delivery?
A patient's obstetrical history is documented as G3 T2 P1 A0 L3. She is currently pregnant with twins. If both twins are delivered at term and are living, what will her GTPAL be updated to after this delivery?
A 28-year-old patient (G0) reports experiencing pain in the joints. Which of the following questions would be MOST appropriate to incorporate into the HPI?
A 28-year-old patient (G0) reports experiencing pain in the joints. Which of the following questions would be MOST appropriate to incorporate into the HPI?
During the Objective portion of a psychiatric exam note, a patient is noted to be weeping silently with minimal facial expression. Which of the following is the MOST appropriate way to document the patient's emotional state?
During the Objective portion of a psychiatric exam note, a patient is noted to be weeping silently with minimal facial expression. Which of the following is the MOST appropriate way to document the patient's emotional state?
Considering the recommendations for female genitalia exams, which of the following actions is LEAST likely to enhance patient comfort and reduce anxiety during the procedure?
Considering the recommendations for female genitalia exams, which of the following actions is LEAST likely to enhance patient comfort and reduce anxiety during the procedure?
Which of the following statements represents the MOST comprehensive and accurate approach to documenting the 'Plan' component in a focused note for a patient presenting with acute bronchitis?
Which of the following statements represents the MOST comprehensive and accurate approach to documenting the 'Plan' component in a focused note for a patient presenting with acute bronchitis?
A 38-year-old (G3 T1 P1 A1 L2) woman presents with complaints of secondary amenorrhea. Which of the following historical elements is LEAST relevant when constructing an initial differential diagnosis?
A 38-year-old (G3 T1 P1 A1 L2) woman presents with complaints of secondary amenorrhea. Which of the following historical elements is LEAST relevant when constructing an initial differential diagnosis?
Why is it recommended to use lubricant sparingly, or not at all, during a Pap smear?
Why is it recommended to use lubricant sparingly, or not at all, during a Pap smear?
During a pelvic exam, which instrument is LEAST likely to be used for direct sample collection or visualization?
During a pelvic exam, which instrument is LEAST likely to be used for direct sample collection or visualization?
Which of the following BEST defines metrorrhagia?
Which of the following BEST defines metrorrhagia?
According to established guidelines, at what age is it GENERALLY recommended to initiate cervical cancer screening?
According to established guidelines, at what age is it GENERALLY recommended to initiate cervical cancer screening?
Which of the following is the MOST accurate and comprehensive definition of a focused note in medical documentation?
Which of the following is the MOST accurate and comprehensive definition of a focused note in medical documentation?
A patient (G4 T2 P1 A1 L3) is currently pregnant. She carries to term, what will be her updated GTPAL after the delivery?
A patient (G4 T2 P1 A1 L3) is currently pregnant. She carries to term, what will be her updated GTPAL after the delivery?
A 28-year-old patient presents with a history notable for one full-term pregnancy, one abortion at 20 weeks due to fetal demise, and twins delivered prematurely who are currently living. How should her obstetrical history be accurately documented using the GTPAL system?
A 28-year-old patient presents with a history notable for one full-term pregnancy, one abortion at 20 weeks due to fetal demise, and twins delivered prematurely who are currently living. How should her obstetrical history be accurately documented using the GTPAL system?
You are reviewing a focused note for a patient presenting with acute dyspnea. Which element, if omitted, would MOST significantly hinder the assessment and management of the patient's respiratory distress?
You are reviewing a focused note for a patient presenting with acute dyspnea. Which element, if omitted, would MOST significantly hinder the assessment and management of the patient's respiratory distress?
In the context of documentation, what is the MOST critical reason medical professionals must emphasize in their notes?
In the context of documentation, what is the MOST critical reason medical professionals must emphasize in their notes?
What is the PRIMARY goal of developing a differential diagnosis within the Assessment section of a patient note?
What is the PRIMARY goal of developing a differential diagnosis within the Assessment section of a patient note?
A patient presents with dyspnea and a non-productive cough that has persisted for three weeks, worsening at night. Which of the following HPI elements, if documented, would MOST effectively guide the initial steps in formulating your differential?
A patient presents with dyspnea and a non-productive cough that has persisted for three weeks, worsening at night. Which of the following HPI elements, if documented, would MOST effectively guide the initial steps in formulating your differential?
A patient presents with hemoptysis. Which of the following questions focuses the history of present illness MOST effectively, providing information that directly informs the differential diagnosis?
A patient presents with hemoptysis. Which of the following questions focuses the history of present illness MOST effectively, providing information that directly informs the differential diagnosis?
During the review of systems (ROS), a patient reports occasional palpitations but denies chest pain or shortness of breath. How should this be documented in a focused note, ensuring accurate representation of the patient's condition?
During the review of systems (ROS), a patient reports occasional palpitations but denies chest pain or shortness of breath. How should this be documented in a focused note, ensuring accurate representation of the patient's condition?
Which of the following elements in the 'Plan' section of a focused note is MOST critical for ensuring continuity of care and effective communication with other healthcare providers?
Which of the following elements in the 'Plan' section of a focused note is MOST critical for ensuring continuity of care and effective communication with other healthcare providers?
A patient (G4 T2 P1 A0 L3) is currently 10 weeks pregnant. During the ultrasound, it is discovered that she is carrying twins. If she carries the twins to full term, how will her GTPAL be updated?
A patient (G4 T2 P1 A0 L3) is currently 10 weeks pregnant. During the ultrasound, it is discovered that she is carrying twins. If she carries the twins to full term, how will her GTPAL be updated?
A patient has a history of three pregnancies. The first resulted in a single child born at 30 weeks gestation, the second pregnancy resulted in twins born at 38 weeks gestation, and the third pregnancy resulted in a miscarriage at 8 weeks gestation. What is her GTPAL?
A patient has a history of three pregnancies. The first resulted in a single child born at 30 weeks gestation, the second pregnancy resulted in twins born at 38 weeks gestation, and the third pregnancy resulted in a miscarriage at 8 weeks gestation. What is her GTPAL?
A patient (G5 T2 P1 A1 L3) is currently pregnant. She previously had one abortion at 10 weeks gestation. How will her GTPAL be documented AFTER she delivers twins vaginally at 35 weeks gestation, both of whom survive?
A patient (G5 T2 P1 A1 L3) is currently pregnant. She previously had one abortion at 10 weeks gestation. How will her GTPAL be documented AFTER she delivers twins vaginally at 35 weeks gestation, both of whom survive?
Upon initial inspection of the external genitalia during a pelvic exam, a small, firm, non-tender nodule is noted on the right labia majora. Which of the following is the MOST appropriate next step?
Upon initial inspection of the external genitalia during a pelvic exam, a small, firm, non-tender nodule is noted on the right labia majora. Which of the following is the MOST appropriate next step?
During a pelvic examination, after inserting the speculum, the cervix appears erythematous with a moderate amount of purulent discharge in the cervical os. Cytology and cultures are obtained. What additional step should be taken to ensure appropriate management and patient counseling?
During a pelvic examination, after inserting the speculum, the cervix appears erythematous with a moderate amount of purulent discharge in the cervical os. Cytology and cultures are obtained. What additional step should be taken to ensure appropriate management and patient counseling?
In the context of a female genitalia exam, which of the following actions is MOST crucial in ensuring patient comfort and minimizing anxiety during speculum insertion, particularly for patients with a history of trauma or discomfort?
In the context of a female genitalia exam, which of the following actions is MOST crucial in ensuring patient comfort and minimizing anxiety during speculum insertion, particularly for patients with a history of trauma or discomfort?
A patient presents with left-sided decreased air movement, coarse crackles in the left lower lobe, dullness on percussion, increased fremitus, and egophony. Which condition is MOST likely?
A patient presents with left-sided decreased air movement, coarse crackles in the left lower lobe, dullness on percussion, increased fremitus, and egophony. Which condition is MOST likely?
A tall, thin 17-year-old male presents with sudden onset right-sided chest pain and shortness of breath. Examination reveals absent breath sounds in the right superior chest wall and hyperresonance. What is the MOST probable diagnosis?
A tall, thin 17-year-old male presents with sudden onset right-sided chest pain and shortness of breath. Examination reveals absent breath sounds in the right superior chest wall and hyperresonance. What is the MOST probable diagnosis?
Which finding is LEAST likely to be associated with consolidation in the lung?
Which finding is LEAST likely to be associated with consolidation in the lung?
A patient with a history of three pregnancies is documented as G3 T1 P1 A1 L2. She is currently 30 weeks pregnant with twins. Assuming she carries the twins to term, what will her updated GTPAL score be after delivery?
A patient with a history of three pregnancies is documented as G3 T1 P1 A1 L2. She is currently 30 weeks pregnant with twins. Assuming she carries the twins to term, what will her updated GTPAL score be after delivery?
A G2 T1 P0 A1 L1 patient presents to the clinic. She reports a history of menorrhagia and anovulatory cycles. The physician suspects possible endometrial hyperplasia. Which element of the patient's history is LEAST relevant to the differential diagnosis at this stage?
A G2 T1 P0 A1 L1 patient presents to the clinic. She reports a history of menorrhagia and anovulatory cycles. The physician suspects possible endometrial hyperplasia. Which element of the patient's history is LEAST relevant to the differential diagnosis at this stage?
When documenting abnormal findings on the chest, what is the MOST effective method for accurately describing their location?
When documenting abnormal findings on the chest, what is the MOST effective method for accurately describing their location?
To accurately locate findings around the circumference of the chest, which of the following methods is MOST appropriate?
To accurately locate findings around the circumference of the chest, which of the following methods is MOST appropriate?
A patient presents with a suspected tension pneumothorax. According to anatomical landmarks relevant to pulmonary procedures, at which intercostal space should a needle be inserted for decompression?
A patient presents with a suspected tension pneumothorax. According to anatomical landmarks relevant to pulmonary procedures, at which intercostal space should a needle be inserted for decompression?
During a female genitalia exam, while visually inspecting the external genitalia, the examiner notices what appears to be a small amount of clear, non-odorous fluid pooling near the urethral meatus. The patient denies any pain, burning, or discomfort. Which of the following is the MOST appropriate next step?
During a female genitalia exam, while visually inspecting the external genitalia, the examiner notices what appears to be a small amount of clear, non-odorous fluid pooling near the urethral meatus. The patient denies any pain, burning, or discomfort. Which of the following is the MOST appropriate next step?
A patient presents with a lung mass discovered on a chest radiograph. The mass is described as being located in the upper portion of the lung, above the clavicles. How should this location be anatomically documented in the patient's chart?
A patient presents with a lung mass discovered on a chest radiograph. The mass is described as being located in the upper portion of the lung, above the clavicles. How should this location be anatomically documented in the patient's chart?
A patient, gravida 4, has had two full-term pregnancies, one premature birth resulting in twins, and one spontaneous abortion. All children from the full-term and premature births are living. Using the GTPAL system, how would you document this patient's obstetrical history?
A patient, gravida 4, has had two full-term pregnancies, one premature birth resulting in twins, and one spontaneous abortion. All children from the full-term and premature births are living. Using the GTPAL system, how would you document this patient's obstetrical history?
The trachea bifurcates into the main stem bronchi at the level of the sternal angle anteriorly. At what level does this bifurcation occur posteriorly?
The trachea bifurcates into the main stem bronchi at the level of the sternal angle anteriorly. At what level does this bifurcation occur posteriorly?
When inserting a needle for a thoracentesis, which anatomical principle is MOST critical to consider to avoid damaging neurovascular structures?
When inserting a needle for a thoracentesis, which anatomical principle is MOST critical to consider to avoid damaging neurovascular structures?
A patient describes their chest pain as a 'discomfort'. What is the MOST appropriate next step to determine the pain's characteristics?
A patient describes their chest pain as a 'discomfort'. What is the MOST appropriate next step to determine the pain's characteristics?
A male patient reports chest pain that radiates to the left shoulder, which he describes as a 'squeezing' sensation. According to the information, which condition is MOST likely?
A male patient reports chest pain that radiates to the left shoulder, which he describes as a 'squeezing' sensation. According to the information, which condition is MOST likely?
During an assessment, a young, healthy adult reports a sudden onset of dyspnea accompanied by pleuritic chest pain. Which of the following conditions should be HIGH on the differential?
During an assessment, a young, healthy adult reports a sudden onset of dyspnea accompanied by pleuritic chest pain. Which of the following conditions should be HIGH on the differential?
When assessing a patient with dyspnea, which initial question is MOST appropriate to gather comprehensive information?
When assessing a patient with dyspnea, which initial question is MOST appropriate to gather comprehensive information?
A patient with a history of smoking presents with hemoptysis. Which aspect of their cough is vital that you elucidate?
A patient with a history of smoking presents with hemoptysis. Which aspect of their cough is vital that you elucidate?
A patient coughs up a large amount of sputum for you to inspect. Aside from color, what other physical characteristic of the phlegm should be noted for diagnostic purposes?
A patient coughs up a large amount of sputum for you to inspect. Aside from color, what other physical characteristic of the phlegm should be noted for diagnostic purposes?
A 32-year-old female presents for a routine check-up. She has a history of one full-term pregnancy and a miscarriage at 10 weeks gestation. How would you document her obstetrical history using the GTPAL system?
A 32-year-old female presents for a routine check-up. She has a history of one full-term pregnancy and a miscarriage at 10 weeks gestation. How would you document her obstetrical history using the GTPAL system?
A patient presents with chest pain that is relieved by sitting up and leaning forward. What is the MOST likely cause of this pain?
A patient presents with chest pain that is relieved by sitting up and leaning forward. What is the MOST likely cause of this pain?
A patient's chart indicates a GTPAL of G6 T3 P1 A1 L4. She is currently pregnant with twins. If she delivers these twins vaginally at 36 weeks gestation, and both survive, what will her updated GTPAL be?
A patient's chart indicates a GTPAL of G6 T3 P1 A1 L4. She is currently pregnant with twins. If she delivers these twins vaginally at 36 weeks gestation, and both survive, what will her updated GTPAL be?
Flashcards
Gravidity
Gravidity
Number of pregnancies a woman has had, regardless of the outcome or number of babies.
Term (T) in OB history
Term (T) in OB history
Number of pregnancies delivered at term (37 weeks or later).
Components of patient history
Components of patient history
Includes past medical conditions, family history, social history, and review of systems.
Physical Exam Components
Physical Exam Components
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Pelvic Exam Equipment
Pelvic Exam Equipment
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Patient positioning for pelvic exam
Patient positioning for pelvic exam
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Pelvic Exam Guidelines (Age)
Pelvic Exam Guidelines (Age)
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Chaperone during exam
Chaperone during exam
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Differential Diagnosis
Differential Diagnosis
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VINDICATE Mnemonic
VINDICATE Mnemonic
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Subjective Info Categories
Subjective Info Categories
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Always Included ROS
Always Included ROS
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Always Included PE Systems
Always Included PE Systems
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SIG E CAPS
SIG E CAPS
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Psych Exam Components
Psych Exam Components
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Assessment Info Clusters
Assessment Info Clusters
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Patient positioning for GU exam
Patient positioning for GU exam
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Patient empowerment during exam
Patient empowerment during exam
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External genitalia structures
External genitalia structures
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Labia majora inspection
Labia majora inspection
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Bartholin gland palpation
Bartholin gland palpation
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Vaginal Discharge Description
Vaginal Discharge Description
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Lubricant Use During Pap Smear
Lubricant Use During Pap Smear
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Cannula
Cannula
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Metrorrhagia
Metrorrhagia
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Cervical Cancer Screening Start Age
Cervical Cancer Screening Start Age
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Principles of Documentation
Principles of Documentation
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Focused Note
Focused Note
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Pertinent Positives/Negatives Location
Pertinent Positives/Negatives Location
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Documentation Importance
Documentation Importance
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Diagnosis Development
Diagnosis Development
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Chief Complaint (CC)
Chief Complaint (CC)
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Subjective Information
Subjective Information
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Objective Information
Objective Information
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OLDCARTS
OLDCARTS
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Pertinent History
Pertinent History
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Pending Labs
Pending Labs
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Numbered Labs/Diagnosis
Numbered Labs/Diagnosis
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Plan
Plan
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Objective
Objective
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Identifying Information
Identifying Information
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Past Medical History (PMH)
Past Medical History (PMH)
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Family History (FH)
Family History (FH)
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Social History
Social History
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Review of Systems (ROS)
Review of Systems (ROS)
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White homogenous discharge
White homogenous discharge
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Lubricant use during Pap
Lubricant use during Pap
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Cannula use in pelvic exam
Cannula use in pelvic exam
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Metrorrhagia definition
Metrorrhagia definition
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Cervical cancer screening age
Cervical cancer screening age
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Focused Note: Components
Focused Note: Components
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Pertinent Positives/Negatives
Pertinent Positives/Negatives
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Objective Section
Objective Section
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Identifying Information Section
Identifying Information Section
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Female Genital Exam
Female Genital Exam
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Physical Exam (Focused)
Physical Exam (Focused)
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Review of Systems (Focused)
Review of Systems (Focused)
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Lithotomy Position
Lithotomy Position
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Pelvic Exam Tools
Pelvic Exam Tools
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Pelvic Exam (Age)
Pelvic Exam (Age)
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Exam Chaperone
Exam Chaperone
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Focused Note Definition
Focused Note Definition
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Social History (SH)
Social History (SH)
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Mons pubis inspection
Mons pubis inspection
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Clitoris Inspection
Clitoris Inspection
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Skene and Bartholin glands exam
Skene and Bartholin glands exam
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The Plan
The Plan
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Auscultation
Auscultation
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Palpation
Palpation
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Vertical Axis Location
Vertical Axis Location
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Circumferential Location
Circumferential Location
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Supraclavicular
Supraclavicular
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Infraclavicular
Infraclavicular
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2nd Intercostal Space
2nd Intercostal Space
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Spontaneous Pneumothorax
Spontaneous Pneumothorax
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Pneumonia
Pneumonia
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Pulmonary Health Strategies
Pulmonary Health Strategies
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Components of a Focused Note
Components of a Focused Note
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Rib Neurovasculature
Rib Neurovasculature
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Dyspnea
Dyspnea
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HPI Attributes (OLDCARTS)
HPI Attributes (OLDCARTS)
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HPI Initial Questions
HPI Initial Questions
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Chest Pain Location Significance
Chest Pain Location Significance
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Sputum Description
Sputum Description
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SOB Progression
SOB Progression
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Pericarditis Pain
Pericarditis Pain
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Pneumothorax symptom
Pneumothorax symptom
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Study Notes
Female Genitalia
- Added history urinary tract infections, glomerulonephritis, is important.
- Perform Pelvic exams only if over 21 years old or indicated by medical history.
History: History
- Include History urinary tract infections, glomerulonephritis, etc., Previous urinary catheterization/dilation and History spina bifida (risk factor for recurrent UTI).
Physical Exam
- Include Pulm and GU
- Identify signs of respiratory distress like tachypnea, cyanosis, pallor, diaphoresis, accessory muscle use, and changes in breathing patterns.
Female Anatomy
- Included external os of the cervix
- Vertical and circumference of the chest to identify abnormalities.
- Lung fissures are split into lobes and right is split into upper, middle, and lower lobes.
- Topographic markers for the lungs including Nipples, Manubriosternal junction (angle of Louis), Suprasternal notch, Costal angles, Vertebra prominens (C-7 spinous process) and Clavicles.
- More lung markers include Supraclavicular, Infraclavicular, Interscapular, Infrascapular, Apices of the lungs and Bases of the lungs.
Before preparing for the exam...
- Only perform Pelvic exams if over 21 yrs of age or indicated by medical history.
External Exam
- Mons pubis, labia majora: Inspect pubic hair pattern/distribution. Inspect for Color, symmetry, moisture, scarring, inflammation, swelling. Palpate for tenderness.
- Labia minora: Inspect symmetry, moisture, inflammation, discharge, excoriations, lesions. Palpate for tenderness.
- Clitoris: size, atrophy, inflammation, adhesions.
- Urinary meatus: Discharge, polyps, caruncles, inflammation.
- Vaginal introitus: Moisture, swelling, discoloration, discharge, lesions, fissures.
- Skene and Bartholin glands: Inspect discharge and swelling and palpate for tenderness.
Internal Exam
- After speculum exam, palpate each side of Bartholin glands at approximate the 4-o'clock and 8-o'clock position between your finger and thumb. and check for swelling or tenderness and note any discharge exuding from the duct opening.
Common Abnormalities
- Vulvar/Vaginal Lesions: Herpes simplex, Syphilis, Cancer, Bartholin cysts, HPV and their associated findings
- Vaginal Pruritus/Pain: Candidiasis, Trichomoniasis, Herpes simplex with Vesicles.
- Vaginal Discharge: with Urethritis/cervicitis, Chlamydia/GC, Mucopurulent discharge
- Homogeneous white discharge which coats and consists of clue cells may indicate Bacterial Vaginosis
- Fishy odor, "whiff” test also suggests Bacterial Vaginosis
- White clumped discharge-Candidiasis
- Yellow/green, often malodorous discharge with vulvar itching or Motile flagellated organisms may be present.
- Pectus Carinatum the sternum & costal cartilages project outwards and is 2ndary to asthma.
- Pectus Excavatum is hollowness of the lower chest portion by the backward displacement of the cartilage, considered a funnel body" of sunken chest"
- Know reduced diaphragmatic excursion and the difference between a hemothorax.
- To help recognize abnormal anatomical traits then generate a diagnosis to provide the best outcome.
Common abnormalities pt 2
- Cystocele-A bulge of the upper two-thirds of the anterior vaginal wall due to a prolapsed bladder and urethrocele
Health Promotion and Education
- Current Cervical Cancer Screening Guidelines for Average-Risk Women come from USPSTF, ACS/ASCCP/ASCP, and ACOG- begin screening at 21 yrs.
- Ages 21-65 yrs cytology every 3 yrs ORAges 30-65 cytology plus HPV testing (for high-risk or oncogenic HPV types) every 5 yrs; HPV testing alone (age 25 or 30)
- At age >65 yrs, can stop testing when assuming three consecutive negative results on cytology or two consecutive negative results on cytology plus HPV testing within 10 yrs before cessation of screening, with the most recent test performed within 5 yrs. Do not recommend if hysterectomy with screening has been completed.
- Immunizations including the CDC Adult Immunization schedule, 2024, RSV, COVID-19, Pneumococcal Vaccine and Influenza and when they are advised
- It is best to look at new research in the immunizations to see the up-to-date changes.
Note:
- Detailed Focus Note: HPI must start with the chief compliant and have a main paragraph and MUST document everything to get paid!.
- Always be dating!
- Note document: "I only" to be accurate (ex. Labs)
- In general the subjective include the PMHx, FH, ROS which includes the general, skin, lungs, cardiac and ask the patient to specify the location of their feelings while taking notes, such as the women's breast and check for discharges of any sort as well.
- To make a good diagnosis, list 5 potential ones and base the diagnosis on the CC and to consider what the primary diagnosis is most likely to be before the next.
Objective
- PE (These should be in top-down fashion),ALWAYS perform Gen’l, Skin, Pulm, and Cardio exam (with pulses) and any lab/diagnostic that has been completed and RESULTED goes here.
- As well do the accessory muscles and check all breathing patterns including their accessory muscles, so when the patient is lying there you are able to see a full profile.
- The exam and labs should be numbered, to easily allow review and rechecking your data.
Oral Case Presentation
Present as follows:
- State the CC including "Cough for 7 days and" and expand on OLD CARTS as well.
- PE is brief but gives only the pertinent information, along with presenting the exam findings.
Assessment
- Synopsis of problem lists in numerical fashion and Diagnosis with rationale/Differentials
- The assessment pearls, which includes addressing pre-morbid conditions, FH, exposures or anything related to in our plans.
- The top primary diagnosis with supporting statements.
Pulmonology
- Describe abnormalities in two dimensions including the vertical axis and the circumference of the chest.
- Lung anatomy includes oblique fissure, fissures that divide the lungs into lobes and right is split into upper, middle, and lower lobes
- Know Anatomy and recognize abnormal exam traits to then generate a diagnosis to provide the best outcome.
- Remember the anatomy pearls especially with chest tubes and intercostal spaces.
- Know about breathing patterns and the accessory muscles used to aide breathing in emergency or more drastic scenarios.
- Identify respiratory traits like tachypnea, cyanosis, pallor, and diaphoresis.
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Description
This quiz covers key aspects of medical history taking, differential diagnosis construction, and patient note documentation. It emphasizes the importance of a thorough History of Present Illness, comprehensive Review of Systems, and accurate recording of lab/diagnostic results.
