History of Present Illness: CC, HPI, PMH, pt profile, family hx, ROS. 7 dimensions of symptom:chronology (how long and constant or intermittent), location, quality (dull, tight, burn?), quantity (pain scale), setting, aggravating/relieving factors, associated manifestations. Generating a diagnosis: differential diagnosis, experiential/pattern recognition and algorithms Mech. of injury= Congenital, Metabolic/toxic, Infectious/inflam/ ischemic, Neoplastic, Trauma Sexual History: Easing communication= confidentiality, create privacy, non-verbal cues, clear language, illusion of time. Sex history= clarify problem, onset and course, why patient thought it developed, any past treatment, pt’s motive, pain, expectations. Evaluates risk factors for STDs Other disease may impact pt- ie. chest pain w/sex, impotence b/c of med, odd symptoms b/c of sexual abuse BE NON-JUDGMENTAL and NON-HETEROCENTRIC Explain why you need the info. Ask if symptoms or syndrome has effected sexual functioning. Identifies deficits in lifestyle of patient due to his illness. IT IS IMPORTANT TO FOCUS ON SEXUAL ACTIVITIES NOT SEXUAL PREFERENCE ask: sexually active? # of partners? how well do you know sexual partner/history? anal/oral? contraceptive? condom? 5times to ask about sex a.when sex is pt.'s chief complaint b. during HPI "how has illness affected you sex life?" mediaction? c. during social hx "are you romantically or sexually involved" d. review of symptoms-during GU exam; male-"trouble getting erect?" female-pain or dryness? e. permission-giving question "Do you have any concerns about sex?" In high risk behavior-->HIV test Ethics: Value-for enhancement of health/knowledge, scientific validity-methodologically rigorous, fair subject selection, favorable risk-benefit ratio- non exploitation, independent review, informed consent- necessary but not sufficient respect for enrolled subject. Research Case Series - associations. Case-Control - w/ disease Cohort study – possible exposure. Selection bias: by dz no dz investigators, Referral bias: doctors, Volunteer Bias. Santosham paper: (HIB and Navajo infants) Randomized, can’t tell if all subjects were accounted for, follow-up was done for pos test a b infants receiving Hib vaccine, intention to treat analysis (measures results with more real world implementation (adherence), vs. research setting, can be important for avoiding bias, neg test c d double blind study, groups were similar meaning they balanced demo, and other confounders, both groups were treated equally, Vaccine Efficacy aka Relative Risk Reduction = (Event Rate Placebo - Event Rate Vaccine)/ Event Rate Placebo, results can be applied to patient care, all clinically important outcomes considered (deaths, hospitalizations, substitute endpoints are valid), treatment worth potential harm NNT=1/ARR, passes Ethics Test (great value to subjects, randomized blinded controlled trial, good selection due to high rate of disease, risks were minimal, IRB independent and security reviews, informed consent was obtained, and respect was assumed). Madsen paper: Retrospective Cohort for MMR ,both groups compared in the same way, no recall bias, follow-up was long and complete, temporal relationship correct, cohort RR is determined, case control Odds Ratio is measured, passes ethics test (MMR & autism is of high value, study is valid because it eliminates biases of design and data collection, subjects were fairly selected, no risk involved, no IRB review, no consent needed from subjects, and no respect for privacy was mentioned). Wakefield paper could have been selection bias, nonspecific dx, interviewer was not blinded, essential info based on parental recall, conflict of interest eventually revealed, findings retracted by all authors except Wakefield. Well Child: Vaccine Schedule: HepB: Birth, 1-4, 6-18mon, DTaP: 2,4,6,15-18mon, Hib: 2,4,6,12-15mon, IPV: 2,4, 6-18mon, MMR: 12-15mon, Varicella: 12-18mon, PCV: 2,4,6,12-15mon, Influenza: 6mon, yearly. Well Child 2: Vaccines are victims of their own success meaning there are diseases you may not see because of herd immunity which can create outbreaks if enough people stop getting immunized. (If not vaccinated, Polio- >paralysis, Pertussis->encephalitis/death, Pneum->death, Rubella->birth defects, Tetanus->death, Dipth->death, H. flu->meningitis, Measles->seizures, death, Mumps->meningitis, deafness) Adverse Effects of Vaccines: varicella is live vax, transmittable to immunocomp family. Adverse effects are rare & take long time to manifest ATTENUATED: no virulence factor vs. CONJUGATED: w/ protein (T-cell response) EFFICACY: controlled trial show effect vs. EFFECTIVENESS: transfer to real-world pop. SURROGATE OUTCOMES: Ab titers/enzyme response (lab results) measuring efficacy. NYS DOH provides Vaccine Info Sheets in 17 languages in 5th grade level (bias side effects and give no clear value of vaccine). Vaccines if no insurance - Vaccines for Children Program or Child Health Plus WomenInfantsChildren: gives baby foods with proof of vaccinations Dx of Cough: Diptheria, Pertussis, HiB, Pneum, Influenza, Varicella Characteristics: duration, productive, sputum color, alleviating/aggravating, rash Pediatric PE: Observe child, least invasive exams 1st, child's own growth/height trajectory, Need to call protective child services in imminent danger, inspect, palpate, percuss, auscultate, heart, lung, abdomen, femoral pulses, congenital hip dislocation, visual, head circumference, ears, mouth. Jean Johnson Screening: purpose: divide eligible subjects into 2 groups: low risk and high risk (for further diagnostic exam). for asymptomatic at risk individuals; meet eligibility criteria, to identify individuals w/ disease in a preclinical stage so it can be treated better. MD’s responsibility: Know/explain risks/benefits of test, get patient's consent, f/u on results. Ideally: disease screened will be a major, serious, common health problem. Disease must be treatable if detected early, test should be acceptable to those eligible. The test should be inexpensive. Results should be valid, reproducible, reliable. Should have high sensitivity, high specificity. Screenings have been shown to reduce mortality in RandomizedCTs. Recommended guidelines breast cancer screening: 40- 69y/o, screen every 1-2 years, with mammography alone or mammography and annual clinical breast examination (CBE). Evidence is strongest for women aged 50-69,gets weaker with decreasing age of women (dense breasts more false positives). 20/30yrs CBE every 3 years, annually after 40. Colorectal cancer: guiac test, sigmoidoscopy, colonoscopy Prostate cancer: rectal exam, PSA Cervical caner: PAP. Prevention: Factors to consider: burden of suffering, effectiveness, risk, and level of evidence. Challenges: ethics, communication (educate and enlist), health care, context (delivery), and evidence. Non-compliance b/c of: side effects, efficacy, cost. Non-adherance: pt perception of seriousness, efficacy of tx, chronicity of tx, quality of doc/pt relation. So educate and enlist (elicit pt’s explanatory model, describe own impressions, and ask pt how your model fits with his). Levels of prevention – when you prevent in the course of illness: Primary: prevent disease from development (prevent lead exposure), Secondary: prevent complications from disease (prevent neuro damage from lead), Teriary: prevent disability from disease (prevent neuro damage from handicapping; special ed). Explanatory model: helps pt understand illness. Meaning can be functional (what I can/can’t do b/c of illness), symbolic (I’m a bad person), or relational (this is like what happened to my father when they found his cancer). 1. What’s/Why happening? (Dx/cause) 2. What’s gonna happen? (prognosis) 3. What are you doing, why (and not something else)? 4. Will it hurt? How much/long? 5. When will you/I know the results? ADHERENCE: Facilitate Tx Adherence →Simplify regimen, tackle 1 prob at a time, Tailor regimen 2 habits/routines, Anticipate probs/devise solns, Describe tx expectations, Review side efx, Involve fam in planning. Jean Johnson: Factors ↑ a woman's chance of CA: 1) personal hx of breast cancer, Family hx. 2) Certain breast changes on Bx, 3). dx of atypical hyperplasia or lobular carcinoma in situ (LClS). 4). Two or more breast biopsies for other benign conditions (due to the condition that led to the biopsy, not to the biopsy itself). 5) BRCA1 and BRCA2 genes (30-70% of all inherited cases), likelihood highest in families with one or more cases of ovarian cancer. Reproductive and menstrual hx: 6) Older age at time of 1st child. 7) Early menarchy (age 11 or younger), 8) late menopause (after age 55), 9) never had children. 10). longterm HRT usage. 11) older women who have mostly dense tissue (BC nearly always develop in the dense tissue—few glands, ligaments low amt fatty tissue—not in the fatty tissue. Note: abnormalities in dense breasts more difficult to detect on mammogram. 11) Radiation therapy to the Chest before 30yo 12) Diet and lifestyle factors? - may explain low risk for Asian women compared with American women. 13) Obesity in postmenopausal women. 14) Alcohol consumption? STATS True pos (a), Fals pos (b) False neg (c), True neg (d). Note: False neg: mammograms miss up to 20% of BCs present at time of screening. FN more freq. in younger women b/c denser breasts ―hide‖ cancers more. False Positives most abnormalities turn out not to be cancer. FP more common in younger women, women who have had previous breast biopsies, women with a family hx of BC, women with fibrocystic disease, and women who are taking estrogen. Prevalence = (# of cases / # people in population). Bayes Theorem/Prior Probability: known prevalence of the disease in the population under consideration, a description of what is known about a variable in the absence of some evidence Sensitivity = A/(A+C): proportion with disease that test positive. Specificity = D/(B+D): proportion without disease that test negative. False Negative: 1 – sensitivity = proportion of cancers missed by the screen; False Positive: 1- Specificity = proportion of cancer free subjects testing positive by the screen. Positive Predictive Value (PPV): A/(A+B), the proportion testing positive who will have the disease. Negative predictive value (NPV): D/(C+D), proportion testing negative who will not have the disease. Lead Time Bias: dx is made earlier in the screened group, apparent increase in survival time, although time to death from the onset of disease is the same in both groups. Length Time Bias: probability of detecting dz is related to the growth rate of the tumor. A higher proportion of slow growing tumors are found in the screened group, causing an apparent increase in survival. Over-diagnosis Bias: (extreme form of length time bias). Detection of very indolent tumors in the screened group produces an apparent increase in the number of cases and in survival, common in prostate cancer. Will Rogers Staging Bias: improved staging changes classification of late local dz to early regional dz seeming improvement of both groups. Giving Bad News: Most people want to know Dx& Px Info is essential for shared decision-making, permits pts & families to plan and cope. Before: Getting started, adequate time, prevent interruptions, family support? Create conducive environ.: privacy, tissues, Translator?. During: 2) What info is already known? Introductions, eye contact, est. what pt. knows, recap situation, assess ability to comprehend bad news, reschedule if necessary. 3) How much do they want to know? Cultural, ethnic, religious, SES, age and developmental influence. If family says don't tell: ask why? what are you afraid of? Etc. Legal obligation to tell. Promote family alliance, honesty promotes trust. 4) Sharing info: be brief/not brutal, provide basic facts, use common language or define terms. Allow time to digest, body language, pause frequently, don’t minimize. Communicating prognosis: inquir e about reason for asking, pts vary, don’t minimize. 5) Responding to feelings: emotional response, cognitive response (denial, blame, guilt, disbelief, fear, loss, shame, intellectualization) 6) Planning and F/U: Plan next steps, discuss potential sources of support, give contact info, set next appointment. People want doctors who assure, comfort, knowledge, listens. Paying for Health Care: Premium – fee to get insurance coverage. Deductible – preset amt of $ patient has to pay before insurance starts paying. Copay – "out of pocket" expense for each episode of medical care. Medicare: old. Medicaid: low income. Group Health Insurance-a single policy covers many people. The premium calc. based on the characteristics of the group as a whole, such as average age and degree of occupational hazard. Individual insurance: each individual's risk potential is evaluated to determine insurability. HMOs: goal of reducing medical costs by focusing on preventative care and utilization management controls. Tx on a prepaid basis = fixed monthly fee, regardless of amount of medical care needed in a given month. Tx from MD and facilities within the HMO network. Choose PCP (gatekeeper) who provides general medical care and must be consulted before seeing a specialist. Costs increase slower than w/ other insurance plans b/c of this control system. Advantages: Low out-of-pocket costs-fixed monthly fee; often have nominal co-payments. Focus on wellness and preventative care. Typically no lifetime maximum payout. Disadvantages of HMOs: Tight controls can make it more difficult to get specialized care. Care from non-HMO providers generally not covered. Pref. Provider Org. (PPO): provide medical service only to a specific group or association. PPO may be sponsored by a particular insurance company, by 1 or more employers, or by some other type of org. PPO physicians provide medical services to the policyholders, at discounted rates and may set up utilization control programs to help reduce the cost of medical care. In return, the sponsor(s) attempts to increase patient volume by creating an incentive for employees or policyholders to use MDs/facilities w/i PPO network. Members pay for services as they are rendered. The PPO sponsor reimburses member the cost of the Tx, minus co-payment %. Or MD can bill insurance company directly for payment and member pays co- payment amount. Price of each service negotiated in advance by the healthcare providers and the PPO sponsor(s). Advantages of PPOs: Free choice of healthcare provider. Out-of-pocket costs generally limited. Disadvantages of PPOs: Less coverage for Tx provided by non-PPO physicians. More paperwork and expenses than HMOs. Point of Service (POS) plan is a managed healthcare system that combines aspects of HMO and PPO. Like HMO, no deductible and usually only minimal co-pay when you use a MD within network. Must choose a PCP gatekeeper who is responsible for all in-network referrals. Out-of-network POS coverage functions more like PPO. Likely to have high deductible and co-pay. Advantages of POS plans Maximum freedom. Minimal co-pay. No deductible. No "gatekeeper" for non- network care. Out-of-pocket costs limited. Disadvantages of POS plans: Substantial co-pay for non-network care. Deductible for non-network care. Tight controls to get specialized care. Indemnity insurance pays for medical services as needed. no panel of benefits, pts and MDs free to use or not use a broad range of diagnostic and treatment options. Loose or nonexis tent constraints. Focus: on tx of established and dx’d disease. Generally: more costly premiums. Patients (and their employers) often choose HMO's over indemnity plans because of cost, and sacrifice some element of choice in so doing. Fee for Service Reimbursement: incentive to do more vs. Capitated Reimbursement: incentive to promote wellness Phys Exam Breast- Inspect: Skin, Symm, Shape, LN: axilla/supraclavicular, CONCENTRIC CIRCLES 3 levels: light/med/deep 3-5dys after start of menses, mass, swelling, pain, nipple discharge/inversion, Paget's, age of menarche?, age of 1st live birth? Male PE: INSPECT penis & scrotum standing/sitting, PALPATE urethra, scrotum, testes, epididymis & vas deferens, HERNIA EXAM (femoral, direct or indirect inguinal). Dx: Common sx.: pain (distended ureter, renal pelvis or bladder, priapism, HZ, hernia), dyuria (UTI causes pyuria & pneumaturia, meatal stenosis), changes in urine flow (nocturia from ↑ freq. & vol & ↓ bladder size, polyuria from polydipsia or DM or DI), red urine (hematauria, march hemoglobinuria), penile discharge (bloody from ulcerations, neoplasm or urethritis or purulent from gonococcal urethritis or chronic prostatitis), penile lesions: STDs, genital rashes, scrotal enlargement (hernia, variococele, spematococele, torsion, strangulated hernia), groin mass or swelling (hernia, carcinoma, adenopathy), erectile dysfunction (organic/psychological – need good hx, pmd, heart, HT, antidepressant, antiandgrogens, bad drugs), infertility (after 1 yr of sex w/o contraceptives – mumps, injury, x-ray) Testicles: tumor, torsion, & epididymitis/epididymo-orchitis. RECTUM: Glove/lubricate, palpate prostate, rectal wall, sphincter tone, guiaic test. Size, symm, nodule, tenderness Abdomen: Visual, auscultation b4 percussion/palpation b/c percussion may alter the freq & intensity of bowel sounds. Absence of bowel sounds is not established unless no sounds are detected during 5 min of continuous auscultation. Percussion assesses size/density of organs, detects fluid/air in abdomen. Peritonitis: rebound tenderness & ↓ bowel sounds = peritonitis. Acute pancreatitis risk factors: EtOH, trauma, hyperlipidemia, gallstones, meds. Signs: Guarding, rigidity, absent/↓ bowel sounds, rebound/referred rebound tenderness, lying still. Barium studies contraindicated in perforation. Colic/Visceral Pain: Distention of bowel/organs. Pt rolls around, moves freq. Usu. perceived pain is far from source. Bowel obstruction: Usu. from adhesions due to abdominal surgery: Assoc w/ emesis. Symptomatic relief w/ vomiting, DX on Kidneys, Ureters, Bladder - KUB (dilated loops, air fluid levels), May lead 2 bowel ischemia. Check 4 hernias. Ischemic bowel: Classic description is pain ≠ exam, usu. not peritoneal, may have ↑ WBC/fever, metabolic acidosis, urgent surgery/angio. McBurney's point (over appendix) "b/t 1-1.5‖ from the ASIS of ileum on a straight line drawn from the process 2 umbilicus." = 2/3rd of the way from the umbilicus to ASIS. Caput medusae: the dilated abdominal veins seen in pts w/ portal HTN. Ultrasound 4 Liver, Biliary & GYN pathology. CT Scan 4 bowel & location of masses/collections. Cholecystitis: RUQ tenderness, fever, WBC, ↑ enzymes. RUQ ultrasound. Biliary Colic: RUQ tenderness, NO fever or WBC elevated enzymes may be present. Pancreatitis: Boring Pain in the upper epigastrium/back: EtOH or gallstone w/ ↑ amylase/lipase. Evaluate with CT scan of abdomen. H&N Exam: Test extraocular movements, Rinne test, Do otoscopy, pulling ear up, out, & back b4 inserting scope. Inspect canal/tymp memb. Identify light reflex anteriorly on tymp memb. Weber test: Weber lateralizes to conductive loss, away from sensorineural loss. Rinne test: sensorineural: Air conduction greater than bone. Conductive: bone conduction greater than air = negative Rinne test. Wax blockage is #1 cause of conduction hearing loss. Eye: pinhole test improves visual acuity if refractory errors are present (most commonly myopia). Pseudochromatic plate test detects color blindness. Schiotz tonometry measures intraocular pressure. Fluorescein staining used to detect abrasions of the cornea. Cobalt blue light: used to detect foreign bodies after fluorescein is put into affected eye. Sequela of blunt trauma 2 eye is a hyphema (blood in the anterior chamber): caused by rupture of small vessels lying near cornea. Strabismus: misalignment of eyes. Esotropia: kind of strabismus where 1 eye is deviated inward. Amblyopia ("lazy eye"): loss of visual acuity in an otherwise healthy eye. Subconjunctival hemorrhage (b/t conjunctiva & sclera) causes the sudden appearance of a bright red spot. Abbrev. 4 visual acuity (VA): OD = Oculus dexter RIGHT eye, OS = Oculus sinister or LEFT eye OU = Oculus uterque or both eyes VA: recorded as a fraction distance the patient is from the chart (usu 20 ft)/the dist at which the avg person can read the same line (200 ft). All mm. by CNIII except LR6SO4. normal intraocular pressure: 10-21.5 mmHg. Nystagmus: abnormal involuntary rhythmic eye movement. PUPILLARY REFLEXES: Absent Direct Reflex: Indicates problem w/ afferent branch (CN V1) of the reflex. Absent Consensual Reflex: Indicates problem w/ efferent branch (CN III, Edinger-Westphal Nucleus) of affected eye. CONVERGENCE: Ability of eyes 2 focus inward/accommodate for near vision. Impaired convergence is seen with Grave's Disease. NYSTAGMUS: Normal when looking in the periphery for extended times. All other nystagmus is abnormal. Causes: Labyrinthitis, MS, Wernicke-Korsakoff, Meniere's Disease EXTRAOCULAR PALSIES: SO4 LR6 Internal Strabismus: Eye points in, due to denervation of the Abducens, CN VI. External Strabismus: Eye points out and down, due to denervation of the Oculomotor, CN III. Eye points out because of influence of Abducens (CN VI) Eye points down because of influence of Trochlear (CN IV) ------> Superior Oblique muscle. VISUAL FIELD DEFICITS: BITEMPORAL HEMIANOPSIA: ↓ of peripheral vision; tunnel vision, occurs w/ Pituitary Tumor. HOMONYMOUS HEMIANOPSIA: ↓ of same visual field in both eyes. Occurs due to lesion in Optic Tract. QUADRANT HEMIANOPSIA: Lesion in the optic radiations.