SOMC 236
CLINICAL FOUNDATIONS
ACA ACTIVITY LOG & PHYSICAL
EXAM SKILLS CHECKLIST
2013-2014
 BLUE BOOK 
UCSD Ambulatory Care Apprenticeship (ACA)
SOMC 236 MS2
ACA ACTIVITY LOG & PHYSICAL EXAM SKILLS CHECKLIST
Certification
STUDENT’S PRINTED NAME:
First name
MI
Last Name
DATE CHECKLIST BOOK RECEIVED BY STUDENT:
DATE CHECKLIST BOOK COMPLETED:
CERTIFICATION BY STUDENT:
My signature below certifies that I have performed each of the listed tasks the required number of times. I also certify
that each person signing off on each task did observe my performance of the task and also indicated to me the
adequacy of my performance.
SIGNATURE OF STUDENT:
DATE:
UCSD Ambulatory Care Apprenticeship (ACA)
SOMC 236 MS2
UCSD Ambulatory Care Apprenticeship (ACA)
SOMC 236 MS2
Dear Clinical Foundation Students:
As a requirement for the Ambulatory Care Apprenticeship (ACA), complete this activity log after each session. This log
will provide us with valuable information about the experience that you have during this component of the Clinical
Foundations course. We are interested in understanding the interactions that you have with both patients and your
preceptors. This log will also help you to review your experience with your preceptor throughout the apprenticeship so that
you can adjust your sessions to provide broader opportunities if necessary.
Resource TEAR OUTS: Discuss with your ACA preceptor
nd
We have included in this log, 2 copies of each sessions’ learning objectives. One copy is your resource to keep; and 2
copy is for you to tear out and give to your preceptor as their resource and as a focus for discussion with your preceptor at
each session.
From the very first meeting with your ACA preceptor you are building a relationship. Being an engaged and active
participant in each ACA session is crucial to your success. You have a limited number of sessions to build a successful
relationship with your ACA preceptor over the two year ACA timeline. Being absent from even one session significantly
diminishes your experience and your opportunities for clinical skills development.
Patients Seen: Please fill in the number of patients, for whom (1) you were an observer only (2) you elicited components
of the history or performed components of the physical alone (i.e. without preceptor observation) (3) were observed by the
preceptor for part of your interaction with the patient, either taking a history or performing PEX components or (4) were
observed by the preceptor during your entire interaction with the patient. If there were patients for whom a “hybrid” of
these descriptions occurred, please choose the one that describes the encounter most accurately (i.e. the # column
should add up to the total number of patients seen).
Types of Clinical Encounters: Please record the number of patients who were seen for (1) a comprehensive H&P (2) a
focused visit for chronic problem(s) (3) a focused visit for an acute problem.
History Components Elicited and Organ Systems Examined: Please circle all of these that you had a chance to elicit
or examine during your session.
Written Medical Records: Please record (1) the number of full or partial SOAP notes you wrote, (2) the number of full
H&Ps you wrote during the session or assigned by your preceptor to be done after the session (3) any other
documentation in the med record you did (e.g. problem lists, medication lists, health maintenance logs etc.) - describe the
type of record and number of each.
Other: Here you can record things like topics your preceptor assigned you to look up between sessions.
Write Ups: At the end of this booklet you will find guides for H&P and SOAP notes.
Please feel free to contact us with any questions.
Rusty Kallenberg, M.D.
ACA Director
Shawn Harrity, M.D.
Clinical Foundations Director
Charlie Goldberg, M.D.
Clinical Foundations Director
Kristin Cadenhead, M.D.
Clinical Foundations Director
Michelle Johnson, M.D.
Clinical Foundations Director
UCSD Ambulatory Care Apprenticeship (ACA)
SOMC 236 MS2
Blank
UCSD Ambulatory Care Apprenticeship (ACA)
SOMC 236 MS2
Session 1 – Preceptor Resource
Just like last year these one-pagers provide an orientation to the tasks of your ACA session each week. There are
tasks for you to do, specific things for you to observe, skills to practice, items to record, topics to learn about and
questions/issues upon which to reflect.
To Do
At the beginning of second year ACA – IF YOU ARE IN A NEW OFFICE:
1. Get to know your preceptor: where from originally, his/her educational background, a bit about his/her personal
life, professional practice history, etc. Share your own. This will be a long-term mentoring relationship and the
more you get to know one another the higher the likelihood that you will enjoy each other in the process.
2. Get to know the other physicians in the office too. They will sometimes stand in for your preceptor and are often
eager to share interesting patients and events with you.
3. Get to know the staff of the office and understand their jobs and how they make the place go.
4. Understand patient flow through the office and how patients check in, where they wait, how the nurses interact
with them and what happens after you and your doc leave the exam room.
5. IF YOU ARE RETURNING TO YOUR PREVIOUS ACA OFFICE
6. Reconnect with your preceptor: share what you’ve both been up to since you last met.
7. Discuss goals for this year: aspects of history taking and physical exam skills that you particularly want to focus on
and learn better. It’s nice to share with your preceptor the overall schedule of the year’s POM sessions & HHD
course work – so s/he has an idea of what you will be learning this year.
At the Beginning of Each Session
1. Look at the schedule and see which patients are scheduled; talk with your preceptor and decide who it might be
inappropriate for you to see with him/her.
2. You should now be regularly seeing a couple of patients by yourself for the initial part of their visits. At the
beginning of the session it’s a good idea to mutually decide with your preceptor which patient(s) might be
candidates for you to see alone initially.
3. This is also a good time to report on any learning issues you looked up or go over any SOAP notes you might have
written from the last session.
To Observe
Recall from last year:
1. Observe why patients are in the office. There are usually one or more of the following simple “reasons for the
visit”: an acute problem, follow up of one or more chronic problem(s), a health maintenance visit, a problem
stemming largely from an emotional/behavioral issue, an “administrative” issue – like needing a form filled out or
a letter written.
2. Observe whether this is a patient known to your preceptor or a first-time visit for the patient; note any
differences in how your preceptor interacts or communicates with new vs. known patients. Continuity of care
plays a large role in delivering patient-centered care; note how your preceptor’s (or your own!) prior knowledge
of the patient affects the conduct of the visit and the handling of problems presented.
3. Observe how your preceptor elicits the history from each patient; how the agenda for the visit is set and how
many issues are discussed.
4. Observe what parts of the physical examination take place for each patient’s specific problems as this reflects
practiced efficiency on the part of your preceptor.
From this year’s POM sessions:
1. Observe situations involving multi-person interviewing: note how your preceptor handles such situations: who
s/he addresses, how s/he includes the others accompanying the patient during the visit.
UCSD Ambulatory Care Apprenticeship (ACA)
SOMC 236 MS2
2. Observe any legal issues that come up during your sessions. Discuss with your preceptor what s/he sees as
his/her role in them, if any.
3. Observe for any dermatology issues that patients present.
To Practice
As before:
1. Always introduce yourself as a now second year medical student working with your preceptor.
2. Ask occasional questions that strike you during the history taking or – if you work this out with your preceptor you might elicit the history of a particular problem while he/she is in the room with you.
3. Keep practicing vital signs on some of the patients you are seeing. As a third year you will be absolutely expected
to be able to do this accurately.
4. Performing parts of the physical exam as appropriate to the patient’s problems. Focus also on parts that you
know you need work on and seek direct observation and feedback from your preceptor when the exam part of
the visit comes up.
5. Remember to always bring your equipment (at least stethoscope) with you to your ACA sessions.
New this year:
6. If you are in a family medicine office – you might try to see more pediatric patients to further practice your
pediatric interviewing and examination skills which you just learned.
7. Practice multi-person interviewing skills if you see a patient who is accompanied by others.
8. Practice taking an occupational history on every patient; this takes just a few seconds; then when you present
your patient’s history – you can say: “This is a 35 yr. old teacher who presents with…”
To Record
Record them in an orderly fashion on the blank pages in your Blue Book. When we activate the eportfolio section
this will be an even more convenient way to keep a record of patients seen.
To Learn About
1. Learning issues will come up during your ACA sessions. At times your preceptor might say, “This is a great topic
for you to look up!” Many questions arise every day during practice. Many physicians don’t have the time to
look them all up. One of the quid-pro-quos of having a student is to have some assistance in tracking down the
answers to many of these questions from practice. Having 1-2 areas to follow up on each session takes
advantage of a key fact of adult learning: having a reason (i.e. helping in patient care) to find out something is a
great motivator to learning. Performing this function for your preceptor and his/her patients demonstrates your
interest in learning and sharing what you’ve learned is proper reciprocation for all the things your preceptor will
teach you.
2. Other issues you yourself will identify related to pure biomedical issues that the patients you saw bring to your
attention or other psychosocial, behavioral, spiritual, socioeconomic or practice management issues that are
important to delivering care in a primary care setting.
To Reflect
“Reflection in action” is a key component of adult learning. In other words one should always be reviewing and
reflecting on how an episode of medical care delivery went. This is the way we identify gaps in care, be they
knowledge, skill or even attitude gaps. Once identified, we can always pursue additional learning to improve our
performance. Below are listed some items to reflect upon during your ACA sessions.
1. What influences might affect how you interact with patients in practice?
2. How do you handle “not knowing” something that you need to know or that the patient asks you about during a
visit? What resources are available to you to find (quick) answers to such questions?
3. Were you affected emotionally by anything you witnessed during the session? What was it and why did it affect
you and what will you do to process these emotions?
UCSD Ambulatory Care Apprenticeship (ACA)
SOMC 236 MS2
4. Were there any professionalism challenges that occurred during the session? How did your preceptor handle
these? How would you handle these on your own?
5. What do you want to share with your peers and POM mentors about your ACA experience?
REMEMBER: If you are having any difficulties in ACA – you should contact Dr. Kallenberg or the ACA support staff as
soon as possible to discuss them.
UCSD Ambulatory Care Apprenticeship (ACA)
SOMC 236 MS2
Blank
UCSD Ambulatory Care Apprenticeship (ACA)
SOMC 236 MS2
Session 1 – Student Resource
Just like last year these one-pagers provide an orientation to the tasks of your ACA session each week. There are
tasks for you to do, specific things for you to observe, skills to practice, items to record, topics to learn about and
questions/issues upon which to reflect.
To Do
At the beginning of second year ACA – IF YOU ARE IN A NEW OFFICE:
1. Get to know your preceptor: where from originally, his/her educational background, a bit about his/her personal
life, professional practice history, etc. Share your own. This will be a long-term mentoring relationship and the
more you get to know one another the higher the likelihood that you will enjoy each other in the process.
2. Get to know the other physicians in the office too. They will sometimes stand in for your preceptor and are often
eager to share interesting patients and events with you.
3. Get to know the staff of the office and understand their jobs and how they make the place go.
4. Understand patient flow through the office and how patients check in, where they wait, how the nurses interact
with them and what happens after you and your doc leave the exam room.
IF YOU ARE RETURNING TO YOUR PREVIOUS ACA OFFICE
1. Reconnect with your preceptor: share what you’ve both been up to since you last met.
2. Discuss goals for this year: aspects of history taking and physical exam skills that you particularly want to focus on
and learn better. It’s nice to share with your preceptor the overall schedule of the year’s POM sessions & HHD
course work – so s/he has an idea of what you will be learning this year.
At the Beginning of Each Session
1. Look at the schedule and see which patients are scheduled; talk with your preceptor and decide who it might be
inappropriate for you to see with him/her.
2. You should now be regularly seeing a couple of patients by yourself for the initial part of their visits. At the
beginning of the session it’s a good idea to mutually decide with your preceptor which patient(s) might be
candidates for you to see alone initially.
3. This is also a good time to report on any learning issues you looked up or go over any SOAP notes you might have
written from the last session.
To Observe
Recall from last year:
1. Observe why patients are in the office. There are usually one or more of the following simple “reasons for the
visit”: an acute problem, follow up of one or more chronic problem(s), a health maintenance visit, a problem
stemming largely from an emotional/behavioral issue, an “administrative” issue – like needing a form filled out or
a letter written.
2. Observe whether this is a patient known to your preceptor or a first-time visit for the patient; note any
differences in how your preceptor interacts or communicates with new vs. known patients. Continuity of care
plays a large role in delivering patient-centered care; note how your preceptor’s (or your own!) prior knowledge
of the patient affects the conduct of the visit and the handling of problems presented.
3. Observe how your preceptor elicits the history from each patient; how the agenda for the visit is set and how
many issues are discussed.
4. Observe what parts of the physical examination take place for each patient’s specific problems as this reflects
practiced efficiency on the part of your preceptor.
From this year’s POM sessions:
1. Observe situations involving multi-person interviewing: note how your preceptor handles such situations: who
s/he addresses, how s/he includes the others accompanying the patient during the visit.
2. Observe any legal issues that come up during your sessions. Discuss with your preceptor what s/he sees as
his/her role in them, if any.
UCSD Ambulatory Care Apprenticeship (ACA)
SOMC 236 MS2
3. Observe for any dermatology issues that patients present.
To Practice
As before:
1. Always introduce yourself as a now second year medical student working with your preceptor.
2. Ask occasional questions that strike you during the history taking or – if you work this out with your preceptor you might elicit the history of a particular problem while he/she is in the room with you.
3. Keep practicing vital signs on some of the patients you are seeing. As a third year you will be absolutely expected
to be able to do this accurately.
4. Performing parts of the physical exam as appropriate to the patient’s problems. Focus also on parts that you
know you need work on and seek direct observation and feedback from your preceptor when the exam part of
the visit comes up.
5. Remember to always bring your equipment (at least stethoscope) with you to your ACA sessions.
New this year:
1. If you are in a family medicine office – you might try to see more pediatric patients to further practice your
pediatric interviewing and examination skills which you just learned.
2. Practice multi-person interviewing skills if you see a patient who is accompanied by others.
3. Practice taking an occupational history on every patient; this takes just a few seconds; then when you present
your patient’s history – you can say: “This is a 35 yr. old teacher who presents with…”
To Record
Record them in an orderly fashion on the blank pages in your Blue Book. When we activate the eportfolio section
this will be an even more convenient way to keep a record of patients seen.
To Learn About
1. Learning issues will come up during your ACA sessions. At times your preceptor might say, “This is a great topic
for you to look up!” Many questions arise every day during practice. Many physicians don’t have the time to
look them all up. One of the quid-pro-quos of having a student is to have some assistance in tracking down the
answers to many of these questions from practice. Having 1-2 areas to follow up on each session takes
advantage of a key fact of adult learning: having a reason (i.e. helping in patient care) to find out something is a
great motivator to learning. Performing this function for your preceptor and his/her patients demonstrates your
interest in learning and sharing what you’ve learned is proper reciprocation for all the things your preceptor will
teach you.
2. Other issues you yourself will identify related to pure biomedical issues that the patients you saw bring to your
attention or other psychosocial, behavioral, spiritual, socioeconomic or practice management issues that are
important to delivering care in a primary care setting.
To Reflect
1. “Reflection in action” is a key component of adult learning. In other words one should always be reviewing and
reflecting on how an episode of medical care delivery went. This is the way we identify gaps in care, be they
knowledge, skill or even attitude gaps. Once identified, we can always pursue additional learning to improve our
performance. Below are listed some items to reflect upon during your ACA sessions.
2. What influences might affect how you interact with patients in practice?
3. How do you handle “not knowing” something that you need to know or that the patient asks you about during a
visit? What resources are available to you to find (quick) answers to such questions?
4. Were you affected emotionally by anything you witnessed during the session? What was it and why did it affect
you and what will you do to process these emotions?
5. Were there any professionalism challenges that occurred during the session? How did your preceptor handle
these? How would you handle these on your own?
6. What do you want to share with your peers and POM mentors about your ACA experience?
UCSD Ambulatory Care Apprenticeship (ACA)
SOMC 236 MS2
REMEMBER: If you are having any difficulties in ACA – you should contact Dr. Kallenberg or the ACA support staff as
soon as possible to discuss them.
UCSD Ambulatory Care Apprenticeship (ACA)
SOMC 236 MS2
Blank
UCSD Ambulatory Care Apprenticeship (ACA)
SOMC 236 MS2
ACA Session 1
Patients Seen
Observed only the preceptorpatient interaction
#
Types Of
Clinical
Encounters
Establish care
or new
consultation
(i.e. full H&P)
Elicited some history alone with
patient
Performed physical exam
component(s) alone with patient
Observed by preceptor:
* taking history
* performing PEX
Observed by preceptor during
entire visit
Focused visit
for chronic
problem(s)
#
History
Components
Elicited
(Circle All)
Organ
Systems
Examined
(Circle All)
Entire HX
Vital signs
HPI (focused
history)
HEENT
Medications
Chest
Allergies
Cardiac
Full SOAP notes written
Other PMH
Neck
Annual exam
established
Patient
ACA Preceptor Signature – Session #1
SH
Partial SOAP notes written
Abdomen
Written H&Ps (done during
session or assigned for
completion prior to next session)
Back
Other:
Vascular
FH
Focused visit
for acute prob
Written Medical Records
Extrem
HMS
Neuro
ROS
Other
Date
#
UCSD Ambulatory Care Apprenticeship (ACA)
SOMC 236 MS2
Blank
UCSD Ambulatory Care Apprenticeship (ACA)
SOMC 236 MS2
Session 2 – Preceptor Resource
Just like last year these one-pagers provide an orientation to the tasks of your ACA session each week. There are
tasks for you to do, specific things for you to observe, skills to practice, items to record, topics to learn about and
questions/issues upon which to reflect.
To Do
At the Beginning of Each Session
1. Look at the schedule and see whose coming; talk with your preceptor and decide who it might be inappropriate
for you to see with him/her.
2. You should now be regularly seeing a couple of patients by yourself for the initial part of their visits. At the
beginning of the session it’s a good idea to mutually decide with your preceptor which patient(s) might be
candidates for you to see alone initially.
3. This is also a good time to report on any learning issues you looked up or go over any SOAP notes you might have
written from the last session.
To Observe
Recall from last year:
1. Observe why patients are in the office; how continuity of care plays a large role in delivering patient-centered
care; how your preceptor elicits the history from each patient; how the agenda for the visit is set and how many
issues are discussed; and what parts of the physical examination take place for each patient’s specific problems
as this reflects practiced efficiency on the part of your preceptor.
2. From this year’s POM sessions:
3. Observe situations involving multi-person interviewing: note how your preceptor handles such situations: who
s/he addresses, how s/he includes the others accompanying the patient during the visit.
4. Observe any legal issues that come up during your sessions. Discuss with your preceptor what s/he sees as
his/her role in them, if any.
5. Observe for any dermatology issues that patients present.
6. Observe how nutritional issues come up in practice: these can occur during an intake H&P or a visit dealing with
chronic disease (in which nutrition always plays a key role!), or even in visits related to mental health issues like
eating disorders.
7. Observe how your preceptor deals with motivating his/her patients to change their health behaviors. This is a
relatively new clinical skill and there is a high likelihood that your preceptor might not be aware of this. You
might discuss what you recently learned in POM about motivational interviewing.
To Practice
As before:
Always introduce yourself as a second year medical student working with your preceptor; practice your history taking skills; keep
practicing vital signs on some of the patients you are seeing; and perform parts of the physical exam as appropriate to the
patient’s problem focusing on parts that you know you need work on and seek direct observation and feedback from your
preceptor when the exam part of the visit comes up.
New this year:
1. If you are in a family medicine office – you might try to see more pediatric patients to further practice your
pediatric interviewing and examination skills which you just learned.
2. Practice multi-person interviewing skills if you see a patient who is accompanied by others.
3. Practice taking an occupational history on every patient; this takes just a few seconds; then when you present
your patient’s history – you can say: “This is a 35 yr. old teacher who presents with…”
4. Practice taking a nutrition or diet history from your patients. You can ask a simple self-assessment question like
“How’s your diet: good, bad, in need of help?” You can also ask the patient to recall what they had for breakfast
or dinner the night before to get an idea.
UCSD Ambulatory Care Apprenticeship (ACA)
SOMC 236 MS2
5. With prior agreement with your preceptor you could arrange to discuss with the patient an aspect of health
behavior that they wish to change using the principles of motivational interviewing.
To Record
It is still important at this stage of your learning to record some facts from each visit in an orderly way so you can
document the learning you are doing and the patient care experiences you are having. Record the patients you saw
with your preceptor today using the following format which is on-line under “ACA Patient Registry” for your
convenience https://meded-portal.ucsd.edu/core_cure/eportfolio/aca/
To Learn About
Learning issues that come up during your ACA sessions from either your preceptor or yourself. These can be related
to pure biomedical issues presented by the patients you saw or other psychosocial, behavioral, spiritual,
socioeconomic or practice management issues that are important to delivering care in a primary care setting.
To Reflect
“Reflection in action” is a key component of adult learning. In other words one should always be reviewing and
reflecting on how an episode of medical care delivery went. This is the way we identify gaps in care, be they
knowledge, skill or even attitude gaps. Once identified, we can always pursue additional learning to improve our
performance. Below are listed some items for reflection:
1. What influences might affect how you interact with patients in practice?
2. How do you handle “not knowing” something that you need to know or that the patient asks you about during a
visit? What resources are available to you to find (quick) answers to such questions?
3. Were you affected emotionally by anything you witnessed during the session? What was it and why did it affect
you and what will you do to process these emotions?
4. Were there any professionalism challenges that occurred during the session? How did your preceptor handle
these? How would you handle these on your own?
5. What do you want to share with your peers and POM mentors about your ACA experience?
REMEMBER: If you are having any difficulties in ACA – you should contact Dr. Kallenberg or the ACA support staff as
soon as possible to discuss them.
UCSD Ambulatory Care Apprenticeship (ACA)
SOMC 236 MS2
Session 2 - Student Resource
Just like last year these one-pagers provide an orientation to the tasks of your ACA session each week. There are
tasks for you to do, specific things for you to observe, skills to practice, items to record, topics to learn about and
questions/issues upon which to reflect.
To Do
At the Beginning of Each Session
1. Look at the schedule and see whose coming; talk with your preceptor and decide who it might be inappropriate
for you to see with him/her.
2. You should now be regularly seeing a couple of patients by yourself for the initial part of their visits. At the
beginning of the session it’s a good idea to mutually decide with your preceptor which patient(s) might be
candidates for you to see alone initially.
3. This is also a good time to report on any learning issues you looked up or go over any SOAP notes you might have
written from the last session.
To Observe
Recall from last year:
1. Observe why patients are in the office; how continuity of care plays a large role in delivering patient-centered
care; how your preceptor elicits the history from each patient; how the agenda for the visit is set and how many
issues are discussed; and what parts of the physical examination take place for each patient’s specific problems
as this reflects practiced efficiency on the part of your preceptor.
From this year’s POM sessions:
1. Observe situations involving multi-person interviewing: note how your preceptor handles such situations: who
s/he addresses, how s/he includes the others accompanying the patient during the visit.
2. Observe any legal issues that come up during your sessions. Discuss with your preceptor what s/he sees as
his/her role in them, if any.
3. Observe for any dermatology issues that patients present.
4. Observe how nutritional issues come up in practice: these can occur during an intake H&P or a visit dealing with
chronic disease (in which nutrition always plays a key role!), or even in visits related to mental health issues like
eating disorders.
5. Observe how your preceptor deals with motivating his/her patients to change their health behaviors. This is a
relatively new clinical skill and there is a high likelihood that your preceptor might not be aware of this. You
might discuss what you recently learned in POM about motivational interviewing.
To Practice
As before:
Always introduce yourself as a second year medical student working with your preceptor; practice your history taking skills; keep
practicing vital signs on some of the patients you are seeing; and perform parts of the physical exam as appropriate to the
patient’s problem focusing on parts that you know you need work on and seek direct observation and feedback from your
preceptor when the exam part of the visit comes up.
New this year:
1. If you are in a family medicine office – you might try to see more pediatric patients to further practice your
pediatric interviewing and examination skills which you just learned.
2. Practice multi-person interviewing skills if you see a patient who is accompanied by others.
3. Practice taking an occupational history on every patient; this takes just a few seconds; then when you present
your patient’s history – you can say: “This is a 35 yr. old teacher who presents with…”
4. Practice taking a nutrition or diet history from your patients. You can ask a simple self-assessment question like
“How’s your diet: good, bad, in need of help?” You can also ask the patient to recall what they had for breakfast
or dinner the night before to get an idea.
UCSD Ambulatory Care Apprenticeship (ACA)
SOMC 236 MS2
5. With prior agreement with your preceptor you could arrange to discuss with the patient an aspect of health
behavior that they wish to change using the principles of motivational interviewing.
To Record
Record them in an orderly fashion on the blank pages in your Blue Book. When we activate the eportfolio section
this will be an even more convenient way to keep a record of patients seen.
To Learn About
Learning issues that come up during your ACA sessions from either your preceptor or yourself. These can be related
to pure biomedical issues presented by the patients you saw or other psychosocial, behavioral, spiritual,
socioeconomic or practice management issues that are important to delivering care in a primary care setting.
To Reflect
“Reflection in action” is a key component of adult learning. In other words one should always be reviewing and
reflecting on how an episode of medical care delivery went. This is the way we identify gaps in care, be they
knowledge, skill or even attitude gaps. Once identified, we can always pursue additional learning to improve our
performance. Below are listed some items for reflection:
1. What influences might affect how you interact with patients in practice?
2. How do you handle “not knowing” something that you need to know or that the patient asks you about during a
visit? What resources are available to you to find (quick) answers to such questions?
3. Were you affected emotionally by anything you witnessed during the session? What was it and why did it affect
you and what will you do to process these emotions?
4. Were there any professionalism challenges that occurred during the session? How did your preceptor handle
these? How would you handle these on your own?
5. What do you want to share with your peers and POM mentors about your ACA experience?
REMEMBER: If you are having any difficulties in ACA – you should contact Dr. Kallenberg or the ACA support staff as
soon as possible to discuss them.
UCSD Ambulatory Care Apprenticeship (ACA)
SOMC 236 MS2
ACA Session 2
Patients Seen
Observed only the preceptorpatient interaction
#
Types Of
Clinical
Encounters
Establish care
or new
consultation
(i.e. full H&P)
Elicited some history alone with
patient
Performed physical exam
component(s) alone with patient
Observed by preceptor:
* taking history
* performing PEX
Observed by preceptor during
entire visit
Focused visit
for chronic
problem(s)
#
History
Components
Elicited
(Circle All)
Organ
Systems
Examined
(Circle All)
Entire HX
Vital signs
HPI (focused
history)
HEENT
Medications
Chest
Allergies
Cardiac
Full SOAP notes written
Other PMH
Neck
Annual exam
established
Patient
ACA Preceptor Signature – Session #2
SH
Partial SOAP notes written
Abdomen
Written H&Ps (done during
session or assigned for
completion prior to next session)
Back
Other:
Vascular
FH
Focused visit
for acute prob
Written Medical Records
Extrem
HMS
Neuro
ROS
Other
Date
#
UCSD Ambulatory Care Apprenticeship (ACA)
SOMC 236 MS2
Blank
UCSD Ambulatory Care Apprenticeship (ACA)
SOMC 236 MS2
Session 3 – Preceptor Resource
Just like last year these one-pagers provide an orientation to the tasks of your ACA session each week. There are
tasks for you to do, specific things for you to observe, skills to practice, items to record, topics to learn about and
questions/issues upon which to reflect.
To Do
At the Beginning of Each Session
1. Look at the schedule and see whose coming; talk with your preceptor and decide who it might be inappropriate
for you to see with him/her.
2. You should now be regularly seeing a couple of patients by yourself for the initial part of their visits. At the
beginning of the session it’s a good idea to mutually decide with your preceptor which patient(s) might be
candidates for you to see alone initially.
3. This is also a good time to report on any learning issues you looked up or go over any SOAP notes you might have
written from the last session.
To Observe
Recall from last year:
1.
Observe why patients are in the office; how continuity of care plays a large role in delivering patient-centered care; how
your preceptor elicits the history from each patient; how the agenda for the visit is set and how many issues are discussed;
and what parts of the physical examination take place for each patient’s specific problems as this reflects practiced efficiency
on the part of your preceptor.
From this year’s POM sessions:
1. Observe situations involving multi-person interviewing: note how your preceptor handles such situations: who
s/he addresses, how s/he includes the others accompanying the patient during the visit.
2. Observe any legal issues that come up during your sessions. Discuss with your preceptor what s/he sees as
his/her role in them, if any.
3. Observe for any dermatology issues that patients present.
4. Observe how nutritional issues come up in practice: these can occur during an intake H&P or a visit dealing with
chronic disease (in which nutrition always plays a key role!), or even in visits related to mental health issues like
eating disorders.
5. Observe how your preceptor deals with motivating his/her patients to change their health behaviors. This is a
relatively new clinical skill and there is a high likelihood that your preceptor might not be aware of this. You
might discuss what you recently learned in POM about motivational interviewing.
To Practice
As before:
Always introduce yourself as a second year medical student working with your preceptor; practice your history taking
skills; keep practicing vital signs on some of the patients you are seeing; and perform parts of the physical exam as
appropriate to the patient’s problem focusing on parts that you know you need work on and seek direct observation
and feedback from your preceptor when the exam part of the visit comes up.
New this year:
1. If you are in a family medicine office – you might try to see more pediatric patients to further practice your
pediatric interviewing and examination skills which you just learned.
2. Practice multi-person interviewing skills if you see a patient who is accompanied by others.
3. Practice taking an occupational history on every patient; this takes just a few seconds; then when you present
your patient’s history – you can say: “This is a 35 yr. old teacher who presents with…”
4. Practice taking a nutrition or diet history from your patients. You can ask a simple self-assessment question like
“How’s your diet: good, bad, in need of help?” You can also ask the patient to recall what they had for breakfast
or dinner the night before to get an idea.
UCSD Ambulatory Care Apprenticeship (ACA)
SOMC 236 MS2
5. With prior agreement with your preceptor you could arrange to discuss with the patient an aspect of health
behavior that they wish to change using the principles of motivational interviewing.
6. Practice your cardiac history and exam skills with appropriate patients.
To Record
Record them in an orderly fashion on the blank pages in your Blue Book. When we activate the eportfolio section
this will be an even more convenient way to keep a record of patients seen.
To Learn About
Learning issues that come up during your ACA sessions from either your preceptor or yourself. These can be related
to pure biomedical issues presented by the patients you saw or other psychosocial, behavioral, spiritual,
socioeconomic or practice management issues that are important to delivering care in a primary care setting.
To Reflect
“Reflection in action” is a key component of adult learning. In other words one should always be reviewing and
reflecting on how an episode of medical care delivery went. This is the way we identify gaps in care, be they
knowledge, skill or even attitude gaps. Once identified, we can always pursue additional learning to improve our
performance. Below are listed some items for reflection:
1. What influences might affect how you interact with patients in practice?
2. How do you handle “not knowing” something that you need to know or that the patient asks you about during a
visit? What resources are available to you to find (quick) answers to such questions?
3. Were you affected emotionally by anything you witnessed during the session? What was it and why did it affect
you and what will you do to process these emotions?
4. Were there any professionalism challenges that occurred during the session? How did your preceptor handle
these? How would you handle these on your own?
5. What do you want to share with your peers and POM mentors about your ACA experience?
REMEMBER: If you are having any difficulties in ACA – you should contact Dr. Kallenberg or the ACA support staff as
soon as possible to discuss them.
UCSD Ambulatory Care Apprenticeship (ACA)
SOMC 236 MS2
Session 3 – Student Resource
Just like last year these one-pagers provide an orientation to the tasks of your ACA session each week. There are
tasks for you to do, specific things for you to observe, skills to practice, items to record, topics to learn about and
questions/issues upon which to reflect.
To Do
At the Beginning of Each Session
1. Look at the schedule and see whose coming; talk with your preceptor and decide who it might be inappropriate
for you to see with him/her.
2. You should now be regularly seeing a couple of patients by yourself for the initial part of their visits. At the
beginning of the session it’s a good idea to mutually decide with your preceptor which patient(s) might be
candidates for you to see alone initially.
3. This is also a good time to report on any learning issues you looked up or go over any SOAP notes you might have
written from the last session.
To Observe
Recall from last year:
1.
Observe why patients are in the office; how continuity of care plays a large role in delivering patient-centered care; how
your preceptor elicits the history from each patient; how the agenda for the visit is set and how many issues are discussed;
and what parts of the physical examination take place for each patient’s specific problems as this reflects practiced efficiency
on the part of your preceptor.
From this year’s POM sessions:
1. Observe situations involving multi-person interviewing: note how your preceptor handles such situations: who
s/he addresses, how s/he includes the others accompanying the patient during the visit.
2. Observe any legal issues that come up during your sessions. Discuss with your preceptor what s/he sees as
his/her role in them, if any.
3. Observe for any dermatology issues that patients present.
4. Observe how nutritional issues come up in practice: these can occur during an intake H&P or a visit dealing with
chronic disease (in which nutrition always plays a key role!), or even in visits related to mental health issues like
eating disorders.
5. Observe how your preceptor deals with motivating his/her patients to change their health behaviors. This is a
relatively new clinical skill and there is a high likelihood that your preceptor might not be aware of this. You
might discuss what you recently learned in POM about motivational interviewing.
To Practice
As before:
Always introduce yourself as a second year medical student working with your preceptor; practice your history taking
skills; keep practicing vital signs on some of the patients you are seeing; and perform parts of the physical exam as
appropriate to the patient’s problem focusing on parts that you know you need work on and seek direct observation
and feedback from your preceptor when the exam part of the visit comes up.
New this year:
1. If you are in a family medicine office – you might try to see more pediatric patients to further practice your
pediatric interviewing and examination skills which you just learned.
2. Practice multi-person interviewing skills if you see a patient who is accompanied by others.
3. Practice taking an occupational history on every patient; this takes just a few seconds; then when you present
your patient’s history – you can say: “This is a 35 yr. old teacher who presents with…”
4. Practice taking a nutrition or diet history from your patients. You can ask a simple self-assessment question like
“How’s your diet: good, bad, in need of help?” You can also ask the patient to recall what they had for breakfast
or dinner the night before to get an idea.
UCSD Ambulatory Care Apprenticeship (ACA)
SOMC 236 MS2
5. With prior agreement with your preceptor you could arrange to discuss with the patient an aspect of health
behavior that they wish to change using the principles of motivational interviewing.
6. Practice your cardiac history and exam skills with appropriate patients.
To Record
Record them in an orderly fashion on the blank pages in your Blue Book. When we activate the eportfolio section
this will be an even more convenient way to keep a record of patients seen.
To Learn About
Learning issues that come up during your ACA sessions from either your preceptor or yourself. These can be related
to pure biomedical issues presented by the patients you saw or other psychosocial, behavioral, spiritual,
socioeconomic or practice management issues that are important to delivering care in a primary care setting.
To Reflect
“Reflection in action” is a key component of adult learning. In other words one should always be reviewing and
reflecting on how an episode of medical care delivery went. This is the way we identify gaps in care, be they
knowledge, skill or even attitude gaps. Once identified, we can always pursue additional learning to improve our
performance. Below are listed some items for reflection:
1. What influences might affect how you interact with patients in practice?
2. How do you handle “not knowing” something that you need to know or that the patient asks you about during a
visit? What resources are available to you to find (quick) answers to such questions?
3. Were you affected emotionally by anything you witnessed during the session? What was it and why did it affect
you and what will you do to process these emotions?
4. Were there any professionalism challenges that occurred during the session? How did your preceptor handle
these? How would you handle these on your own?
5. What do you want to share with your peers and POM mentors about your ACA experience?
REMEMBER: If you are having any difficulties in ACA – you should contact Dr. Kallenberg or the ACA support staff as
soon as possible to discuss them.
UCSD Ambulatory Care Apprenticeship (ACA)
SOMC 236 MS2
ACA Session 3
Patients Seen
Observed only the preceptorpatient interaction
#
Types Of
Clinical
Encounters
Establish care
or new
consultation
(i.e. full H&P)
Elicited some history alone with
patient
Performed physical exam
component(s) alone with patient
Observed by preceptor:
* taking history
* performing PEX
Observed by preceptor during
entire visit
Focused visit
for chronic
problem(s)
#
History
Components
Elicited
(Circle All)
Organ
Systems
Examined
(Circle All)
Entire HX
Vital signs
HPI (focused
history)
HEENT
Medications
Chest
Allergies
Cardiac
Other PMH
Annual exam
established
patient
ACA Preceptor Signature – Session #3
SH
Full SOAP notes written
Neck
Partial SOAP notes written
Abdomen
Written H&Ps (done during
session or assigned for
completion prior to next session)
Back
Other:
Vascular
FH
Focused visit
for acute prob
Written Medical Records
Extrem
HMS
Neuro
ROS
Other
Date
#
UCSD Ambulatory Care Apprenticeship (ACA)
SOMC 236 MS2
Blank
UCSD Ambulatory Care Apprenticeship (ACA)
SOMC 236 MS2
Session 4 – Preceptor Resource
Just like last year these one-pagers provide an orientation to the tasks of your ACA session each week. There are
tasks for you to do, specific things for you to observe, skills to practice, items to record, topics to learn about and
questions/issues upon which to reflect.
To Do
At the Beginning of Each Session
1. Look at the schedule and see whose coming; talk with your preceptor and decide who it might be inappropriate
for you to see with him/her.
2. You should now be regularly seeing a couple of patients by yourself for the initial part of their visits. At the
beginning of the session it’s a good idea to mutually decide with your preceptor which patient(s) might be
candidates for you to see alone initially.
3. This is also a good time to report on any learning issues you looked up or go over any SOAP notes you might have
written from the last session.
To Observe
Recall from last year:
1. Observe why patients are in the office; how continuity of care plays a large role in delivering patient-centered
care; how your preceptor elicits the history from each patient; how the agenda for the visit is set and how many
issues are discussed; and what parts of the physical examination take place for each patient’s specific problems
as this reflects practiced efficiency on the part of your preceptor.
From this year’s POM sessions:
1. Observe situations involving multi-person interviewing: note how your preceptor handles such situations: who
s/he addresses, how s/he includes the others accompanying the patient during the visit.
2. Observe any legal issues that come up during your sessions. Discuss with your preceptor what s/he sees as
his/her role in them, if any.
3. Observe for any dermatology issues that patients present.
4. Observe how nutritional issues come up in practice: these can occur during an intake H&P or a visit dealing with
chronic disease (in which nutrition always plays a key role!), or even in visits related to mental health issues like
eating disorders.
5. Observe how your preceptor deals with motivating his/her patients to change their health behaviors. This is a
relatively new clinical skill and there is a high likelihood that your preceptor might not be aware of this. You
might discuss what you recently learned in POM about motivational interviewing.
6. Observe for genetics issues (screening, family histories, etc.) & any associated ethical aspects.
7. Observe for issues relating to the cost of medicine, insurance coverage, health reform, etc.
To Practice
As before:
Always introduce yourself as a second year medical student working with your preceptor; practice your history taking
skills; keep practicing vital signs on some of the patients you are seeing; and perform parts of the physical exam as
appropriate to the patient’s problem focusing on parts that you know you need work on and seek direct observation
and feedback from your preceptor when the exam part of the visit comes up.
New this year:
1. If you are in a family medicine office – you might try to see more pediatric patients to further practice your
pediatric interviewing and examination skills which you just learned.
2. Practice multi-person interviewing skills if you see a patient who is accompanied by others.
3. Practice taking an occupational history on every patient; this takes just a few seconds; then when you present
your patient’s history – you can say: “This is a 35 yr. old teacher who presents with…”
UCSD Ambulatory Care Apprenticeship (ACA)
SOMC 236 MS2
4. Practice taking a nutrition or diet history from your patients. You can ask a simple self-assessment question like
“How’s your diet: good, bad, in need of help?” You can also ask the patient to recall what they had for breakfast
or dinner the night before to get an idea.
5. With prior agreement with your preceptor you could arrange to discuss with the patient an aspect of health
behavior that they wish to change using the principles of motivational interviewing.
6. Practice your cardiac history and exam skills with appropriate patients.
7. Refine your family history taking as this is the main proxy for genetic history in primary care. This includes
gathering specifics of what relative, at what age and with what outcome for each disease explored. Try using a
paper genogram with a few patients to see how this technique works in practice.
8. Now that you’ve had a refresher on the eye exam – practice your funduscopic exam.
9. Ask a few patients about the cost of their health care and whether they have any concerns.
To Record
Record them in an orderly fashion on the blank pages in your Blue Book. When we activate the eportfolio section
this will be an even more convenient way to keep a record of patients seen.
To Learn About
Learning issues that come up during your ACA sessions from either your preceptor or yourself. These can be related
to pure biomedical issues presented by the patients you saw or other psychosocial, behavioral, spiritual,
socioeconomic or practice management issues that are important to delivering care in a primary care setting.
To Reflect
“Reflection in action” is a key component of adult learning. In other words one should always be reviewing and
reflecting on how an episode of medical care delivery went. This is the way we identify gaps in care, be they
knowledge, skill or even attitude gaps. Once identified, we can always pursue additional learning to improve our
performance. Below are listed some items for reflection:
1. What influences might affect how you interact with patients in practice?
2. How do you handle “not knowing” something that you need to know or that the patient asks you about during a
visit? What resources are available to you to find (quick) answers to such questions?
3. Were you affected emotionally by anything you witnessed during the session? What was it and why did it affect
you and what will you do to process these emotions?
4. Were there any professionalism challenges that occurred during the session? How did your preceptor handle
these? How would you handle these on your own?
5. What do you want to share with your peers and POM mentors about your ACA experience?
REMEMBER: If you are having any difficulties in ACA – you should contact Dr. Kallenberg or the ACA support staff as
soon as possible to discuss them.
UCSD Ambulatory Care Apprenticeship (ACA)
SOMC 236 MS2
Session 4 – Student Resource
Just like last year these one-pagers provide an orientation to the tasks of your ACA session each week. There are
tasks for you to do, specific things for you to observe, skills to practice, items to record, topics to learn about and
questions/issues upon which to reflect.
To Do
At the Beginning of Each Session
1. Look at the schedule and see whose coming; talk with your preceptor and decide who it might be inappropriate
for you to see with him/her.
2. You should now be regularly seeing a couple of patients by yourself for the initial part of their visits. At the
beginning of the session it’s a good idea to mutually decide with your preceptor which patient(s) might be
candidates for you to see alone initially.
3. This is also a good time to report on any learning issues you looked up or go over any SOAP notes you might have
written from the last session.
To Observe
Recall from last year:
1. Observe why patients are in the office; how continuity of care plays a large role in delivering patient-centered
care; how your preceptor elicits the history from each patient; how the agenda for the visit is set and how many
issues are discussed; and what parts of the physical examination take place for each patient’s specific problems
as this reflects practiced efficiency on the part of your preceptor.
From this year’s POM sessions:
1. Observe situations involving multi-person interviewing: note how your preceptor handles such situations: who
s/he addresses, how s/he includes the others accompanying the patient during the visit.
2. Observe any legal issues that come up during your sessions. Discuss with your preceptor what s/he sees as
his/her role in them, if any.
3. Observe for any dermatology issues that patients present.
4. Observe how nutritional issues come up in practice: these can occur during an intake H&P or a visit dealing with
chronic disease (in which nutrition always plays a key role!), or even in visits related to mental health issues like
eating disorders.
5. Observe how your preceptor deals with motivating his/her patients to change their health behaviors. This is a
relatively new clinical skill and there is a high likelihood that your preceptor might not be aware of this. You
might discuss what you recently learned in POM about motivational interviewing.
6. Observe for genetics issues (screening, family histories, etc.) & any associated ethical aspects.
7. Observe for issues relating to the cost of medicine, insurance coverage, health reform, etc.
To Practice
As before:
Always introduce yourself as a second year medical student working with your preceptor; practice your history taking
skills; keep practicing vital signs on some of the patients you are seeing; and perform parts of the physical exam as
appropriate to the patient’s problem focusing on parts that you know you need work on and seek direct observation
and feedback from your preceptor when the exam part of the visit comes up.
New this year:
1. If you are in a family medicine office – you might try to see more pediatric patients to further practice your
pediatric interviewing and examination skills which you just learned.
2. Practice multi-person interviewing skills if you see a patient who is accompanied by others.
3. Practice taking an occupational history on every patient; this takes just a few seconds; then when you present
your patient’s history – you can say: “This is a 35 yr. old teacher who presents with…”
UCSD Ambulatory Care Apprenticeship (ACA)
SOMC 236 MS2
4. Practice taking a nutrition or diet history from your patients. You can ask a simple self-assessment question
like “How’s your diet: good, bad, in need of help?” You can also ask the patient to recall what they had for
breakfast or dinner the night before to get an idea.
5. With prior agreement with your preceptor you could arrange to discuss with the patient an aspect of health
behavior that they wish to change using the principles of motivational interviewing.
6. Practice your cardiac history and exam skills with appropriate patients.
7. Refine your family history taking as this is the main proxy for genetic history in primary care. This includes
gathering specifics of what relative, at what age and with what outcome for each disease explored. Try using
a paper genogram with a few patients to see how this technique works in practice.
8. Now that you’ve had a refresher on the eye exam – practice your funduscopic exam.
9. Ask a few patients about the cost of their health care and whether they have any concerns.
To Record
Record them in an orderly fashion on the blank pages in your Blue Book. When we activate the eportfolio section
this will be an even more convenient way to keep a record of patients seen.
To Learn About
Learning issues that come up during your ACA sessions from either your preceptor or yourself. These can be related
to pure biomedical issues presented by the patients you saw or other psychosocial, behavioral, spiritual,
socioeconomic or practice management issues that are important to delivering care in a primary care setting.
To Reflect
“Reflection in action” is a key component of adult learning. In other words one should always be reviewing and
reflecting on how an episode of medical care delivery went. This is the way we identify gaps in care, be they
knowledge, skill or even attitude gaps. Once identified, we can always pursue additional learning to improve our
performance. Below are listed some items for reflection:
1. What influences might affect how you interact with patients in practice?
2. How do you handle “not knowing” something that you need to know or that the patient asks you about
during a visit? What resources are available to you to find (quick) answers to such questions?
3. Were you affected emotionally by anything you witnessed during the session? What was it and why did it
affect you and what will you do to process these emotions?
4. Were there any professionalism challenges that occurred during the session? How did your preceptor handle
these? How would you handle these on your own?
5. What do you want to share with your peers and POM mentors about your ACA experience?
REMEMBER: If you are having any difficulties in ACA – you should contact Dr. Kallenberg or the ACA support staff as
soon as possible to discuss them.
UCSD Ambulatory Care Apprenticeship (ACA)
SOMC 236 MS2
ACA Session 4
Patients Seen
Observed only the preceptorpatient interaction
#
Types Of
Clinical
Encounters
Establish care
or new
consultation
(i.e. full H&P)
Elicited some history alone with
patient
Performed physical exam
component(s) alone with patient
Observed by preceptor:
* taking history
* performing PEX
Observed by preceptor during
entire visit
Focused visit
for chronic
problem(s)
#
History
Components
Elicited
(Circle All)
Organ
Systems
Examined
(Circle All)
Entire HX
Vital signs
HPI (focused
history)
HEENT
Medications
Chest
Allergies
Cardiac
Full SOAP notes written
Other PMH
Neck
Annual exam
established
patient
ACA Preceptor Signature – Session #4
SH
Partial SOAP notes written
Abdomen
Written H&Ps (done during
session or assigned for
completion prior to next session)
Back
Other:
Vascular
FH
Focused visit
for acute prob
Written Medical Records
Extrem
HMS
Neuro
ROS
Other
Date
#
UCSD Ambulatory Care Apprenticeship (ACA)
SOMC 236 MS2
Blank
UCSD Ambulatory Care Apprenticeship (ACA)
SOMC 236 MS2
Session 5 – Preceptor Resource
Just like last year these one-pagers provide an orientation to the tasks of your ACA session each week. There are
tasks for you to do, specific things for you to observe, skills to practice, items to record, topics to learn about and
questions/issues upon which to reflect.
To Do
At the Beginning of Each Session
1. Look at the schedule and see whose coming; talk with your preceptor and decide who it might be
inappropriate for you to see with him/her.
2. You should now be regularly seeing a couple of patients by yourself for the initial part of their visits. At the
beginning of the session it’s a good idea to mutually decide with your preceptor which patient(s) might be
candidates for you to see alone initially.
3. This is also a good time to report on any learning issues you looked up or go over any SOAP notes you might
have written from the last session.
To Observe
Recall from last year:
1. Observe why patients are in the office; how continuity of care plays a large role in delivering patient-centered
care; how your preceptor elicits the history from each patient; how the agenda for the visit is set and how
many issues are discussed; and what parts of the physical examination take place for each patient’s specific
problems as this reflects practiced efficiency on the part of your preceptor.
From last semester’s POM sessions:
1. Observe situations involving multi-person interviewing: note how your preceptor handles such situations:
who s/he addresses, how s/he includes the others accompanying the patient during the visit.
2. Observe any legal issues that come up during your sessions. Discuss with your preceptor what s/he sees as
his/her role in them, if any.
3. Observe for any dermatology issues that patients present.
4. Observe how nutritional issues come up in practice: these can occur during an intake H&P or a visit dealing
with chronic disease (in which nutrition always plays a key role!), or even in visits related to mental health
issues like eating disorders.
5. Observe how your preceptor deals with motivating his/her patients to change their health behaviors. This is a
relatively new clinical skill and there is a high likelihood that your preceptor might not be aware of this. You
might discuss what you recently learned in POM about motivational interviewing.
6. Observe for genetics issues (screening, family histories, etc.) & any associated ethical aspects.
7. Observe for issues relating to the cost of medicine, insurance coverage, health reform, etc.
New this semester:
1. Observe situations where patients are under stress and/or the interaction is challenging to carry out, and
how your preceptor handles/defuses such situations.
To Practice
As before:
Always introduce yourself as a second year medical student working with your preceptor; practice your history taking
skills; keep practicing vital signs on some of the patients you are seeing; and perform parts of the physical exam as
appropriate to the patient’s problem focusing on parts that you know you need work on and seek direct observation
and feedback from your preceptor when the exam part of the visit comes up.
From last semester:
1. If you are in a family medicine office – you might try to see more pediatric patients to further practice your
pediatric interviewing and examination skills which you just learned.
2. Practice multi-person interviewing skills if you see a patient who is accompanied by others.
UCSD Ambulatory Care Apprenticeship (ACA)
SOMC 236 MS2
3. Practice taking an occupational history on every patient; this takes just a few seconds; then when you present
your patient’s history – you can say: “This is a 35 yr. old teacher who presents with…”
4. Practice taking a nutrition or diet history from your patients. You can ask a simple self-assessment question
like “How’s your diet: good, bad, in need of help?” You can also ask the patient to recall what they had for
breakfast or dinner the night before to get an idea.
5. With prior agreement with your preceptor you could arrange to discuss with the patient an aspect of health
behavior that they wish to change using the principles of motivational interviewing.
6. Practice your cardiac history and exam skills with appropriate patients.
7. Refine your family history taking as this is the main proxy for genetic history in primary care. This includes
gathering specifics of what relative, at what age and with what outcome for each disease explored. Try using
a paper genogram with a few patients to see how this technique works in practice.
8. Now that you’ve had a refresher on the eye exam – practice your funduscopic exam.
9. Ask a few patients about the cost of their health care and whether they have any concerns.
New this semester:
1. Practice communicating with patients who are in challenging situations or under stress. This requires you to
remember your emotion management skills taught last year (recognizing emotions, naming them, and offering
support and partnership in dealing with the patient’s issues).
To Record
Record them in an orderly fashion on the blank pages in your Blue Book. When we activate the eportfolio section
this will be an even more convenient way to keep a record of patients seen.
To Learn About
Learning issues that come up during your ACA sessions from either your preceptor or yourself. These can be related
to pure biomedical issues presented by the patients you saw or other psychosocial, behavioral, spiritual,
socioeconomic or practice management issues that are important to delivering care in a primary care setting.
To Reflect
“Reflection in action” is a key component of adult learning. In other words one should always be reviewing and
reflecting on how an episode of medical care delivery went. This is the way we identify gaps in care, be they
knowledge, skill or even attitude gaps. Once identified, we can always pursue additional learning to improve our
performance. Below are listed some items for reflection:
1. What influences might affect how you interact with patients in practice?
2. How do you handle “not knowing” something that you need to know or that the patient asks you about during a
visit? What resources are available to you to find (quick) answers to such questions?
3. Were you affected emotionally by anything you witnessed during the session? What was it and why did it affect
you and what will you do to process these emotions?
4. Were there any professionalism challenges that occurred during the session? How did your preceptor handle
these? How would you handle these on your own?
5. What do you want to share with your peers and POM mentors about your ACA experience?
REMEMBER: If you are having any difficulties in ACA – you should contact Dr. Kallenberg or the ACA support staff as
soon as possible to discuss them.
UCSD Ambulatory Care Apprenticeship (ACA)
SOMC 236 MS2
Session 5 – Student Resource
Just like last year these one-pagers provide an orientation to the tasks of your ACA session each week. There are
tasks for you to do, specific things for you to observe, skills to practice, items to record, topics to learn about and
questions/issues upon which to reflect.
To Do
At the Beginning of Each Session
1. Look at the schedule and see whose coming; talk with your preceptor and decide who it might be inappropriate
for you to see with him/her.
2. You should now be regularly seeing a couple of patients by yourself for the initial part of their visits. At the
beginning of the session it’s a good idea to mutually decide with your preceptor which patient(s) might be
candidates for you to see alone initially.
3. This is also a good time to report on any learning issues you looked up or go over any SOAP notes you might have
written from the last session.
To Observe
Recall from last year:
1. Observe why patients are in the office; how continuity of care plays a large role in delivering patient-centered
care; how your preceptor elicits the history from each patient; how the agenda for the visit is set and how many
issues are discussed; and what parts of the physical examination take place for each patient’s specific problems
as this reflects practiced efficiency on the part of your preceptor.
From last semester’s POM sessions:
1. Observe situations involving multi-person interviewing: note how your preceptor handles such situations: who
s/he addresses, how s/he includes the others accompanying the patient during the visit.
2. Observe any legal issues that come up during your sessions. Discuss with your preceptor what s/he sees as
his/her role in them, if any.
3. Observe for any dermatology issues that patients present.
4. Observe how nutritional issues come up in practice: these can occur during an intake H&P or a visit dealing with
chronic disease (in which nutrition always plays a key role!), or even in visits related to mental health issues like
eating disorders.
5. Observe how your preceptor deals with motivating his/her patients to change their health behaviors. This is a
relatively new clinical skill and there is a high likelihood that your preceptor might not be aware of this. You
might discuss what you recently learned in POM about motivational interviewing.
6. Observe for genetics issues (screening, family histories, etc.) & any associated ethical aspects.
7. Observe for issues relating to the cost of medicine, insurance coverage, health reform, etc.
New this semester:
1. Observe situations where patients are under stress and/or the interaction is challenging to carry out, and how
your preceptor handles/defuses such situations.
To Practice
As before:
Always introduce yourself as a second year medical student working with your preceptor; practice your history taking
skills; keep practicing vital signs on some of the patients you are seeing; and perform parts of the physical exam as
appropriate to the patient’s problem focusing on parts that you know you need work on and seek direct observation
and feedback from your preceptor when the exam part of the visit comes up.
From last semester:
1. If you are in a family medicine office – you might try to see more pediatric patients to further practice your
pediatric interviewing and examination skills which you just learned.
2. Practice multi-person interviewing skills if you see a patient who is accompanied by others.
UCSD Ambulatory Care Apprenticeship (ACA)
SOMC 236 MS2
3. Practice taking an occupational history on every patient; this takes just a few seconds; then when you present
your patient’s history – you can say: “This is a 35 yr. old teacher who presents with…”
4. Practice taking a nutrition or diet history from your patients. You can ask a simple self-assessment question
like “How’s your diet: good, bad, in need of help?” You can also ask the patient to recall what they had for
breakfast or dinner the night before to get an idea.
5. With prior agreement with your preceptor you could arrange to discuss with the patient an aspect of health
behavior that they wish to change using the principles of motivational interviewing.
6. Practice your cardiac history and exam skills with appropriate patients.
7. Refine your family history taking as this is the main proxy for genetic history in primary care. This includes
gathering specifics of what relative, at what age and with what outcome for each disease explored. Try using
a paper genogram with a few patients to see how this technique works in practice.
8. Now that you’ve had a refresher on the eye exam – practice your funduscopic exam.
9. Ask a few patients about the cost of their health care and whether they have any concerns.
10. New this semester:
11. Practice communicating with patients who are in challenging situations or under stress. This requires you to
remember your emotion management skills taught last year (recognizing emotions, naming them, and
offering support and partnership in dealing with the patient’s issues).
To Record
Record them in an orderly fashion on the blank pages in your Blue Book. When we activate the eportfolio section
this will be an even more convenient way to keep a record of patients seen.
To Learn About
Learning issues that come up during your ACA sessions from either your preceptor or yourself. These can be related
to pure biomedical issues presented by the patients you saw or other psychosocial, behavioral, spiritual,
socioeconomic or practice management issues that are important to delivering care in a primary care setting.
To Reflect
“Reflection in action” is a key component of adult learning. In other words one should always be reviewing and
reflecting on how an episode of medical care delivery went. This is the way we identify gaps in care, be they
knowledge, skill or even attitude gaps. Once identified, we can always pursue additional learning to improve our
performance. Below are listed some items for reflection:
1. What influences might affect how you interact with patients in practice?
2. How do you handle “not knowing” something that you need to know or that the patient asks you about during a
visit? What resources are available to you to find (quick) answers to such questions?
3. Were you affected emotionally by anything you witnessed during the session? What was it and why did it affect
you and what will you do to process these emotions?
4. Were there any professionalism challenges that occurred during the session? How did your preceptor handle
these? How would you handle these on your own?
5. What do you want to share with your peers and POM mentors about your ACA experience?
REMEMBER: If you are having any difficulties in ACA – you should contact Dr. Kallenberg or the ACA support staff as
soon as possible to discuss them.
UCSD Ambulatory Care Apprenticeship (ACA)
SOMC 236 MS2
ACA Session 5
Patients Seen
Observed only the preceptorpatient interaction
#
Types Of
Clinical
Encounters
Establish care
or new
consultation
(i.e. full H&P)
Elicited some history alone with
patient
Performed physical exam
component(s) alone with patient
Observed by preceptor:
* taking history
* performing PEX
Observed by preceptor during
entire visit
Focused visit
for chronic
problem(s)
#
History
Components
Elicited
(Circle All)
Organ
Systems
Examined
(Circle All)
Entire HX
Vital signs
HPI (focused
history)
HEENT
Medications
Chest
Allergies
Cardiac
Full SOAP notes written
Other PMH
Neck
Annual exam
established
patient
ACA Preceptor Signature – Session #5
SH
Partial SOAP notes written
Abdomen
Written H&Ps (done during
session or assigned for
completion prior to next session)
Back
Other:
Vascular
FH
Focused visit
for acute prob
Written Medical Records
Extrem
HMS
Neuro
ROS
Other
Date
#
UCSD Ambulatory Care Apprenticeship (ACA)
SOMC 236 MS2
Blank
UCSD Ambulatory Care Apprenticeship (ACA)
SOMC 236 MS2
Session 6 – Preceptor Resource
Just like last year these one-pagers provide an orientation to the tasks of your ACA session each week. There are
tasks for you to do, specific things for you to observe, skills to practice, items to record, topics to learn about and
questions/issues upon which to reflect.
To Do
At the Beginning of Each Session
1. Look at the schedule and see whose coming; talk with your preceptor and decide who it might be inappropriate
for you to see with him/her.
2. You should now be regularly seeing a couple of patients by yourself for the initial part of their visits. At the
beginning of the session it’s a good idea to mutually decide with your preceptor which patient(s) might be
candidates for you to see alone initially.
3. This is also a good time to report on any learning issues you looked up or go over any SOAP notes you might have
written from the last session.
To Observe
Recall from last year:
1. Observe why patients are in the office; how continuity of care plays a large role in delivering patient-centered
care; how your preceptor elicits the history from each patient; how the agenda for the visit is set and how many
issues are discussed; and what parts of the physical examination take place for each patient’s specific problems
as this reflects practiced efficiency on the part of your preceptor.
From last semester’s POM sessions:
1. Observe situations involving multi-person interviewing: note how your preceptor handles such situations: who
s/he addresses, how s/he includes the others accompanying the patient during the visit.
2. Observe any legal issues that come up during your sessions. Discuss with your preceptor what s/he sees as
his/her role in them, if any.
3. Observe for any dermatology issues that patients present.
4. Observe how nutritional issues come up in practice: these can occur during an intake H&P or a visit dealing with
chronic disease (in which nutrition always plays a key role!), or even in visits related to mental health issues like
eating disorders.
5. Observe how your preceptor deals with motivating his/her patients to change their health behaviors. This is a
relatively new clinical skill and there is a high likelihood that your preceptor might not be aware of this. You
might discuss what you recently learned in POM about motivational interviewing.
6. Observe for genetics issues (screening, family histories, etc.) & any associated ethical aspects.
7. Observe for issues relating to the cost of medicine, insurance coverage, health reform, etc.
New this semester:
1. Observe situations where patients are under stress and/or the interaction is challenging to carry out, and how
your preceptor handles/defuses such situations.
2. Observe for patients who demonstrate memory deficits or evidence of delirium or thought disorders.
To Practice
As before:
Always introduce yourself as a second year medical student working with your preceptor; practice your history taking
skills; keep practicing vital signs on some of the patients you are seeing; and perform parts of the physical exam as
appropriate to the patient’s problem focusing on parts that you know you need work on and seek direct observation
and feedback from your preceptor when the exam part of the visit comes up.
From last semester:
1. If you are in a family medicine office – you might try to see more pediatric patients to further practice your
pediatric interviewing and examination skills which you just learned.
UCSD Ambulatory Care Apprenticeship (ACA)
SOMC 236 MS2
2. Practice multi-person interviewing skills if you see a patient who is accompanied by others.
3. Practice taking an occupational history on every patient; this takes just a few seconds; then when you present
your patient’s history – you can say: “This is a 35 yr. old teacher who presents with…”
4. Practice taking a nutrition or diet history from your patients. You can ask a simple self-assessment question like
“How’s your diet: good, bad, in need of help?” You can also ask the patient to recall what they had for breakfast
or dinner the night before to get an idea.
5. With prior agreement with your preceptor you could arrange to discuss with the patient an aspect of health
behavior that they wish to change using the principles of motivational interviewing.
6. Practice your cardiac history and exam skills with appropriate patients.
7. Refine your family history taking as this is the main proxy for genetic history in primary care. This includes
gathering specifics of what relative, at what age and with what outcome for each disease explored. Try using a
paper genogram with a few patients to see how this technique works in practice.
8. Now that you’ve had a refresher on the eye exam – practice your funduscopic exam.
9. Ask a few patients about the cost of their health care and whether they have any concerns.
New this semester:
1. Practice communicating with patients who are in challenging situations or under stress. This requires you to
remember your emotion management skills taught last year (recognizing emotions, naming them, and offering
support and partnership in dealing with the patient’s issues).
2. Practice using the MMSE (Mini-Mental Status Exam) with appropriate patients.
To Record
Record them in an orderly fashion on the blank pages in your Blue Book. When we activate the eportfolio section
this will be an even more convenient way to keep a record of patients seen.
To Learn About
Learning issues that come up during your ACA sessions from either your preceptor or yourself. These can be related
to pure biomedical issues presented by the patients you saw or other psychosocial, behavioral, spiritual,
socioeconomic or practice management issues that are important to delivering care in a primary care setting.
To Reflect
“Reflection in action” is a key component of adult learning. In other words one should always be reviewing and
reflecting on how an episode of medical care delivery went. This is the way we identify gaps in care, be they
knowledge, skill or even attitude gaps. Once identified, we can always pursue additional learning to improve our
performance. Below are listed some items for reflection:
1. What influences might affect how you interact with patients in practice?
2. How do you handle “not knowing” something that you need to know or that the patient asks you about during a
visit? What resources are available to you to find (quick) answers to such questions?
3. Were you affected emotionally by anything you witnessed during the session? What was it and why did it affect
you and what will you do to process these emotions?
4. Were there any professionalism challenges that occurred during the session? How did your preceptor handle
these? How would you handle these on your own?
5. What do you want to share with your peers and POM mentors about your ACA experience?
REMEMBER: If you are having any difficulties in ACA – you should contact Dr. Kallenberg or the ACA support staff
as soon as possible to discuss them.
UCSD Ambulatory Care Apprenticeship (ACA)
SOMC 236 MS2
Session 6 – Student Resource
Just like last year these one-pagers provide an orientation to the tasks of your ACA session each week. There are
tasks for you to do, specific things for you to observe, skills to practice, items to record, topics to learn about and
questions/issues upon which to reflect.
To Do
At the Beginning of Each Session
1. Look at the schedule and see whose coming; talk with your preceptor and decide who it might be inappropriate
for you to see with him/her.
2. You should now be regularly seeing a couple of patients by yourself for the initial part of their visits. At the
beginning of the session it’s a good idea to mutually decide with your preceptor which patient(s) might be
candidates for you to see alone initially.
3. This is also a good time to report on any learning issues you looked up or go over any SOAP notes you might have
written from the last session.
To Observe
Recall from last year:
1. Observe why patients are in the office; how continuity of care plays a large role in delivering patient-centered
care; how your preceptor elicits the history from each patient; how the agenda for the visit is set and how many
issues are discussed; and what parts of the physical examination take place for each patient’s specific problems
as this reflects practiced efficiency on the part of your preceptor.
From last semester’s POM sessions:
1. Observe situations involving multi-person interviewing: note how your preceptor handles such situations: who
s/he addresses, how s/he includes the others accompanying the patient during the visit.
2. Observe any legal issues that come up during your sessions. Discuss with your preceptor what s/he sees as
his/her role in them, if any.
3. Observe for any dermatology issues that patients present.
4. Observe how nutritional issues come up in practice: these can occur during an intake H&P or a visit dealing with
chronic disease (in which nutrition always plays a key role!), or even in visits related to mental health issues like
eating disorders.
5. Observe how your preceptor deals with motivating his/her patients to change their health behaviors. This is a
relatively new clinical skill and there is a high likelihood that your preceptor might not be aware of this. You
might discuss what you recently learned in POM about motivational interviewing.
6. Observe for genetics issues (screening, family histories, etc.) & any associated ethical aspects.
7. Observe for issues relating to the cost of medicine, insurance coverage, health reform, etc.
New this semester:
1. Observe situations where patients are under stress and/or the interaction is challenging to carry out, and how
your preceptor handles/defuses such situations.
2. Observe for patients who demonstrate memory deficits or evidence of delirium or thought disorders.
To Practice
As before:
Always introduce yourself as a second year medical student working with your preceptor; practice your history taking
skills; keep practicing vital signs on some of the patients you are seeing; and perform parts of the physical exam as
appropriate to the patient’s problem focusing on parts that you know you need work on and seek direct observation
and feedback from your preceptor when the exam part of the visit comes up.
From last semester:
1. If you are in a family medicine office – you might try to see more pediatric patients to further practice your
pediatric interviewing and examination skills which you just learned.
UCSD Ambulatory Care Apprenticeship (ACA)
SOMC 236 MS2
2. Practice multi-person interviewing skills if you see a patient who is accompanied by others.
3. Practice taking an occupational history on every patient; this takes just a few seconds; then when you present
your patient’s history – you can say: “This is a 35 yr. old teacher who presents with…”
4. Practice taking a nutrition or diet history from your patients. You can ask a simple self-assessment question like
“How’s your diet: good, bad, in need of help?” You can also ask the patient to recall what they had for breakfast
or dinner the night before to get an idea.
5. With prior agreement with your preceptor you could arrange to discuss with the patient an aspect of health
behavior that they wish to change using the principles of motivational interviewing.
6. Practice your cardiac history and exam skills with appropriate patients.
7. Refine your family history taking as this is the main proxy for genetic history in primary care. This includes
gathering specifics of what relative, at what age and with what outcome for each disease explored. Try using a
paper genogram with a few patients to see how this technique works in practice.
8. Now that you’ve had a refresher on the eye exam – practice your funduscopic exam.
9. Ask a few patients about the cost of their health care and whether they have any concerns.
New this semester:
1. Practice communicating with patients who are in challenging situations or under stress. This requires you to
remember your emotion management skills taught last year (recognizing emotions, naming them, and offering
support and partnership in dealing with the patient’s issues).
2. Practice using the MMSE (Mini-Mental Status Exam) with appropriate patients.
To Record
Record them in an orderly fashion on the blank pages in your Blue Book. When we activate the eportfolio section
this will be an even more convenient way to keep a record of patients seen.
To Learn About
Learning issues that come up during your ACA sessions from either your preceptor or yourself. These can be related
to pure biomedical issues presented by the patients you saw or other psychosocial, behavioral, spiritual,
socioeconomic or practice management issues that are important to delivering care in a primary care setting.
To Reflect
“Reflection in action” is a key component of adult learning. In other words one should always be reviewing and
reflecting on how an episode of medical care delivery went. This is the way we identify gaps in care, be they
knowledge, skill or even attitude gaps. Once identified, we can always pursue additional learning to improve our
performance. Below are listed some items for reflection:
1. What influences might affect how you interact with patients in practice?
2. How do you handle “not knowing” something that you need to know or that the patient asks you about during a
visit? What resources are available to you to find (quick) answers to such questions?
3. Were you affected emotionally by anything you witnessed during the session? What was it and why did it affect
you and what will you do to process these emotions?
4. Were there any professionalism challenges that occurred during the session? How did your preceptor handle
these? How would you handle these on your own?
5. What do you want to share with your peers and POM mentors about your ACA experience?
REMEMBER: If you are having any difficulties in ACA – you should contact Dr. Kallenberg or the ACA support staff as
soon as possible to discuss them.
UCSD Ambulatory Care Apprenticeship (ACA)
SOMC 236 MS2
ACA Session 6
Patients Seen
Observed only the preceptorpatient interaction
#
Types Of
Clinical
Encounters
Establish care
or new
consultation
(i.e. full H&P)
Elicited some history alone with
patient
Performed physical exam
component(s) alone with patient
Observed by preceptor:
* taking history
* performing PEX
Observed by preceptor during
entire visit
Focused visit
for chronic
problem(s)
#
History
Components
Elicited
(Circle All)
Organ
Systems
Examined
(Circle All)
Entire HX
Vital signs
HPI (focused
history)
HEENT
Medications
Chest
Allergies
Cardiac
Full SOAP notes written
Other PMH
Neck
Annual exam
established
patient
ACA Preceptor Signature – Session #6
SH
Partial SOAP notes written
Abdomen
Written H&Ps (done during
session or assigned for
completion prior to next session)
Back
Other:
Vascular
FH
Focused visit
for acute prob
Written Medical Records
Extrem
HMS
Neuro
ROS
Other
Date
#
UCSD Ambulatory Care Apprenticeship (ACA)
SOMC 236 MS2
Blank
UCSD Ambulatory Care Apprenticeship (ACA)
SOMC 236 MS2
Session 7 – Preceptor Resource
Just like last year these one-pagers provide an orientation to the tasks of your ACA session each week. There are
tasks for you to do, specific things for you to observe, skills to practice, items to record, topics to learn about and
questions/issues upon which to reflect.
To Do
At the Beginning of Each Session
1.
2.
3.
Look at the schedule and see whose coming; talk with your preceptor and decide who it might be inappropriate for you to
see with him/her.
You should now be regularly seeing a couple of patients by yourself for the initial part of their visits. At the beginning of the
session it’s a good idea to mutually decide with your preceptor which patient(s) might be candidates for you to see alone
initially.
This is also a good time to report on any learning issues you looked up or go over any SOAP notes you might have written
from the last session.
To Observe
Recall from last year:
1.
Observe why patients are in the office; how continuity of care plays a large role in delivering patient-centered care; how
your preceptor elicits the history from each patient; how the agenda for the visit is set and how many issues are discussed;
and what parts of the physical examination take place for each patient’s specific problems as this reflects practiced efficiency
on the part of your preceptor.
From last semester’s POM sessions:
1.
2.
3.
4.
5.
6.
7.
Observe situations involving multi-person interviewing: note how your preceptor handles such situations: who s/he
addresses, how s/he includes the others accompanying the patient during the visit.
Observe any legal issues that come up during your sessions. Discuss with your preceptor what s/he sees as his/her role in
them, if any.
Observe for any dermatology issues that patients present.
Observe how nutritional issues come up in practice: these can occur during an intake H&P or a visit dealing with chronic
disease (in which nutrition always plays a key role!), or even in visits related to mental health issues like eating disorders.
Observe how your preceptor deals with motivating his/her patients to change their health behaviors. This is a relatively new
clinical skill and there is a high likelihood that your preceptor might not be aware of this. You might discuss what you
recently learned in POM about motivational interviewing.
Observe for genetics issues (screening, family histories, etc.) & any associated ethical aspects.
Observe for issues relating to the cost of medicine, insurance coverage, health reform, etc.
New this semester:
1. Observe situations where patients are under stress and/or the interaction is challenging to carry out, and how
your preceptor handles/defuses such situations.
2. Observe for patients who demonstrate memory deficits or evidence of delirium or thought disorders.
3. Observe for patients with mood disorders, impulsive/aggressive behaviors or addiction issues.
To Practice
As before:
Always introduce yourself as a second year medical student working with your preceptor; practice your history taking skills; keep
practicing vital signs on some of the patients you are seeing; and perform parts of the physical exam as appropriate to the
patient’s problem focusing on parts that you know you need work on and seek direct observation and feedback from your
preceptor when the exam part of the visit comes up.
From last semester:
1.
2.
3.
If you are in a family medicine office – you might try to see more pediatric patients to further practice your pediatric
interviewing and examination skills which you just learned.
Practice multi-person interviewing skills if you see a patient who is accompanied by others.
Practice taking an occupational history on every patient; this takes just a few seconds; then when you present your patient’s
history – you can say: “This is a 35 yr. old teacher who presents with…”
UCSD Ambulatory Care Apprenticeship (ACA)
SOMC 236 MS2
4.
5.
6.
7.
8.
9.
Practice taking a nutrition or diet history from your patients. You can ask a simple self-assessment question like “How’s your
diet: good, bad, in need of help?” You can also ask the patient to recall what they had for breakfast or dinner the night
before to get an idea.
With prior agreement with your preceptor you could arrange to discuss with the patient an aspect of health behavior that
they wish to change using the principles of motivational interviewing.
Practice your cardiac history and exam skills with appropriate patients.
Refine your family history taking as this is the main proxy for genetic history in primary care. This includes gathering
specifics of what relative, at what age and with what outcome for each disease explored. Try using a paper genogram with a
few patients to see how this technique works in practice.
Now that you’ve had a refresher on the eye exam – practice your funduscopic exam.
Ask a few patients about the cost of their health care and whether they have any concerns.
New this semester:
1. Practice communicating with patients who are in challenging situations or under stress. This requires you to
remember your emotion management skills taught last year (recognizing emotions, naming them, and offering
support and partnership in dealing with the patient’s issues).
2. Practice using the MMSE (Mini-Mental Status Exam) with appropriate patients.
3. Practice using screening tools for depression, anxiety and addictive disorders (CAGE, etc.).
4. REMEMBER to try to do a complete history and physical sometime in the last 2-3 sessions!!
To Record
Record them in an orderly fashion on the blank pages in your Blue Book. When we activate the eportfolio section
this will be an even more convenient way to keep a record of patients seen.
To Learn About
Learning issues that come up during your ACA sessions from either your preceptor or yourself. These can be related to pure
biomedical issues presented by the patients you saw or other psychosocial, behavioral, spiritual, socioeconomic or practice
management issues that are important to delivering care in a primary care setting.
To Reflect
“Reflection in action” is a key component of adult learning. In other words one should always be reviewing and reflecting on
how an episode of medical care delivery went. This is the way we identify gaps in care, be they knowledge, skill or even attitude
gaps. Once identified, we can always pursue additional learning to improve our performance. Below are listed some items for
reflection:
1. What influences might affect how you interact with patients in practice?
2. How do you handle “not knowing” something that you need to know or that the patient asks you about during a visit? What
resources are available to you to find (quick) answers to such questions?
3. Were you affected emotionally by anything you witnessed during the session? What was it and why did it affect you and
what will you do to process these emotions?
4. Were there any professionalism challenges that occurred during the session? How did your preceptor handle these? How
would you handle these on your own?
5. What do you want to share with your peers and POM mentors about your ACA experience?
REMEMBER: If you are having any difficulties in ACA – you should contact Dr. Kallenberg or the ACA support staff as
soon as possible to discuss them.
UCSD Ambulatory Care Apprenticeship (ACA)
SOMC 236 MS2
Session 7 – Student Resource
Just like last year these one-pagers provide an orientation to the tasks of your ACA session each week. There are
tasks for you to do, specific things for you to observe, skills to practice, items to record, topics to learn about and
questions/issues upon which to reflect.
To Do
At the Beginning of Each Session
1.
2.
3.
Look at the schedule and see whose coming; talk with your preceptor and decide who it might be inappropriate for you to
see with him/her.
You should now be regularly seeing a couple of patients by yourself for the initial part of their visits. At the beginning of the
session it’s a good idea to mutually decide with your preceptor which patient(s) might be candidates for you to see alone
initially.
This is also a good time to report on any learning issues you looked up or go over any SOAP notes you might have written
from the last session.
To Observe
Recall from last year:
1.
Observe why patients are in the office; how continuity of care plays a large role in delivering patient-centered care; how
your preceptor elicits the history from each patient; how the agenda for the visit is set and how many issues are discussed;
and what parts of the physical examination take place for each patient’s specific problems as this reflects practiced efficiency
on the part of your preceptor.
From last semester’s POM sessions:
2.
3.
4.
5.
6.
7.
8.
Observe situations involving multi-person interviewing: note how your preceptor handles such situations: who s/he
addresses, how s/he includes the others accompanying the patient during the visit.
Observe any legal issues that come up during your sessions. Discuss with your preceptor what s/he sees as his/her role in
them, if any.
Observe for any dermatology issues that patients present.
Observe how nutritional issues come up in practice: these can occur during an intake H&P or a visit dealing with chronic
disease (in which nutrition always plays a key role!), or even in visits related to mental health issues like eating disorders.
Observe how your preceptor deals with motivating his/her patients to change their health behaviors. This is a relatively new
clinical skill and there is a high likelihood that your preceptor might not be aware of this. You might discuss what you
recently learned in POM about motivational interviewing.
Observe for genetics issues (screening, family histories, etc.) & any associated ethical aspects.
Observe for issues relating to the cost of medicine, insurance coverage, health reform, etc.
New this semester:
1. Observe situations where patients are under stress and/or the interaction is challenging to carry out, and
how your preceptor handles/defuses such situations.
2. Observe for patients who demonstrate memory deficits or evidence of delirium or thought disorders.
3. Observe for patients with mood disorders, impulsive/aggressive behaviors or addiction issues.
To Practice
As before:
Always introduce yourself as a second year medical student working with your preceptor; practice your history taking skills; keep
practicing vital signs on some of the patients you are seeing; and perform parts of the physical exam as appropriate to the
patient’s problem focusing on parts that you know you need work on and seek direct observation and feedback from your
preceptor when the exam part of the visit comes up.
From last semester:
1.
2.
3.
If you are in a family medicine office – you might try to see more pediatric patients to further practice your pediatric
interviewing and examination skills which you just learned.
Practice multi-person interviewing skills if you see a patient who is accompanied by others.
Practice taking an occupational history on every patient; this takes just a few seconds; then when you present your
patient’s history – you can say: “This is a 35 yr. old teacher who presents with…”
UCSD Ambulatory Care Apprenticeship (ACA)
SOMC 236 MS2
4.
5.
6.
7.
8.
9.
Practice taking a nutrition or diet history from your patients. You can ask a simple self-assessment question like “How’s
your diet: good, bad, in need of help?” You can also ask the patient to recall what they had for breakfast or dinner the
night before to get an idea.
With prior agreement with your preceptor you could arrange to discuss with the patient an aspect of health behavior
that they wish to change using the principles of motivational interviewing.
Practice your cardiac history and exam skills with appropriate patients.
Refine your family history taking as this is the main proxy for genetic history in primary care. This includes gathering
specifics of what relative, at what age and with what outcome for each disease explored. Try using a paper genogram
with a few patients to see how this technique works in practice.
Now that you’ve had a refresher on the eye exam – practice your funduscopic exam.
Ask a few patients about the cost of their health care and whether they have any concerns.
New this semester:
1. Practice communicating with patients who are in challenging situations or under stress. This requires you to
remember your emotion management skills taught last year (recognizing emotions, naming them, and
offering support and partnership in dealing with the patient’s issues).
2. Practice using the MMSE (Mini-Mental Status Exam) with appropriate patients.
3. Practice using screening tools for depression, anxiety and addictive disorders (CAGE, etc.).
4. REMEMBER to try to do a complete history and physical sometime in the last 2-3 sessions!!
To Record
Record them in an orderly fashion on the blank pages in your Blue Book. When we activate the eportfolio section
this will be an even more convenient way to keep a record of patients seen.
To Learn About
Learning issues that come up during your ACA sessions from either your preceptor or yourself. These can be related to pure
biomedical issues presented by the patients you saw or other psychosocial, behavioral, spiritual, socioeconomic or practice
management issues that are important to delivering care in a primary care setting.
To Reflect
“Reflection in action” is a key component of adult learning. In other words one should always be reviewing and reflecting on
how an episode of medical care delivery went. This is the way we identify gaps in care, be they knowledge, skill or even attitude
gaps. Once identified, we can always pursue additional learning to improve our performance. Below are listed some items for
reflection:
1. What influences might affect how you interact with patients in practice?
2. How do you handle “not knowing” something that you need to know or that the patient asks you about during a visit?
What resources are available to you to find (quick) answers to such questions?
3. Were you affected emotionally by anything you witnessed during the session? What was it and why did it affect you
and what will you do to process these emotions?
4. Were there any professionalism challenges that occurred during the session? How did your preceptor handle these?
How would you handle these on your own?
5. What do you want to share with your peers and POM mentors about your ACA experience?
REMEMBER: If you are having any difficulties in ACA – you should contact Dr. Kallenberg or the ACA support staff as
soon as possible to discuss them.
UCSD Ambulatory Care Apprenticeship (ACA)
SOMC 236 MS2
ACA Session 7
Patients Seen
Observed only the preceptorpatient interaction
#
Types Of
Clinical
Encounters
Establish care
or new
consultation
(i.e. full H&P)
Elicited some history alone with
patient
Performed physical exam
component(s) alone with patient
Observed by preceptor:
* taking history
* performing PEX
Observed by preceptor during
entire visit
Focused visit
for chronic
problem(s)
#
History
Components
Elicited
(Circle All)
Organ
Systems
Examined
(Circle All)
Entire HX
Vital signs
HPI (focused
history)
HEENT
Medications
Chest
Allergies
Cardiac
Full SOAP notes written
Other PMH
Neck
Annual exam
established
patient
ACA Preceptor Signature – Session #7
SH
Partial SOAP notes written
Abdomen
Written H&Ps (done during
session or assigned for
completion prior to next session)
Back
Other:
Vascular
FH
Focused visit
for acute prob
Written Medical Records
Extrem
HMS
Neuro
ROS
Other
Date
#
UCSD Ambulatory Care Apprenticeship (ACA)
SOMC 236 MS2
Blank
UCSD Ambulatory Care Apprenticeship (ACA)
SOMC 236 MS2
Session 8 – Preceptor Resource
Just like last year these one-pagers provide an orientation to the tasks of your ACA session each week. There are
tasks for you to do, specific things for you to observe, skills to practice, items to record, topics to learn about and
questions/issues upon which to reflect.
To Do
At the Beginning of Each Session
1.
2.
3.
Look at the schedule and see whose coming; talk with your preceptor and decide who it might be inappropriate for you
to see with him/her.
You should now be regularly seeing a couple of patients by yourself for the initial part of their visits. At the beginning of
the session it’s a good idea to mutually decide with your preceptor which patient(s) might be candidates for you to see
alone initially.
This is also a good time to report on any learning issues you looked up or go over any SOAP notes you might have
written from the last session.
To Observe
Recall from last year:
1.
Observe why patients are in the office; how continuity of care plays a large role in delivering patient-centered care; how
your preceptor elicits the history from each patient; how the agenda for the visit is set and how many issues are
discussed; and what parts of the physical examination take place for each patient’s specific problems as this reflects
practiced efficiency on the part of your preceptor.
From last semester’s POM sessions:
2.
3.
4.
5.
6.
7.
8.
Observe situations involving multi-person interviewing: note how your preceptor handles such situations: who s/he
addresses, how s/he includes the others accompanying the patient during the visit.
Observe any legal issues that come up during your sessions. Discuss with your preceptor what s/he sees as his/her role
in them, if any.
Observe for any dermatology issues that patients present.
Observe how nutritional issues come up in practice: these can occur during an intake H&P or a visit dealing with chronic
disease (in which nutrition always plays a key role!), or even in visits related to mental health issues like eating
disorders.
Observe how your preceptor deals with motivating his/her patients to change their health behaviors. This is a relatively
new clinical skill and there is a high likelihood that your preceptor might not be aware of this. You might discuss what
you recently learned in POM about motivational interviewing.
Observe for genetics issues (screening, family histories, etc.) & any associated ethical aspects.
Observe for issues relating to the cost of medicine, insurance coverage, health reform, etc.
New this semester:
1. Observe situations where patients are under stress and/or the interaction is challenging to carry out, and
how your preceptor handles/defuses such situations.
2. Observe for patients who demonstrate memory deficits or evidence of delirium or thought disorders.
3. Observe for patients with mood disorders, impulsive/aggressive behaviors or addiction issues.
4. Observe if and how your preceptor screens for and elicits a history of abuse in appropriate patients.
To Practice
As before:
Always introduce yourself as a second year medical student working with your preceptor; practice your history taking skills; keep
practicing vital signs on some of the patients you are seeing; and perform parts of the physical exam as appropriate to the
patient’s problem focusing on parts that you know you need work on and seek direct observation and feedback from your
preceptor when the exam part of the visit comes up.
From last semester:
1.
2.
If you are in a family medicine office – you might try to see more pediatric patients to further practice your pediatric
interviewing and examination skills which you just learned.
Practice multi-person interviewing skills if you see a patient who is accompanied by others.
UCSD Ambulatory Care Apprenticeship (ACA)
SOMC 236 MS2
3.
4.
5.
6.
7.
8.
9.
Practice taking an occupational history on every patient; this takes just a few seconds; then when you present your
patient’s history – you can say: “This is a 35 yr. old teacher who presents with…”
Practice taking a nutrition or diet history from your patients. You can ask a simple self-assessment question like “How’s
your diet: good, bad, in need of help?” You can also ask the patient to recall what they had for breakfast or dinner the
night before to get an idea.
With prior agreement with your preceptor you could arrange to discuss with the patient an aspect of health behavior
that they wish to change using the principles of motivational interviewing.
Practice your cardiac history and exam skills with appropriate patients.
Refine your family history taking as this is the main proxy for genetic history in primary care. This includes gathering
specifics of what relative, at what age and with what outcome for each disease explored. Try using a paper genogram
with a few patients to see how this technique works in practice.
Now that you’ve had a refresher on the eye exam – practice your funduscopic exam.
Ask a few patients about the cost of their health care and whether they have any concerns.
New this semester:
1. Practice communicating with patients who are in challenging situations or under stress. This requires you to
remember your emotion management skills taught last year (recognizing emotions, naming them, and
offering support and partnership in dealing with the patient’s issues).
2. Practice using the MMSE (Mini-Mental Status Exam) with appropriate patients.
3. Practice using screening tools for depression, anxiety and addictive disorders (CAGE, etc.).
4. Practice screening for a history of abuse in appropriate patients.
5. REMEMBER to try to do a complete history and physical sometime in the last 2-3 sessions!!
To Record
Record them in an orderly fashion on the blank pages in your Blue Book. When we activate the eportfolio section
this will be an even more convenient way to keep a record of patients seen.
To Learn About
Learning issues that come up during your ACA sessions from either your preceptor or yourself. These can be related to pure
biomedical issues presented by the patients you saw or other psychosocial, behavioral, spiritual, socioeconomic or practice
management issues that are important to delivering care in a primary care setting.
To Reflect
“Reflection in action” is a key component of adult learning. In other words one should always be reviewing and reflecting on
how an episode of medical care delivery went. This is the way we identify gaps in care, be they knowledge, skill or even attitude
gaps. Once identified, we can always pursue additional learning to improve our performance. Below are listed some items for
reflection:
1. What influences might affect how you interact with patients in practice?
2. How do you handle “not knowing” something that you need to know or that the patient asks you about during a visit?
What resources are available to you to find (quick) answers to such questions?
3. Were you affected emotionally by anything you witnessed during the session? What was it and why did it affect you
and what will you do to process these emotions?
4. Were there any professionalism challenges that occurred during the session? How did your preceptor handle these?
How would you handle these on your own?
5. What do you want to share with your peers and POM mentors about your ACA experience?
REMEMBER: If you are having any difficulties in ACA – you should contact Dr. Kallenberg or the ACA support staff as
soon as possible to discuss them.
UCSD Ambulatory Care Apprenticeship (ACA)
SOMC 236 MS2
Session 8 – Student Resource
Just like last year these one-pagers provide an orientation to the tasks of your ACA session each week. There are
tasks for you to do, specific things for you to observe, skills to practice, items to record, topics to learn about and
questions/issues upon which to reflect.
To Do
At the Beginning of Each Session
1.
2.
3.
Look at the schedule and see whose coming; talk with your preceptor and decide who it might be inappropriate for you
to see with him/her.
You should now be regularly seeing a couple of patients by yourself for the initial part of their visits. At the beginning of
the session it’s a good idea to mutually decide with your preceptor which patient(s) might be candidates for you to see
alone initially.
This is also a good time to report on any learning issues you looked up or go over any SOAP notes you might have
written from the last session.
To Observe
Recall from last year:
1.
Observe why patients are in the office; how continuity of care plays a large role in delivering patient-centered care; how
your preceptor elicits the history from each patient; how the agenda for the visit is set and how many issues are
discussed; and what parts of the physical examination take place for each patient’s specific problems as this reflects
practiced efficiency on the part of your preceptor.
From last semester’s POM sessions:
1.
2.
3.
4.
5.
6.
7.
Observe situations involving multi-person interviewing: note how your preceptor handles such situations: who s/he
addresses, how s/he includes the others accompanying the patient during the visit.
Observe any legal issues that come up during your sessions. Discuss with your preceptor what s/he sees as his/her role
in them, if any.
Observe for any dermatology issues that patients present.
Observe how nutritional issues come up in practice: these can occur during an intake H&P or a visit dealing with chronic
disease (in which nutrition always plays a key role!), or even in visits related to mental health issues like eating
disorders.
Observe how your preceptor deals with motivating his/her patients to change their health behaviors. This is a relatively
new clinical skill and there is a high likelihood that your preceptor might not be aware of this. You might discuss what
you recently learned in POM about motivational interviewing.
Observe for genetics issues (screening, family histories, etc.) & any associated ethical aspects.
Observe for issues relating to the cost of medicine, insurance coverage, health reform, etc.
New this semester:
1. Observe situations where patients are under stress and/or the interaction is challenging to carry out, and
how your preceptor handles/defuses such situations.
2. Observe for patients who demonstrate memory deficits or evidence of delirium or thought disorders.
3. Observe for patients with mood disorders, impulsive/aggressive behaviors or addiction issues.
4. Observe if and how your preceptor screens for and elicits a history of abuse in appropriate patients.
To Practice
As before:
Always introduce yourself as a second year medical student working with your preceptor; practice your history taking skills; keep
practicing vital signs on some of the patients you are seeing; and perform parts of the physical exam as appropriate to the
patient’s problem focusing on parts that you know you need work on and seek direct observation and feedback from your
preceptor when the exam part of the visit comes up.
From last semester:
1.
2.
If you are in a family medicine office – you might try to see more pediatric patients to further practice your pediatric
interviewing and examination skills which you just learned.
Practice multi-person interviewing skills if you see a patient who is accompanied by others.
UCSD Ambulatory Care Apprenticeship (ACA)
SOMC 236 MS2
3.
4.
5.
6.
7.
8.
9.
Practice taking an occupational history on every patient; this takes just a few seconds; then when you present your
patient’s history – you can say: “This is a 35 yr. old teacher who presents with…”
Practice taking a nutrition or diet history from your patients. You can ask a simple self-assessment question like “How’s
your diet: good, bad, in need of help?” You can also ask the patient to recall what they had for breakfast or dinner the
night before to get an idea.
With prior agreement with your preceptor you could arrange to discuss with the patient an aspect of health behavior
that they wish to change using the principles of motivational interviewing.
Practice your cardiac history and exam skills with appropriate patients.
Refine your family history taking as this is the main proxy for genetic history in primary care. This includes gathering
specifics of what relative, at what age and with what outcome for each disease explored. Try using a paper genogram
with a few patients to see how this technique works in practice.
Now that you’ve had a refresher on the eye exam – practice your funduscopic exam.
Ask a few patients about the cost of their health care and whether they have any concerns.
New this semester:
1. Practice communicating with patients who are in challenging situations or under stress. This requires you to
remember your emotion management skills taught last year (recognizing emotions, naming them, and
offering support and partnership in dealing with the patient’s issues).
2. Practice using the MMSE (Mini-Mental Status Exam) with appropriate patients.
3. Practice using screening tools for depression, anxiety and addictive disorders (CAGE, etc.).
4. Practice screening for a history of abuse in appropriate patients.
5. REMEMBER to try to do a complete history and physical sometime in the last 2-3 sessions!!
To Record
Record them in an orderly fashion on the blank pages in your Blue Book. When we activate the eportfolio section
this will be an even more convenient way to keep a record of patients seen.
To Learn About
Learning issues that come up during your ACA sessions from either your preceptor or yourself. These can be related to pure
biomedical issues presented by the patients you saw or other psychosocial, behavioral, spiritual, socioeconomic or practice
management issues that are important to delivering care in a primary care setting.
To Reflect
“Reflection in action” is a key component of adult learning. In other words one should always be reviewing and reflecting on
how an episode of medical care delivery went. This is the way we identify gaps in care, be they knowledge, skill or even attitude
gaps. Once identified, we can always pursue additional learning to improve our performance. Below are listed some items for
reflection:
1. What influences might affect how you interact with patients in practice?
2. How do you handle “not knowing” something that you need to know or that the patient asks you about during a visit?
What resources are available to you to find (quick) answers to such questions?
3. Were you affected emotionally by anything you witnessed during the session? What was it and why did it affect you
and what will you do to process these emotions?
4. Were there any professionalism challenges that occurred during the session? How did your preceptor handle these?
How would you handle these on your own?
5. What do you want to share with your peers and POM mentors about your ACA experience?
REMEMBER: If you are having any difficulties in ACA – you should contact Dr. Kallenberg or the ACA support staff as
soon as possible to discuss them.
UCSD Ambulatory Care Apprenticeship (ACA)
SOMC 236 MS2
ACA Session 8
Patients Seen
Observed only the preceptorpatient interaction
#
Types Of
Clinical
Encounters
Establish care
or new
consultation
(i.e. full H&P)
Elicited some history alone with
patient
Performed physical exam
component(s) alone with patient
Observed by preceptor:
* taking history
* performing PEX
Observed by preceptor during
entire visit
Focused visit
for chronic
problem(s)
#
History
Components
Elicited
(Circle All)
Organ
Systems
Examined
(Circle All)
Entire HX
Vital signs
HPI (focused
history)
HEENT
Medications
Chest
Allergies
Cardiac
Full SOAP notes written
Other PMH
Neck
Annual exam
established
patient
ACA Preceptor Signature – Session #8
SH
Partial SOAP notes written
Abdomen
Written H&Ps (done during
session or assigned for
completion prior to next session)
Back
Other:
Vascular
FH
Focused visit
for acute prob
Written Medical Records
Extrem
HMS
Neuro
ROS
Other
Date
#
UCSD Ambulatory Care Apprenticeship (ACA)
SOMC 236 MS2
Blank
UCSD Ambulatory Care Apprenticeship (ACA)
SOMC 236 MS2
Session 9 – Preceptor Resource
Just like last year these one-pagers provide an orientation to the tasks of your ACA session each week. There are
tasks for you to do, specific things for you to observe, skills to practice, items to record, topics to learn about and
questions/issues upon which to reflect.
To Do
At the Beginning of Each Session
1.
2.
3.
Look at the schedule and see whose coming; talk with your preceptor and decide who it might be inappropriate for you
to see with him/her.
You should now be regularly seeing a couple of patients by yourself for the initial part of their visits. At the beginning of
the session it’s a good idea to mutually decide with your preceptor which patient(s) might be candidates for you to see
alone initially.
This is also a good time to report on any learning issues you looked up or go over any SOAP notes you might have
written from the last session.
To Observe
Recall from last year:
1.
Observe why patients are in the office; how continuity of care plays a large role in delivering patient-centered care; how
your preceptor elicits the history from each patient; how the agenda for the visit is set and how many issues are discussed;
and what parts of the physical examination take place for each patient’s specific problems as this reflects practiced efficiency
on the part of your preceptor.
From last semester’s POM sessions:
1.
2.
3.
4.
5.
6.
7.
Observe situations involving multi-person interviewing: note how your preceptor handles such situations: who s/he
addresses, how s/he includes the others accompanying the patient during the visit.
Observe any legal issues that come up during your sessions. Discuss with your preceptor what s/he sees as his/her role in
them, if any.
Observe for any dermatology issues that patients present.
Observe how nutritional issues come up in practice: these can occur during an intake H&P or a visit dealing with chronic
disease (in which nutrition always plays a key role!), or even in visits related to mental health issues like eating disorders.
Observe how your preceptor deals with motivating his/her patients to change their health behaviors. This is a relatively new
clinical skill and there is a high likelihood that your preceptor might not be aware of this. You might discuss what you
recently learned in POM about motivational interviewing.
Observe for genetics issues (screening, family histories, etc.) & any associated ethical aspects.
Observe for issues relating to the cost of medicine, insurance coverage, health reform, etc.
New this semester:
1. Observe situations where patients are under stress and/or the interaction is challenging to carry out, and how
your preceptor handles/defuses such situations.
2. Observe for patients who demonstrate memory deficits or evidence of delirium or thought disorders.
3. Observe for patients with mood disorders, impulsive/aggressive behaviors or addiction issues.
4. Observe if and how your preceptor screens for and elicits a history of abuse in appropriate patients.
5. Discuss with your preceptor whether s/he has had any experiences with impaired colleagues.
To Practice
As before:
Always introduce yourself as a second year medical student working with your preceptor; practice your history taking skills; keep
practicing vital signs on some of the patients you are seeing; and perform parts of the physical exam as appropriate to the
patient’s problem focusing on parts that you know you need work on and seek direct observation and feedback from your
preceptor when the exam part of the visit comes up.
From last semester:
1.
2.
If you are in a family medicine office – you might try to see more pediatric patients to further practice your pediatric
interviewing and examination skills which you just learned.
Practice multi-person interviewing skills if you see a patient who is accompanied by others.
UCSD Ambulatory Care Apprenticeship (ACA)
SOMC 236 MS2
3.
4.
5.
6.
7.
8.
9.
Practice taking an occupational history on every patient; this takes just a few seconds; then when you present your
patient’s history – you can say: “This is a 35 yr. old teacher who presents with…”
Practice taking a nutrition or diet history from your patients. You can ask a simple self-assessment question like “How’s
your diet: good, bad, in need of help?” You can also ask the patient to recall what they had for breakfast or dinner the
night before to get an idea.
With prior agreement with your preceptor you could arrange to discuss with the patient an aspect of health behavior
that they wish to change using the principles of motivational interviewing.
Practice your cardiac history and exam skills with appropriate patients.
Refine your family history taking as this is the main proxy for genetic history in primary care. This includes gathering
specifics of what relative, at what age and with what outcome for each disease explored. Try using a paper genogram
with a few patients to see how this technique works in practice.
Now that you’ve had a refresher on the eye exam – practice your funduscopic exam.
Ask a few patients about the cost of their health care and whether they have any concerns.
New this semester:
1. Practice communicating with patients who are in challenging situations or under stress. This requires you to
remember your emotion management skills taught last year (recognizing emotions, naming them, and
offering support and partnership in dealing with the patient’s issues).
2. Practice using the MMSE (Mini-Mental Status Exam) with appropriate patients.
3. Practice using screening tools for depression, anxiety and addictive disorders (CAGE, etc.).
4. Practice screening for a history of abuse in appropriate patients.
5. REMEMBER to try to do a complete history and physical sometime in the last 2-3 sessions!!
To Record
Record them in an orderly fashion on the blank pages in your Blue Book. When we activate the eportfolio section
this will be an even more convenient way to keep a record of patients seen.
To Learn About
Learning issues that come up during your ACA sessions from either your preceptor or yourself. These can be related to pure
biomedical issues presented by the patients you saw or other psychosocial, behavioral, spiritual, socioeconomic or practice
management issues that are important to delivering care in a primary care setting.
To Reflect
“Reflection in action” is a key component of adult learning. In other words one should always be reviewing and reflecting on
how an episode of medical care delivery went. This is the way we identify gaps in care, be they knowledge, skill or even attitude
gaps. Once identified, we can always pursue additional learning to improve our performance. Below are listed some items for
reflection:
1. What influences might affect how you interact with patients in practice?
2. How do you handle “not knowing” something that you need to know or that the patient asks you about during a visit?
What resources are available to you to find (quick) answers to such questions?
3. Were you affected emotionally by anything you witnessed during the session? What was it and why did it affect you
and what will you do to process these emotions?
4. Were there any professionalism challenges that occurred during the session? How did your preceptor handle these?
How would you handle these on your own?
5. What do you want to share with your peers and POM mentors about your ACA experience?
REMEMBER: If you are having any difficulties in ACA – you should contact Dr. Kallenberg or the ACA support staff as
soon as possible to discuss them.
UCSD Ambulatory Care Apprenticeship (ACA)
SOMC 236 MS2
Sessions 9-10 – Student Resource
Just like last year these one-pagers provide an orientation to the tasks of your ACA session each week. There are
tasks for you to do, specific things for you to observe, skills to practice, items to record, topics to learn about and
questions/issues upon which to reflect.
To Do
At the Beginning of Each Session
1.
2.
3.
Look at the schedule and see whose coming; talk with your preceptor and decide who it might be inappropriate for you
to see with him/her.
You should now be regularly seeing a couple of patients by yourself for the initial part of their visits. At the beginning of
the session it’s a good idea to mutually decide with your preceptor which patient(s) might be candidates for you to see
alone initially.
This is also a good time to report on any learning issues you looked up or go over any SOAP notes you might have
written from the last session.
To Observe
Recall from last year:
1.
Observe why patients are in the office; how continuity of care plays a large role in delivering patient-centered care; how
your preceptor elicits the history from each patient; how the agenda for the visit is set and how many issues are
discussed; and what parts of the physical examination take place for each patient’s specific problems as this reflects
practiced efficiency on the part of your preceptor.
From last semester’s POM sessions:
1.
2.
3.
4.
5.
6.
7.
Observe situations involving multi-person interviewing: note how your preceptor handles such situations: who s/he
addresses, how s/he includes the others accompanying the patient during the visit.
Observe any legal issues that come up during your sessions. Discuss with your preceptor what s/he sees as his/her role
in them, if any.
Observe for any dermatology issues that patients present.
Observe how nutritional issues come up in practice: these can occur during an intake H&P or a visit dealing with chronic
disease (in which nutrition always plays a key role!), or even in visits related to mental health issues like eating
disorders.
Observe how your preceptor deals with motivating his/her patients to change their health behaviors. This is a relatively
new clinical skill and there is a high likelihood that your preceptor might not be aware of this. You might discuss what
you recently learned in POM about motivational interviewing.
Observe for genetics issues (screening, family histories, etc.) & any associated ethical aspects.
Observe for issues relating to the cost of medicine, insurance coverage, health reform, etc.
New this semester:
1. Observe situations where patients are under stress and/or the interaction is challenging to carry out, and
how your preceptor handles/defuses such situations.
2. Observe for patients who demonstrate memory deficits or evidence of delirium or thought disorders.
3. Observe for patients with mood disorders, impulsive/aggressive behaviors or addiction issues.
4. Observe if and how your preceptor screens for and elicits a history of abuse in appropriate patients.
5. Discuss with your preceptor whether s/he has had any experiences with impaired colleagues.
To Practice
As before:
Always introduce yourself as a second year medical student working with your preceptor; practice your history taking skills; keep
practicing vital signs on some of the patients you are seeing; and perform parts of the physical exam as appropriate to the
patient’s problem focusing on parts that you know you need work on and seek direct observation and feedback from your
preceptor when the exam part of the visit comes up.
From last semester:
1.
If you are in a family medicine office – you might try to see more pediatric patients to further practice your pediatric
interviewing and examination skills which you just learned.
UCSD Ambulatory Care Apprenticeship (ACA)
SOMC 236 MS2
2.
3.
4.
5.
6.
7.
8.
9.
Practice multi-person interviewing skills if you see a patient who is accompanied by others.
Practice taking an occupational history on every patient; this takes just a few seconds; then when you present your
patient’s history – you can say: “This is a 35 yr. old teacher who presents with…”
Practice taking a nutrition or diet history from your patients. You can ask a simple self-assessment question like “How’s
your diet: good, bad, in need of help?” You can also ask the patient to recall what they had for breakfast or dinner the
night before to get an idea.
With prior agreement with your preceptor you could arrange to discuss with the patient an aspect of health behavior
that they wish to change using the principles of motivational interviewing.
Practice your cardiac history and exam skills with appropriate patients.
Refine your family history taking as this is the main proxy for genetic history in primary care. This includes gathering
specifics of what relative, at what age and with what outcome for each disease explored. Try using a paper genogram
with a few patients to see how this technique works in practice.
Now that you’ve had a refresher on the eye exam – practice your funduscopic exam.
Ask a few patients about the cost of their health care and whether they have any concerns.
New this semester:
1. Practice communicating with patients who are in challenging situations or under stress. This requires you to
remember your emotion management skills taught last year (recognizing emotions, naming them, and
offering support and partnership in dealing with the patient’s issues).
2. Practice using the MMSE (Mini-Mental Status Exam) with appropriate patients.
3. Practice using screening tools for depression, anxiety and addictive disorders (CAGE, etc.).
4. Practice screening for a history of abuse in appropriate patients.
5. REMEMBER to try to do a complete history and physical sometime in the last 2-3 sessions!!
To Record
Record them in an orderly fashion on the blank pages in your Blue Book. When we activate the eportfolio section
this will be an even more convenient way to keep a record of patients seen.
To Learn About
Learning issues that come up during your ACA sessions from either your preceptor or yourself. These can be related to pure
biomedical issues presented by the patients you saw or other psychosocial, behavioral, spiritual, socioeconomic or practice
management issues that are important to delivering care in a primary care setting.
To Reflect
“Reflection in action” is a key component of adult learning. In other words one should always be reviewing and reflecting on
how an episode of medical care delivery went. This is the way we identify gaps in care, be they knowledge, skill or even attitude
gaps. Once identified, we can always pursue additional learning to improve our performance. Below are listed some items for
reflection:
1. What influences might affect how you interact with patients in practice?
2. How do you handle “not knowing” something that you need to know or that the patient asks you about during a visit?
What resources are available to you to find (quick) answers to such questions?
3. Were you affected emotionally by anything you witnessed during the session? What was it and why did it affect you
and what will you do to process these emotions?
4. Were there any professionalism challenges that occurred during the session? How did your preceptor handle these?
How would you handle these on your own?
5. What do you want to share with your peers and POM mentors about your ACA experience?
REMEMBER: If you are having any difficulties in ACA – you should contact Dr. Kallenberg or the ACA support staff as
soon as possible to discuss them.
UCSD Ambulatory Care Apprenticeship (ACA)
SOMC 236 MS2
ACA Session 9
Patients Seen
Types Of
Clinical
Encounters
#
Observed only the preceptorpatient interaction
#
Establish care
or new
consultation
(i.e. full H&P)
Organ
Systems
Examined
(Circle All)
Entire HX
Vital signs
HPI (focused
history)
HEENT
Medications
Chest
Allergies
Cardiac
Focused visit
for chronic
problem(s)
Other PMH
Focused visit
for acute prob
* taking history
* performing PEX
SH
Annual exam
established
Patient
Observed by preceptor during
entire visit
#
Neck
Partial SOAP notes written
Abdomen
Written H&Ps (done during
session or assigned for
completion prior to next session)
Back
Other:
Vascular
FH
Observed by preceptor:
Written Medical Records
Full SOAP notes written
Elicited some history alone with
patient
Performed physical exam
component(s) alone with patient
History
Components
Elicited
(Circle All)
Extrem
HMS
Neuro
ROS
Other
ACA Preceptor Signature – Session #9
Date
ACA Session 10
Patients Seen
Observed only the preceptorpatient interaction
Types Of
Clinical
Encounters
#
Establish care
or new
consultation
(i.e. full H&P)
Elicited some history alone with
patient
Performed physical exam
component(s) alone with patient
Observed by preceptor:
* taking history
* performing PEX
Observed by preceptor during
entire visit
Focused visit
for chronic
problem(s)
#
History
Components
Elicited
(Circle All)
Organ
Systems
Examined
(Circle All)
Entire HX
Vital signs
HPI (focused
history)
HEENT
Medications
Chest
Allergies
Cardiac
Other PMH
Annual exam
established
patient
ACA Preceptor Signature – Session #9
SH
Full SOAP notes written
Neck
Partial SOAP notes written
Abdomen
Written H&Ps (done during
session or assigned for
completion prior to next session)
Back
Other:
Vascular
FH
Focused visit
for acute prob
Written Medical Records
Extrem
HMS
Neuro
ROS
Other
Date
#
UCSD Ambulatory Care Apprenticeship (ACA)
SOMC 236 MS2
Blank
UCSD Ambulatory Care Apprenticeship (ACA)
SOMC 236 MS2
• PHYSICAL EXAM SKILLS CHECKLIST
• OUTLINE OF THE PHYSICAL EXAM
Additional physical exam checklist
Most physical exam components should be observed during the ACA and recorded on the ACA activity log. However,
because of the nature of the male GU/rectal and female pelvic/breast exams, these are often not performed by
students during their ACA sessions. Please have the following skills check off by the instructor during the sessions
which are set up for you to learn these exams.
Clinical Foundations Directors
September, 2011-12
UCSD Ambulatory Care Apprenticeship (ACA)
SOMC 236 MS2
#
TASK
1
PERFORM MALE GU
EXAM
2
PERFORM MALE RECTAL
EXAM
3
PERFORM FEMALE
BREAST EXAM
4
PERFORM FEMALE
PELVIC EXAM
DATE COMPLETED
OBSERVER SIGNATURE
OBSERVER PRINTED NAME
UCSD Ambulatory Care Apprenticeship (ACA)
SOMC 236 MS2
CHECKLIST for complete physical exam
suggested
examination sequence
•
Wash your hands.
•
Ask the patient to sit up, preferably on the edge of the bed or exam table.
•
Position yourself in front of the patient, moving to either side as needed.
GENERAL SURVEY:
Observe patient’s LOC, signs of distress, apparent state of health, height/weight/build, posture/motor activity,
manner/affect/reactions, dress/grooming/hygiene
VITAL SIGNS:
1. Blood pressure in one arm. If abnormal, measure in other arm to compare
2. Palpate and count radial pulse for at least 15 seconds
3. Palpate radial pulses simultaneously for symmetry
4. Respiratory rate: With fingers still on patient’s wrist, count respiratory rate
5. Assess postural changes in pulse and BP if indicated
UPPER EXTREMITIES:
•
Inspect: hands, arms, noting nail changes, skin lesions, asymmetry in muscle bulk
•
Assess tone by rotating/flexing/extending each arm at shoulder, elbow and wrist
•
Palpate for tenderness, palpable epitrochlear nodes
•
If indicated, perform more thorough inspection and palpation of joints for evidence of synovitis/joint
deformities and test passive and active range of motion
HEENT:
Head:
Eyes:
Ears:
Inspect and/or palpate: skull, hair and scalp
(OD = right eye; OS = left eye):
a) Visual acuity (CN II)
b) Visual fields → check by confrontation, one eye at a time (CNII)
c) General inspection:
• Eyelids & periorbital area ⇒ lesions, ptosis, periorbital edema, exophthalmos.
• Globe, sclera, conjuctivae, cornea ⇒ look for discoloration or opacification.
d) Pupils: (think “PERRLA”, where P=Pupils E = Equal, R = round, RL = reactive to light
A = accommodation [aka “near reaction”]. Pupils should constrict with near effort.)
e) Extra-ocular movements → 6 cardinal directions of gaze (CN II, IV, VI)
f) Fundoscopic exam: find red reflex, optic disc, inspect retina
(AD=right ear; AS=left ear):
a) Screen hearing with rubbing fingers, ticking watch or whispered word (CN VIII)
b) If hearing abnormal, perform tuning fork exam (use 512 Hz fork):
•
Weber ⇒ A normal Weber test is midline; abnormal Weber sound lateralizes to one side; if
conductive hearing loss, lateralizes to “bad” ear; if sensorineural loss, lateralizes to “good” ear
• Rinne ⇒ A normal Rinne exam
 a ir conduction gre a te r tha n
c) Inspect and palpate auricle, postauricular space.
d) Otoscopy:
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SOMC 236 MS2
•
•
external auditory canal.
tympanic membrane
Nose:
a) Inspect nasal septum, turbinates, mucosa
b) Palpate maxillary and frontal sinuses for tenderness (seen in sinusitis)
Throat & Mouth:
a) Visually inspect the entire oral cavity and oropharynx
b) If indicated, palpate for areas of induration, including base of tongue
NECK:
a) Inspect for any obvious masses or asymmetry, for position of trachea, for thyroid asymmetry or
enlargement with and without patient swallowing
b) Palpate lymph nodes: pre-auricular, post-auricular, sub-mandibular, sub-mental, posterior cervical,
anterior cervical, supra-clavicular. Enlarged lymph node
fixe
vs. mobile,
d
tender vs. non-tender; how big?
c) Thyroid palpation:
•
Standing behind the pt., palpate for nodules or diffuse enlargement (aka “thyromegaly”), with and
without patient swallowing
• If indicated, auscultate for thyroid bruit
d) Range of motion of neck: flexion, extension, lateral rotation
BACK EXAM:
a) Inspect → look for asymmetry, spine curvature and alignment
b) Light palpation over spinous processes and paraspinous muscles, followed by fist percussion of spine
and costovertebral angle (CVA)
THORAX AND LUNG EXAM:
a) Observe:
• Respiratory rate and rhythm if not already done. Normal adult RR = 14-20.
• Effort of breathing: use of accessory muscles or intercostal retraction?
• Shape of chest/thorax
• Audible stridor, wheezing?
b) Palpate:
•
•
Respiratory expansion: Ask pt to inhale fully
 a s s e s s s ym m e try a nd ra nge
Tactile fremitus - “99”, ensure that pt speaks loud enough.
o Palpate bilaterally and symmetrically
Pearl: ↑ with consolidation of airspaces or compression of lung.
↓ (or absent) with fluid or air in pleural space or with obstructed bronchus
c) Percuss: Position patient (if possible) sitting, with arms crossed in front of chest
•
•
•
Percuss lung fields side to side, from apices to bases and laterally.
Characterize sound as: resonant, dull, hyperresonant.
Using percussion, estimate diaphragmatic excursion (full expiration ⇒ full inspiration), normal = 5-6
cm.
d) Auscultate: pt breathes through open mouth ⇒ caution about lightheadedness
Auscultate side to side, apices to bases
UCSD Ambulatory Care Apprenticeship (ACA)
SOMC 236 MS2
1. Breath sounds:
o Intensity: increased, decreased, absent.
o Quality: vesicular, bronchial (sound tubular), bronchovesicular (intermediate)
2. Adventitious Sounds (extra sounds):
o crackles (fine vs. coarse, also known as rales), wheezes, rhonchi.
o assess their timing in the respiratory cycle (inspiratory, expiratory)
Do these sounds clear with coughing?
3. If percussion or auscultations abnormal, check for egophany (E→A): ask patient to say “ee”, will
get an “ee” to “ay” change if consolidation or compression of air spaces
REMEMBER TO CONDUCT BOTH A POSTERIOR & ANTERIOR CHEST
EXAM !!
BRE AS TS and AX ILL AE:
a) Inspect: skin, symmetry, contour with patient sitting, arms at sides; repeat with arms overhead, with
hands pressed against hips, and with patient leaning forward
b) Ask patient to assume a supine position. Palpate each breast with patient’s ipsilateral arm
extended over head, examining entire breast tissue for consistency, tenderness, and masses
c) Palpate nipples for masses, discharge, and tenderness
d) In sitting position (or supine), ask patient to relax arms at side. To examine left axilla, support the
patient’s left wrist/forearm with your left hand; palpate with fingers of right hand toward apex of axilla,
behind pectoral muscle, then slide down. For exam of right axilla, use right hand for support, left hand to
palpate
Ask the patient to assume a supine position with his/her head preferably at a 30° angle (patient may
already by supine during breast exam).
UCSD Ambulatory Care Apprenticeship (ACA)
SOMC 236 MS2
HE ART:
a) Inspect precordium, observing any cardiac motion
b) Palpate, from the patient’s right side).Other than the apical impulse, pulsations will typically not be
appreciated in the other areas and often signify a possible abnormal condition:
• Apical impulse (left 4-5th ICS, at or medial to midclavicular line)
• RV area (tricuspid area): (left sternal border, over 3rd, 4th, 5th ICS)
• Aortic area (right 2nd ICS).
• Pulmonic area (left 2nd and 3rd l ICS).
Note presence of lifts (heaves) and/or thrills (transmitted murmurs).
c) Auscultate:
•
•
Using the diaphragm of stethoscope, auscultate in at least five places including: apex (mitral area),
left sternal border (tricuspid area), pulmonic area and aortic area
Using the bell of stethoscope, repeat auscultation, especially over tricuspid and mitral areas, where
more likely to hear low pitched sounds.
Heart Sounds: Characterization
1. S1 & S2: intensity, rate, rhythm, splitting of S1and/or S2 (physiologic or abnormal).
2. Additional heart sounds: gallops (S3, S4) clicks, rubs, murmurs
•
•
•
For any murmurs, assess
(a) Timing:
 Systolic: AS, IHSS, MR, TR, PS.
 Diastolic: AR, MS, TS.
(b) Intensity: Where is it “best heard”? (e.g.” Grade II/VI”)
 I = barely audible
 II= faint, but easily audible.
 III=moderately loud.
 IV=loud
 V = loud, may be heard with stethoscope partly off chest
 VI=audible w/ stethoscope completely OFF the chest.
(c) Shape: e.g. crescendo, decrescendo, crescendo-decrescendo, plateau
(d) Duration: e.g. holosystolic, mid-systolic, early diastolic, etc.
(e) Location & radiation: does murmur radiate to left axillary line or to carotids?
(f) Associated thrill present?
To bring out apical heart sounds or mitral murmurs, ask pt to assume left lateral decubitus position
To bring out aortic murmurs or sounds, ask patient to sit and lean forward
JVP:
JVP is a rough estimation of right atrial pressure. Position the patient with the head of the bed or table at 30 to 45º,
turning patient’s head away from the side that you are examining
a) Identify the internal jugular vein (IJV) pulsations:
•
The external jugular vein is superficial and you can often see it. To accentuate it, ask the pt to
valsalva. The IJ vein lies medial to it, under the sternocleidomastoid muscle.
• Carotid artery pulsations will NOT be eliminated by pressure. Carotid pulsations are NOT affected by
position or inspiration; IJV pulsations are.
b) Determine jugular venous pressure: Measure vertical distance relative to the sternal angle (extend a
ruler parallel to the exam table from the top of the IJ pulsations to over the sternal angle, drop a
perpendicular to the sternal angle and measure this distance). Add 5-cm to sternal angle measurement to
get measurement of JVP relative to right atrium, in cm. An elevated JVP is >8-9 cm
CAROTID ARTERIES:
UCSD Ambulatory Care Apprenticeship (ACA)
SOMC 236 MS2
a) Inspect neck for carotid pulsations
b) Palpate carotid pulse bilaterally, but not simultaneously
c) Auscultate carotid arteries bilaterally
Ask patient to lie flat with arms rested comfortably at sides or folded across chest. Position yourself at
the RIGHT side of the table.
ABDOMEN:
a) Inspect:
• Skin (e.g. lesions, scars, striae, caput medusae).
• Contour (e.g. flat, protuberant, bulging flanks, gravid).
• Any obvious midline pulsations (e.g. abd aortic aneurysm).
b) Auscultate (BEFORE palpation and percussion):
Bowel sounds → assess frequency (normal,↑,↓ or absent) and characterize the sounds (rushes,
tinkles, etc.)
• Bruits (epigastrium: abdominal aorta; upper quadrants: renal arteries)
c) Percuss: tympany vs. dullness.
d) Palpate:
•
•
•
•
•
Palpate painful areas LAST
Light palpation followed by deep palpation. Check for masses.
If indicated, assess for rebound tenderness: A sign of peritoneal inflammation, it is positive if pt has
more pain with withdrawal of examiner’s hand.
If suspect ascites, check for fluid wave or percuss for shifting dullness.
LIVER:
a) Percuss vertical span of liver dullness in the right mid-clavicular line
b) Palpate liver edge: start below the edge determined by percussion, pressing fingers of right hand in and
up. Ask pt to inspire deeply to facilitate palpation.
SPLEEN:
Using a two handed technique (left hand beneath the lower left rib cage and lifting, right and palpating), palpate for a
spleen tip (usually not felt). If spleen is enlarged, can also percuss for it in Traube’s space, and below the left costal
border
RECTAL EX AM:
Position patient on side, knees flexed, with top leg placed further anteriorly than bottom leg OR ask patient to stand
and bend over table
a) Inspect perirectal area: fissures, external hemorrhoids, anal warts.
b) Glove up and palpate rectal vault, assessing rectal tone, stool in rectal vault, hemorrhoids, masses or
other abnormalities in rectal mucosa. In males, palpate prostate for size, tenderness and consistency
c) If stool present, check guaiac test.
FEMORAL AND INGUINAL ARE AS :
a) Palpate femoral and inguinal nodes
b) Palpate femoral pulses bilaterally
c) Auscultate femoral arteries for bruits
LOWER EXTREMITIES:
a) Inspect legs for muscle bulk, discoloration, ulcers, joint swelling or abnormality, abnormal movement (e.g.
fasiculations, jerks)
UCSD Ambulatory Care Apprenticeship (ACA)
SOMC 236 MS2
b) Inspect feet including toes and soles
c) Assess tone by rotating/flexing/extending each leg at hip, knee and ankle
d) Palpate dorsalis pedis and posterior tibialis pulses in feet; if asymmetric or decreased in amplitude,
palpate popliteal pulses
e) Palpate distal extremities for edema.
f) If indicated, perform more thorough inspection and palpation of joints for evidence of synovitis/joint
deformities and test passive and active range of motion
Ask patient to sit on edge of bed or table
NEURO EXAM:
CR ANI AL NERVES
a) CN I (olfactory): Test sense of smell on each side (occlude contralateral nostril)
b) CN II (optic nerve): Assess visual acuity and visual fields by confrontation, one eye at a time
c) Test pupillary reaction (direct and consensual) to light (CN II,III)
Afferent limb = ipsilateral CNII; Efferent limb = bilateral CN III
d) CN III, IV,VI (oculomotor, trochlear, abducens): Test 6 cardinal directions of gaze
e) CN V (trigeminal):
• Assess masseter strength (ask pt to clench jaw).
• Check light touch, and sharp vs. dull sensations on face(V1, V2,V3 divisions)
f) Test corneal reflex (touch the cornea with wisp of cotton) Afferent limb = CN 5; efferent limb=CN 7
g) CN VII (facial): Ask pt to: raise eyebrows, frown, close eyes tightly against resistance, show teeth, smile
and puff out cheeks.
h) CN VIII (acoustic): see Ear exam.
i) CN IX and X (glossopharyngeal, vagus):
• Listen to the voice
• Observe the palate rise when pt says “ah” (if not possible CN 10 defect).
• Test gag reflex on each side.
j) CN XI (spinal accessory):
• Ask patient to turn head to each side against resistance.
• Ask patient to shrug shoulders against resistance
k) CN XII (hypoglossal):
•
•
Inspect resting tongue for atrophy, fasiculations
Ask pt to protrude tongue, which should be midline (will deviate TOWARDS weak side, if lesion
present).
MOTOR EX AM
a) Observe body position
b) Observe involuntary movements: Note location, quality, rate, rhythm and amplitude, and their relation to
posture, activity, fatigue, emotion
c) Observe muscle bulk: atrophy, hypertrophy
 proxim a l vs . dis ta l, unila te
d) Determine muscle tone (see exam of extremities): nml, flaccid, spastic, rigid Note: hypotonia suggests
LMN lesion; spasticity suggests UMN lesion; lead pipe or cogwheel rigidity suggests extrapyramidal
system lesion
e) Test muscle strength (Do not test with patient’s muscle shortened fully, which is when it is strongest)
Grade strength as 0 to 5:
0 = no evidence of contractibility.
1 =barely detectible contraction but no joint movement.
2 = active movement with gravity eliminated.
3 = active movement against gravity.
4= active movement against gravity and some resistance.
UCSD Ambulatory Care Apprenticeship (ACA)
SOMC 236 MS2
5 =active movement against full resistance without evidence of fatigue.
•
Bilateral Upper Extremities:
1. Abduction of the shoulder Deltoids (axillary nerve: C5, 6)
2. Adduction of the shoulder
3. Flexion of the elbow Biceps (musculocutaneous n.: C5, 6).
4. Extension of the elbow Triceps (radial nerve: C6, 7, 8).
5. Wrist extensors (C6, 7, 8) and flexors (C6, 7, 8).
6. Hand grip (C7, C8, T1)
7. Finger abduction: interossei (ulnar nerve, C8, T1)
8. Opposition of the thumb (C8, T1, median nerve)
•
Bilateral Lower Extremities:
1. Hip flexion
Iliops
(lumbaroaplexus:
s
L2, 3, 4)
2. Hip extension Gluteus maximus (S1)
3. Hip adduction (L2, L3, L4) and abduction (L4, L5, S1)
4. Knee extension Quadriceps (L2, 3, 4)
5. Knee flexion Hamstrings (L4, L5, and S1)
6. Ankle dorsiflexion (mainly L4, L5) and plantar flexion (mainly S1)
SENSORY EX AM:
General rules ⇒ compare symmetric areas on two sides of body, compare proximal to distal (pain, touch, temp),
vary pace of the testing
a) Test pain (spinothalamic tracts): Ask patient to close eyes. Test sharp vs. dull discrimination
b) Test temperature sensation (spinothalamic tracts): May omit if pain sensation normal. Touch the skin
with cold or warm object and ask to identify “hot” and “cold”
c) Test light touch (spinothalamic and posterior columns): Touch skin with fine wisp of cotton and ask
patient to respond whenever a touch is felt, comparing one area with another
d) Test vibration (posterior columns) Apply128 Hz tuning fork to distal interphalangeal joints of the fingers
and toes, asking pt what they feel (vibration) and when it stops. If sensation is impaired, proceed
proximally to bony prominences
e) Test Position/Proprioception (dorsal columns). Holding sides of digits (fingers and toes), away from
other digits, move up or down and ask patient to identify direction moved. If fingers and toes OK, do not
need to test more proximally.
Additional tests of sensory function not typically done in routine screening neuro exam:
f) Discriminative sensations (sensory cortex)
•
•
Stereognosis: Test the recognition of object placed in hand (coin, key, paperclip) when eyes closed.
Graphesthesia: Write #s in pt’s hand (pick any 2) with patient’s eyes closed
•
2-point discrimination: Using two ends of an opened paperclip, touch skin in two places
simultaneously. Alternate with a one point touch, asking patient to distinguish type of touch. Normal
distance patient can discriminate two points < 5 mm on finger pads.
REFLEXES:
The scale is rated on 0-4+, where:
0 = no response
1+ = diminished or low average
a) Test deep tendon reflexes:
• Biceps (C5-6)
• Brachioradialis (C5-6)
• Triceps (C7-8)
• Patellar (L2,3,4)
• Achilles (S1)
2+ = average / normal
b)
3+ = brisker than average
4+ = hyperactive with clonus
Test superficial reflexes:
• Babinski’s/Plantar (L5--S1).
• Anal (S4-5).
UCSD Ambulatory Care Apprenticeship (ACA)
SOMC 236 MS2
COORDIN ATION AN D CEREBELL AR FUNCTION:
a) Test cerebellar function:
• Rapid alternating movements (hand slap, toe tap)
• Rapid repeating movements (index finger to thumb).
• Point to Point Movements: (finger-to-nose, heel-to-shin)
b) Ask patient to stand to check gait and station
•
•
•
Check gait: usual, and heel-to-toe. (Can also check balance and lower extremity strength with
single foot hop and walk on heels and toes)
Perform Rhomberg test, guarding against patient’s possible loss of balance
Assess for presence of pronator drift
SPINE
Observe alignment of the spine.
Assess range of motion of the spine---flexion, extension, rotation, lateral bending (function)
MENTAL STATUS EX AM:
a) Appearance and Behavior:
•
Level of consciousness:
Alert
Lethargic (pt appears drowsy, but responds to loud voice)
Obtunded (need to shake pt to have him/her respond to Q’s).
Stupor (need painful stimuli to arouse pt from sleep).
Coma (doesn’t respond even to painful stimuli).
• Posture and Motor Behavior
• Facial Expression
• Manner, Affect and Relationship to Persons and Things
Affect= An observable, usually episodic, tone of feeling, expressed through voice, facial expression
and demeanor
b) Speech and Language:
• Quantity: Talkative or quiet? Spontaneous or only responsive to Qs?
• Rate: Fast or slow?
• Loudness: Loud or soft?
• Articulation of words: Articulation clear and distinct?
• Fluency: involves the rate, flow and melody of speech and the content and use of words
c) Mood: Mood=A more sustained emotion that may color a person’s view of the world
d) Thoughts and Perceptions:
•
Thought Process: Assess the logic, relevance, organization and coherence
Variations and abnormalities in thought processes include circumstantiality, derailment, flight of ideas,
neologisms, incoherence, blocking, confabulation, perseveration, and echolalia
• Thought Content: Usually assessed during course of the interview
Abnormalities of thought content include compulsions, obsessions, phobias, anxieties, feelings of
unreality, feelings of depersonalization, delusions
• Perceptions: Inquire about false perceptions such as illusions or hallucinations
llusions=misinterpretation of real external stimuli
Hallucinations=subjective sensory perceptions in the absence of relevant external stimuli
• Insight and Judgment: usually best assessed during the interview
Insight=awareness that symptoms or disturbed behaviors are normal or abnormal
Judgment=process of comparing and evaluating alternatives when deciding on a course of action
e) Cognitive Functions
•
•
Orientation: to person, place, time, date?
Attention:
UCSD Ambulatory Care Apprenticeship (ACA)
SOMC 236 MS2
f)
Digit Span: Recite a series of numbers, starting two at a time, asking patient to recite back to you;
increase the series by one number until patient misses twice with series of the same length. Repeat
process again asking patient to repeat numbers backward.
Normal=five digits forward, four
backward
Serial 7s: Ask patient to subtract 7 serially starting at 100. Normal=complete serial 7s in 1½ minutes
with < 4 errors
Spelling Backward: Ask patient to spell 5 letter word backward, e.g. WORLD
• Remote Memory: Ask patient about events relevant to patient’s past
• Recent Memory: Ask patient about the events of the day
• New Learning Ability: Ask patient to repeat and remember 3 words; after 3 to 5 minutes ask what the
words were
Higher Cognitive Functions
•
•
•
•
Information and Vocabulary: Note patient’s grasp of information, complexity of ideas, vocabulary
used; can ask about specific facts such as presidents, other political figures, five large cities, etc.
Calculating Ability: Test patient’s ability to do arithmetical calculations or word problems (e.g. such
as making change)
Abstract Thinking: Ask patient to interpret proverbs or to tell you how certain objects are alike
(similarities)
Constructional Ability: Ask patient to copy figures of increasing complexity or put numbers and
hands on a clock

UCSD Ambulatory Care Apprenticeship (ACA)
SOMC 236 MS2
SOAP NOTE STRUCTURE
There are two basic alternative structures to writing a SOAP note:
Version A (“pure” problem-oriented):
Version B (“hybrid” problem-oriented):
Patient ID
Problem # 1
Patient ID
Subjective:
S
O
A
P
Problem # 2
S
O
- Problem # 1
- Problem # 2
Objective:
(entire focused PE from VS to toes)
A
P
Assessment/Plan:
- Problem # 1: Ass.  Plan
Dx -> Tx -> F/U
- Problem # 2: Ass.  Plan
Dx -> Tx -> F/U
COMMENTS:
1) In a SOAP note for a focused visit the Problem title is equivalent to the “chief complaint” of a complete H&P. In
both situations there can be more than one problem or chief complaint.
2) The Problem title should be either a diagnosis (e.g. HTN, DM) OR a complaint (e.g. abd. pain, burning on
urination, etc.) or a sign (e.g. tachycardia, heart murmur).
3) The “subjective” of a SOAP note is equivalent to the HPI of the complete H&P and there needs to be one for each
problem (just as there would be one HPI for each chief complaint in the H&P).
4) In a SOAP note one usually integrates relevant portions of the PMHx, FamHx and SocialHx in the “subjective”
section, rather than each having their own heading as in a complete H&P.
5) “Assessment” comes in two forms:
- a diagnosis (e.g. HTN, DM) + a status statement (e.g. worse, improved, stable, controlled), OR
- a symptom or sign (e.g. diarrhea, abd. pain, heart murmur) + a ddx (differential dx.) with the most likely
listed first
- There should always be a discussion with the assessment if the diagnosis status is not optimal to explain
why it isn’t or, in the case of a symptom or sign, why the ddx includes what it does and in the order listed.
6) “Plans” include first the diagnostic tests or maneuvers ordered; followed by the therapeutic maneuvers ordered
(e.g. meds, patient education, physical therapy, etc.); followed by the disposition or follow up for the patient (e.g.
dr. or pt. to call, email, fax or return in X days, weeks, months).
SOAP Note structure – 2-19-00
If found, please return to
ACA Coordinator
Undergraduate Medical Education (UGME)
UCSD School of Medicine
9500 Gilman Drive, Mail Code 0606
La, Jolla, CA 92093-0606
Office Location:
MET 120.17a
Or call for pickup at
858.534.2710