Comprehensive Physical Exam Flashcards
(40 cards)
Why record Date and Time of History
In urgent, emergent, or hospital could matter for patient care; liability reasons (personal, legal)
Identifying Data
age, gender, marital status, and occupation
Source of history or referral
patient, a family member or
friend, an officer, a consultant, or the clinical record (source dictates reliability)
Reliability of history
if relevant, “patient is vague when
describing symptoms”
Chief Complaint(s)
quote the patient—–no specific
complaints, report their reason for the visit
Present Illness
complete, clear, and chronologic
description of the problems prompting the patient’s visit
Present Illness: principal symptom
(1) location; (2) quality; (3) quantity or
severity; (4) timing, including onset, duration, and frequency; (5) the setting in which it occurs; (6) factors that have aggravated or relieved the symptom;and (7) associated manifestations.
Present Illness: Pertaining details
Example: Risk factors - Coronary artery disease can be associated with chest pain; effect on patients life; each symptom gets its own paragraph; Medications (name, dose, route, freq); allergies; tobacco; alc & drug
Past history
Childhood Illnesses; Adult Illnesses: Health Maintenance—be specific about every vaccine and screening test (get yes or no for each)
Family History
outline the age and health, or age and cause of death, of each immediate relative including parents, grandparents, siblings, children, and grandchildren—-hypertension, coronary artery disease, elevated cholesterol levels, stroke, diabetes, thyroid or renal disease, arthritis, tuberculosis, asthma or lung disease, headache, seizure disorder, mental illness, suicide, substance abuse, and allergies, as well as symptoms reported by the patient. Ask about any history of breast, ovarian, colon, or prostate cancer.
Personal and Social History
Personality and interests, sources of support, coping style, strengths, and concerns. Expanded Personal and Social history personalizes your relationship with the patient and builds rapport.
Review of Systems
Start with a fairly general question as you address each of the different systems,
then shift to more specific questions about systems that may be of concern—-“How about your lungs and breathing?”—-major health events discovered during the Review of Systems should be moved to the Present Illness or Past History
Approach to the Patient
identify yourself as a student–calm and organized–, avoid interpreting your findings
Adjust the Environment
adjust bed, patient, good lighting( Tangential lighting), quiet when possible, temp. when possible
Check Your Equipment
Peads equipment, batteries, general
Make the Patient Comfortable
Patient Privacy and Comfort, Draping the Patient, Courteous Clear Instructions, Keeping the Patient Informed
Observe Standard and Universal Precautions (Standard and MRSA precautions)
all blood, body fluids, secretions, excretions (except sweat), nonintact skin, and mucous membranes may contain transmissible infectious agents
Hand Washing
- a. before touching a patient, even if gloves are worn;
b. before exiting the patient’s care area after touching the patient or the
patient’s immediate environment;
c. after contact with blood, body fluids, or excretions, or wound dressings;
d. prior to performing an aseptic task (e.g., placing an intravenous drip, preparing an injection);
e. if hands are moving from a contaminated-body site to a clean-body site
during patient care; and
f. after glove removal. - Use soap and water when hands are visibly soiled (e.g., blood, body fluids), or after caring for patients with known or suspected infectious diarrhea
(e. g., Clostridium difficile, norovirus).
Universal precautions
prevent parenteral, mucous membrane, and noncontact exposures of health care
workers to bloodborne pathogens
Potentially Infectious Body Fluids
visible blood, semen, and
vaginal secretions and cerebrospinal, synovial, pleural, peritoneal, pericardial,
and amniotic fluids
The Cardinal Techniques of Examination
Inspection, Palpation, Percussion, Auscultation
Sequence of Examination
“head to toe”:
Maximize the patient’s comfort—Avoid unnecessary changes in position—Enhance clinical efficiency
Examining from the Patient’s Right Side
jugular venous pressure are more reliable, the palpating hand rests more
comfortably on the apical impulse, the right kidney is more frequently palpable
than the left, and examining tables are frequently positioned to accommodate a
right-handed approach.
Examining the Patient at Bedrest
changes sequence of examination—head, neck, and anterior chest with the patient lying supine—roll the patient onto each side to listen to the lungs, examine the back, and
inspect the skin—finish supine
