Consultation and History Taking Flashcards
(199 cards)
1
Q
Gather the necessary information to form a tentative diagnosis
A
Interviewing and health history
2
Q
Main reason why the patient is seeking advice
A
Chief complaint
3
Q
Amplifies the chief complaint by giving a full, clear, chronological account of each symptom and what events were related to them
A
History of present illness
4
Q
Principal symptom: where the pain occurs
A
Location
5
Q
Principal symptom: adjective describing the pain
A
Quality
6
Q
Principal symptom: degree of the pain
A
Quantity/Severity
7
Q
Principal symptom: onset, duration, frequency of the pain
A
Timing
8
Q
Principal symptom: the ways that the patient employs that amplify the pain
A
Aggravating factors
9
Q
Principal symptom: the ways that the patient employs that ease the pain
A
Relieving factors
10
Q
Principal symptom: signs or symptoms that occur along with the pain
A
Associated symptoms or manifestations
11
Q
Principal symptom: e.g. laboratory results
A
Relevant data
12
Q
Principal symptom: what the patient doesn’t have or isn’t experiencing
A
Significant negatives
13
Q
Patient’s prior illnesses, injuries, medical interventions
A
Past medical history
14
Q
Patient’s present state of health, environmental conditions, personal habits, health related conditions
A
Current health status
15
Q
Pattern of familial illness
A
Familial history
16
Q
Family tree of diseases
A
Genogram
17
Q
Patient as a person
A
Psychosocial history
18
Q
To identify problems which the patient did not mention
A
Review of systems
19
Q
AIL: Urinating too much in a day
A
Polyuria
20
Q
AIL: can’t stop the urge to urinate
A
Urinary incontinence
21
Q
T/F: Review charts before interviewing the patient
A
True
22
Q
T/F: Environment doesn’t affect communication
A
False
23
Q
T/F: There’s no need to consider privacy when interviewing the patient
A
False
24
Q
T/F: The setting must be free from interruptions
A
True
25
T/F: Speak to the patient at eye level
True
26
T/F: Dress cleanly and appropriately
True
27
T/F: Don't watch your demeanor
False
28
T/F: When asking the patient questions, don't inquire several times
False
29
T/F: Allow the patient to recount their own stories
True
30
T/F: Incorporate passive listening
False
31
T/F: Don't incorporate facilitative listening
False
32
T/F: Repeat words to encourage the patient to give more details
True (this technique is called reflection)
33
T/F: Ask the patient to clarify unclear and ambiguous words
True (this technique is called clarification)
34
T/F: Show understanding and acceptance by making the patient feel secure and encouraging them to continue
True (this technique is called emphatic response)
35
T/F: Observe the patient for clues of anger, anxiety, depression
True (this technique is called confrontation)
36
T/F: Don't mind your posture
False
37
T/F: Show signs of panic and hurriedness
False
38
T/F: Take note of posture, gestures, eye contact
True
39
T/F: Ask the patient indirect questions
False
40
T/F: Ask the patient questions from general to specific
True
41
T/F: Avoid questions answerable by yes or no when taking HPI
True
42
T/F: Use language that is inappropriate and hard to understand
False
43
Gathering data: coffee, drugs, liquor, prescription drugs, marijuana, illicit use of drugs
Alcohol and drug history
44
T/F: Orient the patient with brief and transitional phrases
True
45
T/F: Ask the patient if there is anything else they want to talk about
True (this technique is called closing)
46
T/F: During note taking, it is okay to divert your attention from the patients
False (do not divert your attention from the patient)
47
T/F: During note taking, jot down long phrases and words that will guide you in making the final report
False (only use short phrases and words)
48
T/F: Take notes when the patient is talking about sensitive information
False (it is best not to take notes when the patient is talking about sensitive information)
49
T/F: Ask the patient about their weight changes
True
50
AIL: Increase in body fats or accumulation of fluid
Weight gain
51
AIL: Loss of energy, sense of weariness, withdrawal from activities
Fatigue
52
AIL: Caused by musculoskeletal or neurologic disorders
Weakness
53
AIL: Feelings of coldness, gooseflesh, shivering, rising temperature, hot feelings and sweats, defervescence, shaking, or chills
Fever
54
What should you investigate when a person has fever?
Travel and contact with a sick person
55
Change in hair distribution may be a sign that there is a problem with the patient's _______
Skin
56
AIL: High level of urea in the blood
Uremia
57
AIL: Yellowish skin that may be caused by a problem in the liver or gall bladder
Obstructive jaundice
58
AIL: Parasitic insect that live on clothing and bedding used by an infected person
Body lice
59
AIL: Redness of the skin
Erythema
60
A type of headache that is felt only on one side of the head
One-sided headache
61
A type of headache that is felt on both sides of the head
Bilateral headache
62
A type of headache that has been occurring for a few hours or days
Acute headache
63
A type of headache that has been occurring for several months or years
Chronic headache
64
A type of headache that is recurrent
Tension headache or migraine
65
An acute and severe headache may suggest..
Subarachnoid hemorrhage
66
A headache that is progressively becoming severe may suggest..
Presence of tumor
67
A headache accompanied by nausea and vomiting may suggest..
Brain tumor
68
A type of headache that suggests problem in the eyes
Frontal headache
69
AIL: Blurring of vision
Error of refraction or refractive error
70
AIL: A sudden blurring of vision may suggest..
Retinal detachment
71
AIL: Blurring at near
Hyperopia
72
AIL: Blurring at far
Myopia
73
AIL: Visual disturbance when reading at near
Presbyopia
74
AIL: What causes a defect in the central visual field?
Development of cataract
75
AIL: Slow peripheral loss due to an increase in intraocular pressure
Glaucoma
76
AIL: One-sided visual field; loss of vision in one-half of the visual field
Hemianopsia
77
AIL: Loss of vision in one quadrant of the visual field
Quadrantanopia
78
AIL: Inflammation of the conjunctivita which causes redness of the eyes
Conjunctivitis (sore eyes)
79
Visible moving strands
Muscae volitantes or floaters
80
AIL: Fixed areas of blindness
Scotoma or lesion of visual pathways
81
AIL: Caused by the obstruction of the lacrimal canal
Excessive tearing
82
AIL: Double vision due to the weakness or paralysis of an extraocular muscle or tumor at the back of the eyeball
Diplopia
83
AIL: Change of color in the eye
Scleral icterus or conjunctival icterus
84
AIL: Which organs may be affected if the patient is icteric?
Liver or gall bladder
85
AIL: Another term for dizziness
Vertigo
86
AIL: Perceived sound without external stimuli or ringing of the ears
Tinnitus
87
AIL: Patient is complaining that people are mumbling
Sensorineural hearing loss
88
AIL: Hearing loss and vertigo may suggest..
Meniere's disease
89
AIL: May be caused by an inflammation of the ear canal or perforation/rupture of the ear drum
Ear discharge
90
AIL: Inflammation of the middle ear
Otitis media
91
AIL: May be caused by pollen, contacts with the environment, allergic rhinitis
Nasal discharge
92
AIL: Pain in the sinus area
Sinusitis
93
AIL: Nasal stuffiness on one side
Nasal deviation
94
AIL: Another term for nosebleed
Epistaxis
95
AIL: Inflammation of the gums or bleeding gums
Gingivitis
96
AIL: Sore tongue
Apthous ulcers
97
AIL: Sore throat may suggest a problem with which body system ?
Respiratory
98
AIL: Over usage of voice
Hoarseness
99
AIL: Acute infection in the mouth may result to..
Laryngitis
100
AIL: Swollen glands in the neck may be due to..
Goiter, lymphadenitis, or lymphomas
101
AIL: Pain in the myocardium (heart attack)
Myocardial infarction
102
AIL: Pain in the myocardium (chest pain)
Angina pectoris
103
AIL: Pain in the aorta
Dissecting aneurysm
104
AIL: Pain in the trachea and large bronchi
Heartburn that may cause esophagus reflux esophagitis
105
AIL: Painful deep breathing due to an inflammation in the cartilage
Costochondritis
106
AIL: Chest heaviness may suggest..
Cardiac problems
107
AIL: Skipping, pounding, and occasional stopping of heartbeat; heartbeat is felt by the patient
Palpitation
108
AIL: Heart rate is over 100bmp
Tachycardia
109
AIL: Heart rate is below 60bmp
Bradycardia
110
AIL: Non-painful but uncomfortable awareness of breathing; shortness of breath
Dyspnea
111
AIL: Breathing quicky
Hyperventilation
112
AIL: Difficulty in breathing when lying down
Orthopnea
113
AIL: Difficulty in breathing at night
Paroxysmal nocturnal dyspnea
114
Sound produced that is caused by partial air obstruction
Wheezing
115
AIL: Accumulation of excessive fluid
Edema
116
AIL: Edema in lower extremities
Bipedal edema
117
AIL: Edema in the face
Facial edema
118
AIL: Edema in the abdomen causing enlarged wasitline
Ascites
119
AIL: Edema with puffy eyelids may suggest a severe problem in what organ?
Kidney
120
AIL: Edema with renal problems
Hypoalbuminemia
121
AIL: Edema all over the body
Anasarca
122
AIL: Cough with no phlegm
Dry cough
123
AIL: Cough with phlegm
Productive cough
124
AIL: A white colored phlegm may suggest..
Viral infection
125
AIL: A green colored phlegm may suggest..
Bacterial infection
126
AIL: Coughing with blood suggests that there is a problem in which organ?
Lungs
127
AIL: A build up of mucus in the lungs
Bronchiectasis
128
AIL: Coughing up or spitting out blood
Hemoptysis
129
AIL: Difficulty in swallowing
Dysphagia
130
AIL: Difficulty in swallowing liquid may suggest a disorder of what muscle?
Esophageal muscle
131
AIL: Feeling of burning or warmth that is felt retrosternal from the epigastric area to the neck
Heartburn that may cause reflux esophagitis
132
Causes abdominal bloating, distention, or flatus (farting)
Excessive gas
133
Medication used to prevent farting
Anti-flatulent medication
134
(Visceral/Parietal) Pain felt from hollow organs
Visceral pain
135
(Visceral/Parietal) Pain caused by inflammation
Parietal pain
136
(Visceral/Parietal) Pain that is more localized
Parietal pain
137
(Visceral/Parietal) Pain that is poorly localized
Visceral pain
138
(Visceral/Parietal) Pain that is aggravated by coughing or movement
Parietal pain
139
(Visceral/Parietal) Pain that is burning, cramping, aching
Visceral pain
140
(Visceral/Parietal) Pain that is associated with nausea and vomiting
Visceral pain
141
Pain that travels from an initial site; radiating pain
Referred pain
142
Colicky pain suggests a problem with what muscle contraction?
Peristalsis
143
AIL: Vomitus with blood
Hematemesis
144
AIL: loss or lack of appetite
Anorexia
145
AIL: Stomach is feeling sick
Nausea
146
AIL: Spasmodic movement of the chest and diaphragm that proceeds and culminate to vomiting
Retching
147
AIL: Forceful expulsion of gastric contents through the mouth
Vomiting
148
AIL: Raising of esophageal and gastric contents in the absence of nausea and vomiting
Regurgitation that may be caused by an incompetent gastroesophageal sphincter
149
AIL: May result to brownish or blackish vomitus
Duodenal and gastric ulcers
150
AIL: Presently grey stool
Acholic stool
151
AIL: Passage of hard or painful stools; incomplete defacation
Constipation
152
AIL: Passage of excessively frequent stools
Diarrhea
153
AIL: Greasy foul smelling stool
Steatorrhea
154
AIL: Inability to absorb enough nutrients
Malabsorption syndrome
155
A discoloration of the skin and eyes is caused by high levels of _____ in the blood
Bilirubin
156
A discoloration of the skin and eyes may suggest a problem in the _____
Liver, gallbladder, or bile duct
157
Jaundice may be caused by an obstruction of the _____ or obstruction of the _____
Common bile duct or pancreas
158
Dark urine suggests impaired excretion of _____
Bilirubin
159
Color of the stool of someone with obstructive jaundice
Acholic or light colored
160
Pain caused by a sudden distention of the renal capsule
Kidney pain
161
Pain in the ureter
Urethral pain
162
Pain in the ureter may be caused by stones in the _____
Urinary tract
163
AIL: Condition of having kidney stones
Nephrolithiasis
164
AIL: Condition of having gallstones
Cholelithiasis
165
Where is prostatic felt?
Perineum
166
Pain during urination may be caused by the presence of _____ or _____
Stones or tumors
167
AIL: Presence of blood in urine
Hematuria
168
Pain during urination with blood may be caused by the presence of...
Tumor
169
Urination with blood in the absence of pain may be caused by...
Cancer
170
AIL: Caused by an infection of the bladder that comes with a sudden urge to urinate
Urinary urgency
171
AIL: An urge to urinate but unable to
Urinary hesitancy
172
AIL: The need to strain in order to urinate
Straining to void
173
AIL: Urine does not flow smoothly
Dribble
174
AIL: Pain during urination without frequency is suggestive of...
Urethritis
175
AIL: Excessive thirst or excess drinking
Polydipsia
176
AIL: Group of diseases that injures the part of the kidney that filters blood
Glomerulonephritis
177
AIL: Intense urge to urinate with straining but little to no result
Vesical tenesmus
178
AIL: Intense urge to defecate but little to no result
Rectal tenesmus
179
AIL: Swelling of the limbs due to veins having trouble sending blood from the limbs back to the heart
Venous disease/Venous insufficiency
180
AIL: An inflammatory process that causes a blood clot to form and block one or more veins, usually in your legs
Thrombophlebitis
181
AIL: Caused by weak vein walls and valves or an increase blood pressure in veins
Varicose veins
182
AIL: Inflammation of the tendons
Tendonitis
183
AIL: Inflammation of the bursa
Bursitis
184
AIL: Causes joint pain throughout the body
Rheumatoid arthritis
185
AIL: Joint pain
Arthralgia
186
AIL: Muscular pain
Myalgia
187
AIL: Butterfly rash is commonly associated with what condition
Systemic lupous erythematosus
188
AIL: Appears as the body's reaction to allergy or drug reactions
Urticaria or hives
189
AIL: Low blood sugar level
Hypoglycemia
190
AIL: Low blood pressure caused by a sudden change in position
Postural hypotension
191
AIL: Paroxysmal disorder with or without loss of consciousness; change in brain's electrical activity
Seizure
192
AIL: Sudden temporary loss of consciousness when blood flow to the brain is insufficient
Syncope (fainting)
193
AIL: Involuntary movement/shaking of one or more parts of the body
Tremors
194
AIL: Tingling sensation of the skin
Paresthesia
195
AIL: Occurs when your body does not produce enough hormones
Hypothyroidism
196
AIL: Hypothyroidism can result to _____ due to a deceleration of the body's metabolism
Obesity
197
AIL: Occurs when your body produces too much hormones
Hyperthyroidism
198
AIL: Hyperthyroidism can result to _____ due to an acceleration of the body's metabolism
Weight loss
199
Another term for black stool
Melena
