Exam 1 Flashcards

Sept 9 (43 cards)

1
Q

What is subjective information?

A

What the patient says

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2
Q

What is objective information?

A

What you can measure

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3
Q

What is the purpose of a health history?

A

Collect subjective data and complete a picture of the person’s past and present health

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4
Q

What guidelines are there for an effective interview?

A

Use therapeutic communication, minimize distractions, use understandable language, avoid rushing, eye level

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5
Q

What are the goals of an interview?

A

Discover information, provide information, negotiate, counsel

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6
Q

When does history taking begin?

A

With your realtionship with the pt

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7
Q

What to avoid when taking history

A

Medical jargon, overtire the pt and leading questions

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8
Q

What to do when taking history

A

Introduce yourself, adress pt properly, be courteous, make eye contact, be flexible, take notes sparingly, start with general concerns then move to specific, clarify with WWWHW questions, verify and summarize

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9
Q

What are sensitive issues?

A

alcohol and drug use, religion, sexual history and orientation

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10
Q

How to approch sensitive issues

A

Ensure privacy, be direct and firm, don’t apologize, don’t preach, use understandable language, don’t push too hard, therapeutic communication

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11
Q

What are the categories of history taking?

A

Biographical data
Reson for seeking care
present and past illness
past history
family history
review of systems
functional assessment/ ADL’s

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12
Q

Reson for seeking care questions

A

What problems or symptoms brought you here?
How long has this problem been present?
Where did these symptoms begin?

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13
Q

Present problem or illness

A

Chronology of events
health state prior
first symptom
exposure
typical attack
impact on illness
stability of problem
immediate reason for visit
review of involved systems
medication listt
chronology review
problem list

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14
Q

8 charateristics of each patient symptom

A

location
charater or quality
quantity or severity
timing
setting
aggravating or reliving factors
associated factors
pt’s perception

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15
Q

WILDCATS

A

w- words to describe
i- intensity
l- location
d- duration
c- comfort
a- aggrevating/ alleviating
t- treatment
s- side effects

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16
Q

Past medical histoy

A

Overall health before and past medical and surgical history

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17
Q

Past medical history includes

A

Childhood illness
accidents or injuries
serious or chronic illnesses
hospitalization
operations
obstetric hisoty
immunizations
last exam date
allergies
current medications

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18
Q

Purpose of review of systems

A

Evaluate the past and present health state of each body system with subjective information

19
Q

Factors impacting history taking

A

self esteem. acceptance by peers, tension with parents

20
Q

Cover issues of concern

A

HEEADSSS
home
education
eating
activities
drugs
sexuality
suicide
safety

21
Q

Older adults history taking

A

Cormorbities (overlapping health issues)
Chronic symptoms might not be reported
complete drug assessment essential
assessment of functional capacity (getting up from a chair, making own food)

22
Q

prep for physical exam

A

enviroment, equipment, client

23
Q

Physical exam organization

A

compare side to side
offer rest periods
perform painful procedures last
use common language
record quick notes
logical sequence (head to toe)

24
Q

Client approch

A

Wash hands
Introduce youself
begin with vital signs
perform from head to toe
explain everything to client (what your doing and findings)

25
Physical exam in infants
sit in parents lap
26
Physical exam in toddlers
play with equpiment fast and quick
27
Physical exam in preschool
Demonstrate
28
Physical exam in school age
may want to be alone
29
Physical exam in adolescent
may want to be alone tell normal findings
30
physical exam sequence
general survey vital signs skin, hair, nails head and neck thorax and lung heart vascular system abdomen female and male reproductive systems musculoskeletal sensory neuro
31
Physical exam in aging adult
can they see and hear attention span
32
4 techniques
inspection palpation percussion auscultation
33
palpation
sensation of hands
34
palmar palpation
Surface of fingers
35
ulnar surface palpation
back of hand
36
direct percussion
striking fingers/ hands directly on body
37
indirect percussion
both hands required
38
percussion tympany sound
lough high pitched (abdomen)
39
percussion sound resonance
lung
40
percussion sound hyperresonance
hyper inflated lung
41
percussion sound dullness
liver
42
percussion sound flatness
bone/muscle
43