Brainscape's Knowledge GenomeTM


Top Flashcards (Certified)
All Flashcards

Review MedTerm > H&P Week 1 Flashcards > Flashcards

H&P Week 1 Flashcards

(89 cards)

Start Studying
1
Q

When discovering details about the patient’s concerns, what is important to establish?

A

It is very important to establish that you are in a PARTNERSHIP with your patient.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

T/F: When discovering details about the patient’s concerns, you should actively ask questions and limit the patient’s speaking.

A

False! It is extremely important to ask open-ended questions and LISTEN to the patient.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

T/F: Do not ask a patient for clarification, because it shows you are not competent.

A

False! Ask for clarification when needed. It is important to truly understand why they’re there and what they already know/believe to be true about their condition.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

What is the Power Differential with a patient? Do we follow this?

A

Provider = position of strength
Patient = vulnerable

Our goal is to eliminate this power differential to make the patient feel as comfortable as possible.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

T/F: You should always knock before entering the room.

A

True! Make it known you are entering the room in an effort to make the patient comfortable.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

How do you introduce yourself to a patient and accompanying members?

A

Introduce yourself using title and role. Find out who the patient is, then meet the others in the room and discern the relationship.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

T/F: Using medical jargon with your patients is great and makes you appear more competent.

A

False! Attempt to match your vocabulary to the patient. It is your goal for the patient to understand their diagnosis, so try to minimize the medical jargon.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

After a patient has finished stating their medical history and you are done asking questions, what should you do?

A

Summarize and ask for clarification. Ensure that you have the story.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

What is a barrier to communication that we need to learn to “sit through”?

A

Silence is a barrier to communication when taking a medical history. Allow the patient to tell their story and give them time to be able to tell you their story. Learn to sit through the silence and become comfortable with it.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

T/F: When entering a patient room, you should remain standing.

A

False! To make the patient more comfortable, sit down, even if the patient remains standing.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

T/F: Eye contact will always be appropriate and respectable to patients.

A

False! Eye contact may be culturally inappropriate for some patients. Try to discern this based on the eye contact the patient maintains with you, then work through it.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

What are the 8 aspects of taking a medical history?

A
  1. Identification
  2. Chief Complaint (CC)
  3. History of Present Illness (HPI)
  4. Past Medical History
  5. Family History
  6. Social History
  7. Review of Systems
  8. Concluding Questions
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

What does Identification (ID) entail while taking a medical history?

A

Name, age, DOB, Date of Service (DOS), gender/sex/pronouns, race, source of information, and referral source.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

T/F: When writing the chief complaint, use the word complaint to describe what symptoms brought the patient here.

A

False! Avoid using the word “complaint”. Instead, use “Concern” as it is preferable.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

In the Chief Complaint/Concern, is it okay to say a patient is complaining of something?

A

No! Patients are not complainers. Prefer to use the word Concern.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

For a History of Present Illness (HPI), what acronym is used?

A

OPQRSTA

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

In OPQRSTA, what does O stand for?

A

Onset: When did the problem start?

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

In OPQRSTA, what does P stand for?

A

Palliative/Provocative/Progression/Prior Episodes:
What makes the pain better versus what makes it worse? Has it gotten better or worse or the same? Has this ever happened before?

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

In OPQRSTA, what does Q stand for?

A

Quantity/Quality:
How often does the problem occur and what does it feel like?

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

In OPQRSTA, what does R stand for?

A

Region/Radiating:
Where does it hurt? Does the pain radiate elsewhere?

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

In OPQRSTA, what does S stand for?

A

Severity/Scale Rating: Is this the worst pain you’ve ever had? Worse pain you’ve ever experienced versus no pain at all on a scale of 1-10. There are different scales you can use.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

In OPQRSTA, what does T stand for?

A

Timing/Treatment:
How long have you had this problem and how does it fluctuate throughout the day? What have you tried to make it better?

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

In OPQRSTA, what does A stand for?

A

Associated Events/Signs/Symptoms:
Was there any injury that could have started this pain? Is there something we can objectively/physically see to associate with the problem (signs)? What other symptoms are present?

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

When asking about the patient’s past history, what do you ask history of?

A

Medical conditions/diagnoses (the big 8)
Medications
Allergies
Hospitalizations/Surgeries
Immunizations

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
What is the Personal Medical History (The Big 8)?
1. Cancer 2. Hypertension/Hypercholesterolemia 3. Diabetes 4. Heart problems 5. Lung problems 6. Thyroid problems 7. Bleeding disorders/strokes 8. Depression or other psychiatric disorders
26
T/F: In regards to medications in the medical history, it is not important to discuss discontinued medications.
False! We want to discuss discontinued medications in regards to when they were discontinued and why.
27
Allergies to the environment are more commonly considered????
Seasonal allergies is more commonly considered a medical diagnosis.
28
With a Family History, who do we want to ask the patient about?
First degree relatives that are related by blood.
29
What types of questions are we asking in regards to a Family History?
We are to ask about each family member and indicate if alive or deceased as well as age. We also want to ask about the main heritable diseases (the big 8).
30
What is a Social History? Also known as ???
Also called personal history. This is where you ask about a patient's habits that may impact their health.
31
What is a Review of Systems (ROS)?
A systematic look at the body systems in which we look completely at a patient's health.
32
Why is a Review of Systems important?
It ensures you aren't missing another component of the problem the patient is being seen for.
33
T/F: When taking a medical history, it is never okay to ask multiple questions at once.
False! While doing a Review of Systems, you can ask multiple questions at once for each body system.
34
What is a Pertinent Positive?
Findings that are present and help confirm or support a suspected diagnosis.
35
What is a Pertinent Negative?
Findings that are absent and help confirm or support a suspected diagnosis.
36
When offering support, what must you always do?
You must always be FACTUAL and TRUTHFUL. Do NOT give false hope.
37
What is a Complete History?
History to establish care the first time you meet a patient. Involves a physical exam. Can also be done for a hospital admission note.
38
What is an Inventory History?
When you have a new patient with many medical problems. Touches on the main points with minimal detail. This will take more than one visit, but it gives you a "feel" for what is happening.
39
What is a Problem (Focused) History?
An acute problem in which the history is only related to the Chief Complaint.
40
What is an Interim History?
What happened since you were last seen. Likely for a hospital or ED follow up visit.
41
T/F: Herbal medications are not important to inquire about.
False! Don’t forget to ask about herbal medications as these can have a big impact on the body or be a cultural aspect of the patient's care.
42
T/F: All questions you ask a patient will likely have pertinent responses.
False! Not all questions you may ask are pertinent. You may find things that are incidental and don’t relate to the problem we are encountering in today’s visit.
43
What would be a case scenario in which silence may not be beneficial while taking a medical history?
When working with adolescents/teenagers. Give them time to talk, but also be wary that you may need to push and prod to get answers.
44
What are examples of Sensitive Issues?
Substance use, domestic violence, sexuality, and/or spirituality.
45
When taking a sensitive history, what is important to emphasize?
Emphasize that the information will help you provide better care and asking is standard practice. Make sure that is true!
46
When do you take a sensitive history?
-First visit -Next routine visit for those you missed on the first visit -Every annual preventive exam -Any visit with suspicious symptoms
47
T/F: While discussing sensitive issues, it is especially important to reinforce confidentiality and provide privacy.
True! This will help the patient to feel more comfortable and trust to share things.
48
What type of screening questionnaire is TACE?
Alcohol
49
What type of screening questionnaire is CAGE?
Alcohol
50
What is DAST-10?
A Drug Abuse Screening Test
51
What is CRAFT? What age group is this for?
Substance Use Questionnaire specifically for adolescents.
52
What is Motivational Interviewing?
Counseling approach to promote behavioral change in a patient. Get the patient to open up to you.
53
With Motivational Interviewing, what is one of the most important factors of the approach?
Affirming the patient's goals and plans.
54
T/F: With Motivational Interviewing, the goal is to limit empathy in order to promote patient's self efficacy.
False! It is extremely important to express empathy in order for the patient to feel safe to open up to you and promote collaboration.
55
T/F: With Motivational Interviewing, the patient should rely on you indefinitely.
False! It is especially important to promote self-efficacy in this scenario so that the patient may learn to rely on themselves to maintain their health. They should not rely on us every step of the way.
56
What are the rates of Domestic Violence for men and women?
1 in 4 women experience it. 1 in 10 men experience it.
57
What is Intimate Partner Violence?
Describes physical, sexual, or psychological harm by a current or former intimate partner.
58
T/F: When addressing Intimate Partner Violence, it is not necessary to discuss social factors.
False! Social factors play a massive role in IPV.
59
What is HITS?
Intimate Partner Violence Screening.
60
T/F: When discussing sexual history with a patient, it is important to make them feel singled out as if they are the only ones you ask this question to.
False! You want it known that you ask these questions of all patients regardless of age or marital status. Tell them it is just as important as other questions of physical and mental health.
61
What is Sex defined as?
Biological traits that society associates with being male or female.
62
What is Gender defined as?
Cultural meanings attached to being masculine & feminine, which influences personal identities.
63
What is Sexuality defined as?
Sexual attraction, practices, and identity which may or may not align with sex and gender.
64
What are the 5 P's of Sexual History?
1. Partners (gender, number, monogamy) 2. Practices (type of sexual contact) 3. Protection from STDs 4. Past History of STDs 5. Prevention of Pregnancy
65
If a patient's sexual history is positive, what needs to be asked and performed?
Ask: New or multiple partners Non-existent or inconsistent use of condoms STD symptoms Perform: Screen for STDs Counseling for HIV/STD prevention
66
What is a Spiritual History?
A spiritual history obtains information on a person's spiritual life, history, and practices and how these affect their ability to cope with their present healthcare crisis.
67
What percentage of USA Adults consider religion important?
81%
68
What are the names of 3 Spiritual Assessments?
FACT, FICA, HOPE.
69
What are the barriers when discussing Sensitive Issues?
-Not a lot of time to talk about deep topics. -Training can be difficult. -Uncertainty if we don’t know a lot about what the patient is saying or if we feel comfortable talking about it as a provider. -Fear or projecting your own beliefs on someone can be really challenging.
70
When performing a physical exam, what direction should you move from?
Move from head to toe performing your exam in a consistent sequence (easier to remember).
71
T/F: Sensitive exams should always be performed just with the patient alone.
False! A patient may feel more comfortable if a chaperone is present for sensitive exams.
72
What is the first objective thing you measure on a physical exam?
Always start with vitals, especially if reported abnormal by who roomed the patient.
73
Name the 4 exam techniques.
Inspection, palpation, percussion, auscultation.
74
What does Inspection on a physical exam entail?
When you enter the room, using your senses such as sight and smell to gather information about the patient and their condition.
75
T/F: Lighting and exposure are not essential for inspection on a physical exam.
False! Both adequate lighting and good exposure of the skin are essential. We can't inspect a body through clothes.
76
What is Tangential Lighting?
A way of using light to enhance the exam, low angled light will create shadows that will indicate surface abnormalities.
77
T/F: You should hurry through inspection on a physical exam.
False! This process should be unhurried as we are able to do this throughout the visit.
78
What does Palpation on a physical exam entail?
Using touch to determine things like pain, size, consistency, skin texture, masses, fluid, crepitus (crackly noise), etc.
79
What is Crepitus?
Crackly noise that indicates air under the skin or in a joint.
80
What is the most sensitive surface of the hands?
Palmar surface of fingers.
81
What is the best aspect of the hand for vibration?
Ulnar surface of the hand.
82
What is the best surface of the hand for temperature?
Dorsal surface of the hand.
83
What does Percussion on a physical exam entail?
Striking one object against another to produce vibration and sound waves.
84
How can we use percussion on a physical exam?
We can use it to detect changes in sound and to detect pain.
85
How can percussion be helpful for diagnosing kidney pain?
If percussion of the kidneys is painful, the kidney is inflamed.
86
What is Direct Percussion?
Percussing on the tissue itself (bare skin).
87
What is Indirect Percussion?
Percussing on your fingers over the tissue itself.
88
What does Auscultation on a physical exam entail?
Listening to the presence/absence and characteristics of sound through the use of a stethoscope.
89
T/F: When using auscultation, we should target one sound at a time.
True! If possible, try to control this. For example, have a person hold their breath shortly while listening to the heart so the sounds of the lungs don't interfere.

Review MedTerm (10 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2025 Bold Learning Solutions. Terms and Conditions