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Physical Diagnosis > PD3- Midterm > Flashcards

PD3- Midterm Flashcards

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1
Q 
goals of pt documentation:
provide ? thru accurate doc
capture ? of pt illness/improve security levels
assure appropriate ? to institutions 
justify ? consumed
assure appropriate ?
A 
quality of care
severity
comparisons
hospital resources
reimbursement
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2
Q

comorbid cond is secondary dx when:

  • pt receives ? at time of admission
  • list under ?
  • do not use ?
  • develops subsequent to?
  • affects ? and/or ?
A 
Tx
PMH of H&P
has a history of
hospital admission
tx received/LOS
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3
Q

for dictation you must write a ? in pt chart

A

short note

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4
Q

admissions discharges and operative notes- can report via?

A

dictation

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5
Q

? must be countersigned with in 24h

A

admission orders

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6
Q

admission orders - mneumonic?

A 
adc vaandilm
admit to
dx
condition
vitals
activities
allergies
nursing orders
diet
iv
labs
meds
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7
Q

condition - 2 statuses?

A

condition

code

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8
Q

vitals
every hr on ?
do NOT write
freq of ? status assessment

A

unstable pt
per nursing order
neuro

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9
Q

don’t write ? orders

A

STAT

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10
Q

include ? under assessment of admission H&P

A

risk factors

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11
Q

each DRG is give a ?

1.0 = lump sum ?

A 
relative weight (RW)
$4500
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12
Q

discharge note similar to a ?

A

daily progress note

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13
Q

discharge orders- MUST indicate that pt is ?

A

being discharged

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14
Q

discharge SUMMARY is a ? that summarizes pt’s ? hospital stay/ complete w/in ?

A

SEPARATE, entire

30D of discharge

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15
Q

complete h&p, nfo on labs, tests, assessment & plan ?

A

admission NOTE

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16
Q

adc vaandilm?

A

admission ORDER

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17
Q

SOAP note, specify all discharge info and instructions in plan

A

discharge NOTE

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18
Q

medical order to discharge pt to where and with whom, discontinuation orders

A

discharge ORDERS

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19
Q

written form or dictation summarizing pts hospital stay, w/in 30 days

A

discharge SUMMARY

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20
Q

acute abdomen w/out pain

A

geriatrics
diabetes
steroids

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21
Q

capsular swelling- type of ?

A

pain

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22
Q 
pain
gripping?
dull, aching?
crampy, contricting?
biliary usually starts as?
A

intestinal obstruction
pyelonephritis
biliary or renal colic
epigastric

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23
Q

pain after eating- possible ? of and viscera

A

vascular dz

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24
Q

green vomit- obstruction distal to ?

A

ampulla of vater

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25
periodic peritonitis in?
familial mediteranean fever
26
malabsorption syndrome?
CF, celiacs
27
aganglionic megacolon
hirschsprungs dz
28
liver 4-8cm at ? 6-12cm at? hepatomeg when percussed ? below costal margin?
midsternal line midclavicular line 2-3cm
29
f/e of cervical spine? | lateral flexion?
70 degrees | 50 degrees
30
right shoulder pain? 3
GB dz, peptic ulcer, liver abscess/tumor
31
in alley's (shoulder) document level of ?
thoracic vertebra reached
32
cross chest/horizontal adduction test for ?
ac joint impingement
33
arm extended and forearm supinated w/ elbow slightly flexed, resists shoulder forward flexion
speeds test- biceps tendonitis
34
``` thoracic outlet syn test? head rotated to face tested shoulder extend and laterall rotate head examiner extends pt shoulder pt takes a deep breath and pos = ? ```
adson maneuver | loss of radial pulse
35
anterior and superior dislocation of radial head
nursemaid's elbow
36
test this by resisting wrist flexion and pronation?
golfer's elbow
37
hoffman's dz tested via ? ; tests ? tendons
finkelsteins; APL,EPB
38
pt makes fist, hcp pressing radial and ulnar artery and releases one at a time; delay/ absence of flushing = ?
allen test | partial/complete occlusion
39
inflammation of flexor tendon and synovial sheath, finger catches as it extends
trigger finger
40
avulsion of flexor tendon of 4/5 finger
jersey finger
41
collaterals of knee
apley's distraction
42
neuromata of knee
tinel's sign
43
ballottment- tapping/clicking, patella 'floats' outward when pressure released = ?
effusion
44
lachman's pulls tibia anteriorly and stabilizes femus; lax its of ? indicates ?
>5cm, ACL injury
45
thickening on posterosuperior aspect of calcaneus?
pump bump - Haglund's deformity
46
flexion deformity of PIP joints toes 2-5; causes hyperextension of MTP
hammertoes
47
hyperextension of MTP joint of great toe w/ possible tearing of flexor tendon?
turf toe
48
geri pt may be lucid but ?
disoriented
49
~4+ dz in 70% greater than?
65
50
ADLs- primary responsibility?
promoting safety
51
polypharmacy- 13% US population but takes almost ? of all meds Rx
30%
52
to prevent poly pharm, ? is key!
communication
53
refusal or failure to provide elderly person with life necessities i.e. food water, comfort, safety, etc
elder neglect | also abandonment, financial or material exploitation
54
decubitus ulcer- final common p/w? irreversible changes in ?
ischemia, 2 hrs uninterrupted pressure
55
prevent decubitus ulcers- pressures less than ?
30 mm Hg
56
leading cause of institutionalization in elderly
urinary incontinence
57
goal of palliative care?
best QOL
58
high rates of depression in ? and ? geri pts
dementia, PD
59
psychotherapy ? in geri depression
underutilized
60
associated with sig medical and psych morbidity
grief
61
MCC of suicide in geri
physical illness | lost loved one
62
collaborative person centered form elicits and strengthens motivation for change?
motivational interviewing
63
``` MI: express ? support? roll with ? develop ? ```
empathy self-efficacy resistance discrepancy
64
key to lifestyle changes?
motivation
65
4 concepts in adult learning 1. selfconcept moves from ? to ? 2. use ? as a resource for learning 3. motivation is influenced by ? 4. ? of knowledge
dependency>>>self-direction life experience societal roles immediate application
66
colorectal ca study- pt perception of working well with dr- ?
commitment skills and relationship
67
SEGUE framework can also be used as ?
assessment tool
68
improved outcomes in smoking cessation and pos results in obesity counseling?
5 As
69
``` 5 As ? risk ? change ? and collaborate on set goals ? in addressing challenge ? for f/u ```
``` assess advise agree assist arrange ```
70
in adult edu, HCP doesn't consider?
lifespan development

Physical Diagnosis (4 decks)

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