Physical exam Flashcards

1
Q

A statement in the patient’s own words that describes the reason for the visit is called:

A

chief complaint (CC)

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2
Q

When documenting a patient’s allergies in a paper record, they are typically written in ___ ink.

A

red ink

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3
Q

Which type of communication technique is utilized in order to encourage the patient to respond in more detail?

A

open-ended

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4
Q

Which instrument is used to examine and view the ears?

A

otoscope

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5
Q

What term defines a physician listening to the patient’s heart or digestive organs?

A

auscultation

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6
Q

to measure

A

mensuration

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7
Q

Which word is an electrical recording or graph of the heart?

A

electrocardiogram

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8
Q

Which position will the patient be placed in for symptoms of shock?

A

Trendelenburg

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9
Q

A patient comes in for an examination of external hemorrhoids. Which position should the patient be positioned in for this exam?

A

Sims

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10
Q

A tuning fork is used to check the patient’s auditory acuity and bone vibration, as well as:

A

diabetic peripheral neuropathy.

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11
Q

questions that provide a guide to the patient’s general health and help detect conditions

A

Systems review (SR) or review of systems (ROS)

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12
Q

Record of a patient’s demographic information, along with the history, physical examination, and initial lab findings

A

Database

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13
Q

Subjective findings

A

symptoms, they are what the patient feels and can be interpreted only by the patient.

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14
Q

Objective findings

A

signs, They are the indicators of health or disease that a provider detects when examining a patient.

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15
Q

closed questions

A

ask for specific information. This form of questioning limits the answer to one or two words—in many cases, yes or no.

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16
Q

asks for general information or states the topic to be discussed, but only in general terms.

A

open ended question

17
Q

The patient completely rejects the information.

A

Denial

18
Q

Rewording or rephrasing a statement to check the meaning and interpretation.

A

Restatement

19
Q

Past history (PH) or past medical history (PMH)

A

A summary of the patient’s previous health.

20
Q

clarification

A

actively listening and responding to the pt

21
Q

Patient sits on the exam table with the head of the table elevated 90 degrees

A

Fowler position

22
Q

Supine position

A

on your back. The patient lies flat with face upward and the lower legs supported by the table extension

23
Q

The patient lies upward, with the weight distributed primarily to the surface of the back

A

Dorsal recumbent position

24
Q

Prone Position

A

on your belly. The patient lies face down on the table on the ventral surface of the body

25
Q

Patient is placed on the left side, with left arm and shoulder drawn back behind the body so that the body’s weight is predominantly on the chest

A

Sims Position

26
Q

Place the patient on his or her back with the knees sharply flexed and the arms at the sides or folded over the chest. usually used for ladies vaginal exams

A

Lithotomy Position

27
Q

This position can be achieved only if the examination table separates so that the legs can be elevated higher than the head

A

Trendelenburg Position

28
Q

How to interact with children

A

-allow to touch stethoscope
-praise for good behavior
-game to distract

29
Q

What to do for an anxious pt

A

be calm

30
Q

How do you correct an error on a paper chart ?

A

line through the error and initial

31
Q

How do you correct an error on a Electronic chart?

A

addendum

32
Q

Percussion hammer

A

also called reflex hammer , used to strike the tendons of the knee and elbow to test the neurologic reflexes.

33
Q

Main reason in the patient’s own words that describes the reason for the visit

A

Chief complaint

34
Q

Involves tapping or striking the body

A

Percussion

35
Q

Performed with one hand, both hands, or finger, fingertips, or palmar aspect of the hand

A

Palpation