review of systems and medical screening Flashcards
(42 cards)
what are the steps in reviewing systems and med screening?
gather info from
- past med hx
- med screening
- social hx
- Current Health Behaviors
what are important details for collecting info an nausea/ vomiting?
- Is there a reason for nausea?
- how often?
- what does it look liek- coffee grounds
- ask if there are any other signs with the n/v
- is the vomiting with nausea or without
- taking any meds
a patient has coffee ground vomit, what does this mean?
coffee ground vomitus represents blood
(hematemesis)
When shoudl N/V be reported to phys?
- persistant
- nausea that needs med use
what are possible reasons for N/V
- GI disorders
- Infection (hepatitis,influenza)
- MI
- Cancer
- Vestibular disorders
- Migraines
- Pregnancy
- Adverse drug reactions
Fever/Sweats/Chills are a response to
a systemic response to a systemic illness
if a patient reports Fever/Sweats/Chills, what should you ask them ?
- see if they have been taking temp,
- have they noted excess sweating, are they feverish ect.
what is a significant temp?
significant if 99.5 or higher for >2wks
- this could be a self limiting virus
At what point is a temp an urgent referral?
over 102
T/F if the pt does not have an temperature, then they must not have an infection
false, dotn need to have a temp to have an infection.
Good way to rule in, not a good way to rule out.
- get a full picture, does the pt present with (fatigue,malaise,decreased thermoregulation in elderly
- post op pts are also at risk for infection
when are night sweats a concern?
when they are:
- regular
- inturupt sleep
- have other symps
- fever
- wt loss
- important to note that night sweats can occur with menopause, some meds, warm rooms, many other reasons
- population to be on the look out for, post op and elderly
what can be some causes for Fever/Sweats/Chills?
•Infections •Metastatic cancers •Rheumatic disorders •Menopause
when is weight changes considered a red flag?
-5-10% change over 4-6 months that is unexplained or unintentional (diet or activity)
a pregnant woman has gained 7 lbs in 1 week, what shoudl you do?
refer.
->5 lb wt gain in 1wk or>5 lb loss in first trimester shoudl be reffered
-
Why is weight monitoring important in CHF?
fluid accumulation is a sign of CHF exacerbation
> 2‐3 lbs in a day = referral
What could cause weight changes?
- Metastatic cancers (unexplained,>10lbsover6mo)
- Depression
- GI disorders
- Infections
- Anorexia nervosa
- Chronic pulmonary,cardiac or renal failure
- Rheumatic disorders
- Endocrine disorders, thyroiddysfunction, DM
Can Paresthesia, Weakness or Balance Problems be a cause for concern?
yes.
there is a concern if it is a: -bilateral
-atypical pattern
- UE/LE together
-other neuro sxs present (vision,taste,smell,hearing)
- saddle anethesia
- we should determine if a referral is needed. we-re often the ones txign paraethesia, so we need to make sure it is not coming from a sinister source and it can indeed by intreated by PT
when is weakness a concern?
•Concern if non‐myotomal
•Concern if any other neuro sx present(vision,taste,smell,hearing)?
•Urinary retention,increased frequency,overflow incontinence
- Weakness complaint with negative neuro exam (balance, sensation, strength ,reflexes)–consider it a yellow flag and monitor through course of care.
What could balance problems be related to?
If present with
Dizziness or lightheadedness:
•Vestibular issues
•Vascular insufficiency
possibly 2/2
•Neurologic disorders
•Adverse drug reactions
•Musculoskeletal injury/disease
When is a night pain a concern?
- Difficulty sleeping or falling asleep due to sxs
- Wakes at night due to sxs and unable to easily (i.e.change position)fall back to sleep
- Pain not relieved by lying down
- Pain unchanged w/ position change,food
- Frequency(x/wk,x/night) duration
- Due to possible:
- Infection
- Neoplasm
- Other…inflammation,OA
What is the difference btwn normal fatigue and concerning fatigue ?
fatigue thats normal can be caused by life, grief, or work
- Concern if interfering with function for more than 2 to 4 wks •Especially if not related to above factors
•Presentation maybe subtle
•Description of pts fatigue •Explanation? - have pt explain to you why they are feeling that way
what could cause fatigue?
- Psychosocial
- Endocrine/Metabolic
- Infections
- Neoplasms
- Cardiopulmonary
- Connective Tissue Disease
- Sleep Disturbances
- Medication Use
what is malaise?
a feeling of general discomfort- feeling off or nto well
- “like im coming down with something”
- usually associated with fever
- what my mom always says
- often pts reveal this in convo, not in a questionaire
Consider that the patients issues could have Mentation or Cognition influences? what type of flag is this considered?
perform a medical screen on Mentation or Cognition through observation
- alertness, orientation, attention , thought process, good historian
- yellow flag - phys shoudl be aware if not, monitor this
- get sufficient detail for discussion w/ physician
