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PA: Exam 1 > 1. SESSION 1: History & Physical Exam Overview > Flashcards

1. SESSION 1: History & Physical Exam Overview Flashcards

0
Q

Nurse Practitioner approach v. Medical approach.

  • Medical diagnosis is concerned with…
  • Nursing diagnosis is concerned with…
A

Independent but interrelated:

  • Medical diagnosis is concerned with etiology of disease and curing
  • Nursing diagnosis is concerned with impact of health on the individual and caring.
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1
Q

Assessment Factors for Holistic Approach (6)

A

1) Growth and Development
2) Emotional Status
3) Cultural, Religious and Socioeconomic Background
4) Performance of daily living
5) Patterns of coping
6) Patient perception of and satisfaction with his or her health status

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2
Q

The preferred method of organizing clinical information is ther problem oriented approach:

A

S: Subjective (What the patient/family tells you)
O: Objective (What you observe - physical exam and labs)
A: Assessment (What you think is going on)
P: Plan (What you plan to do - five steps)

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3
Q

Define Sign v. Symptom

A 
Sign = Objective Data.  (What the health care provider observes or tests)
Symptom = What the person says about self during history taking.
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4
Q

Deviated Septum (Sign or Symptom

A

SIGN

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5
Q

Indigestion: Sign or symptom?

A

SYMPTOM

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6
Q

Coarse Hair: Sign or Symptom?

A

SIGN

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7
Q

Absent R Nasolabial Fold: Sign or Symptom?

A

SIGN

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8
Q

Sore shoulder: Sign or symptom?

A

SYMPTOM.

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10
Q

Intermittent Cough: Sign or Symptom?

A

SIGN

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11
Q

Orthopnea: Sign or symptom?

A

SYMPTOM

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12
Q

Blurred Vision: Sign or symptom?

A

SYMPTOM

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13
Q

Voice Change: Sign or Symptom?

A

Could be sign or symptom

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14
Q

Non-tender Abdomen: Sign or symptom?

A

SIGN

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15
Q

Morning Stiffness: Sign or symptom?

A

Symptom

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16
Q

Cyanosis: Sign or symptom?

A

SIGN

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17
Q

Blood in Urine: Sign or symptom?

A

Could be sign or symptom

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18
Q

Edema: Sign or symptom?

A

SIGN

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19
Q

Intact Gag Reflex: Sign or Symptom?

A

Could be sign or symptom.

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20
Q

Unequal Pupils: Sign or symptom?

A

SIGN

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21
Q

Palpatations: Sign or symptom?

A

Symptom

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22
Q

Dizziness: Sign or symptom?

A

Symptom

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23
Q

Epistaxis: Sign or symptom?

A

Sign

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24
Q

Nausea: Sign or symptom?

A

SYMPTOM

25
Q

Weight Gain: Sign or symptom?

A

Could be either

26
Q

___% of diagnoses could be made based on the history

___% of diagnoses could be made based on history + phys exam

A

70%, 90%

27
Q

Six attributes of a successful clinician:

A

1) Approachable
2) An empathetic listener
3) Self-reflective
4) Respectful
5) Courteous
6) Professional

28
Q

Six nonverbal skills to use in pt communication

A

1) Physical appearance
2) Posture
3) Gestures
4) Facial expression
5) Eye contact
6) Voice and touch

29
Q

Ten traps of interviewing

A

1) Providing false assurance
2) Giving unwanted advice
3) Using authority
4) Using avoidance language
5) Engaging in distancing
6) Using professional jargon
7) Using leading or biased questions
8) Talking too much
9) Interrupting
10) Using “why” questions

30
Q

American life span (men / women)

A 
Men = 74
Women = 79
31
Q

Four different ways of doing data collection and when each should be used:

A

1) Complete (Traditional H&P) Data Base (Used on first visit)
2) Episodic Data Base (More problem centered)
3) Follow-up data base (More problem centered)
4) Emergency Data Base (ABCs)

32
Q

What are the “ABCs?”

A

Airway
Breathing
Circulation

33
Q

What 9 components comprise the “classic” history and physical?

A

1) Introductory information
2) CC (Chief complaint)
3) HPI (History of present illness)
4) PMH (Past medical history)
5) Current social history
6) Social, occupational and family history
7) Functional assessment
8) Review of systems (ROS)
9) PE (Physical Examination)

34
Q

What should be included in a health history?

A

1) Identifying Data: Name, age, sex, race/ethnicity, place of birth, marital status, occupation
2) Source of history and reliability

35
Q

How do you record the chief complaint? (4 characteristics)

A

1) Represents the primary reason pt is seeking medical att’n
2) By convention, it is stated in the patient’s words and written in quotation marks.
3) May include a short statement on duration.
4) It is not a diagnostic statement

36
Q

History of Present Illness (HPI)

  • What is this for the well person?
  • What is this for the sick person?
  • What does this include?
A

1) For the well person: Short statement about their general state of health.
2) For the ill person: A detailed chronological account of their chief complaint.
3) You will include 8 pieces of information referred to as an analysis of the symptom.

37
Q

Critical characteristics of a symptom (Essential for billing) - HPI (9)

A 
P: Provocative or Palliative
Q: Quality or Quantity
R: Region or Radiation
S: Severity Scale
T: Timing
U: Understanding Patient's Perception
38
Q

How to quantify smoking history

A

Packs per day x # Years smoking = PACK YEARS.

39
Q

Shorthand for obstetric / contraceptive history:

A

G# P# Ab#

Gravida
Para
Abortus

40
Q

What does the “G” stand for in OB/Contraceptive history shorthand? Name and define.

A

GRAVIDA: The number of times a woman is pregnant regardless of if this pregnancy was carried to term. If applicable, current pregnancy is in this count.

41
Q

What does the “P” stand for in OB / Contraceptive History?

A

PARA. The number of viable pregnancies. (>20 weeks)

42
Q

What does the “Ab” stand for in the OB/contraceptive shorthand?

A

ABORTUS. The number of aborted pregnancies (planned or spontaneous).

43
Q

Seven things included in past medical health:

A

1) General Health
2) Past Childhood Illnesses
3) Adult Medical Illnesses
4) OB / Contraceptive History
5) Hospitalizations / Operations
6) Psychiatric History
7) Accidents or Injuries

44
Q

Ten components of “Current Health Status”

A

1) Current meds
2) Allergies
3) Habits
4) Screening tests
5) Immunizations
6) Sleep Patterns
7) Exercise / Leisure Activities
8) Diet
9) Environmental Hazards
10) Use of safety measures

45
Q

7 Preventative Measures to Discuss

A

1) Alcohol, drug, tobacco counseling
2) Cancer screening
3) Infectious disease prevention
4) Proper diet and exercise
5) Methods of stress reduction
6) Injury Prevention
7) Environmental and occupational hazards

46
Q

Ten components of “social history”

A

1) Home situation
2) Marital status
3) Vocation
4) Relationships
5) Finances
6) Travel
7) Military
8) Typical Day
9) Religious beliefs
10) Transportation issues

47
Q

In family history, a [shape] represents a male and a [other shape] represents a female.

A 
Square = male
Circle = female.
48
Q

What does ADL vs. IADL stand for?

  • Define
  • Give examples of each
A

ADL (Activites of daily living)

  • Basic tasks of every day life
  • Examples: Transfer, toileting, bathing, dressing.

IADL (Instrumental Activites of Daily living)

  • Tasks related to INDEPENDENT living.
  • Examples: Telephone, shopping, managing medications, doing housework.
49
Q

What is included in the Review of Systems (ROS) - 17

A

1) General Health STate
2) Skin
3) Hair
4) HEENT
5) Neck
6) Breast / axilla
7) Cardiovascular
8) Peripheral vascular
9) Respiratory
10) Gastrointestinal
11) Urinary System
12) Genital System
13) Sexual Health
14) Musculoskeletal
15) Neurologic
16) Hematologic
17) Endocrine

50
Q

Seven “Fs” that could be causing distension:

A

1) Fluid
2) Fetus
3) Fat
4) Flatus
5) Fibroids
6) Fatal Tumor
7) Feces

51
Q

Four assessment techniques (Same order for every system but abdomen)

A

1) Inspection
2) Palpation
3) Percussion
4) Auscultation

52
Q

What is the purpose of palpation?

A

Confirms points you noticed during inspection

53
Q

Palpation: Uses sense of touch to assess (9)

A

Texture, moisture, temperature, organ location & size, masses, vibrations or pulsations, crepitus, thrills, presence of tenderness

54
Q

In palpation, what parts of the hands do you use?

A

1) Tips of fingers
2) Dorsa of hands (temperature, hair distribution)
3) Palmar aspect of MCP joints or ulnar surface (for vibration)

55
Q

Percussion: Method

A
  • Middle finger on middle finger at 90 degree angle

- Or use direct method (for sinuses, child’s thorax)

56
Q

Four sounds and what they mean (in terms of percussion):

A

Tympany: Abdomen is air-filled
Hyper-resonance: Too much air in lungs (Resonance = normal air that usually fills the lungs)
Dullness: Sound of dense organs (Liver, spleen)
Slackness: Sound over bone.

57
Q

Use the ____ of the stethoscope to auscultate lower pitched sounds. This is the _______ (smaller / larger) part.

A

Bell = Smaller (for lower pitched sounds)

58
Q

What does HCM stand for?

A

Health Care Maintenance

59
Q

What are the following abbreviations:
Dx
VIS
SH / FH

A

Diagnostics
Vaccine Info Sheet
Social History / Family History

PA: Exam 1 (10 decks)

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