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N507 Exam 1 > Chapter 1 > Flashcards

Chapter 1 Flashcards

1
Q

Comprehensive Assseessment

A
  • new patients
  • fundamental/personalized knowledge about pt
  • strengthens relationship
  • ID/rule out physical causes r/t pt conerns
  • baseline
  • platform for health education
  • proficiency in essential skills of physical exam
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2
Q

Focused Assessment

A
  • established pts (routine or urgent care)
  • focused concerns/symptoms
  • address symptoms r/t body system
  • exam methods relevant to concern throughly and carefully
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3
Q

Subjective Data

A
  • what pt tells you

- symptoms and history (chief complaint and review of symptoms)

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4
Q

Objective Data

A
  • what you detect during exam, labs, tests

- all physical exam findings or signs

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5
Q

components of comprehensive health history

A
  1. identifying data and source of history; reliability
  2. chief complaint
  3. present illness
  4. past history
  5. family history
  6. personal and social history
  7. review of symptoms
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6
Q

Identifying Data

A

age, gender, occupation, marital status

source of history/referral (usually pt or family member)

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7
Q

Reliability

A

varies by pt memory, trust, mood

vague, confusing, reliable

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8
Q

Chief complaint

A

one or ore symptoms or concerns causing pt to seek care

use quotes

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9
Q

Present Illness

A

amplifies chief complaint, describes how each symptom develops
includes pts thoughts about illness
pulls in relevant portions of review of symptoms (pertinent positives and negatives)

may include medications, allergies, tobacco use, alcohol if pertinent to present illness

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10
Q

Past History

A 
childhoods illnesses
adult illnesses (medical, surgical, OB/GYN, psych)
health maintenance (immunizations, screenings, lifestyle, home safety)
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11
Q

Family History

A

age & health/cause of death of siblings, parents, grandparents

presence of absence of specific diseases (HTN, DM, CA)

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12
Q

Personal/Social History

A 
educational level, job
family of origin
current household
personal interests (religion)
lifestyle (exercise, diet, sexual orientation)
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13
Q

Review of Symptoms

A

presence or absence of common symptoms related to each of the major body systems

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14
Q

7 attributes of physical symptoms

A 
Location
Quality
Quantity or Severity
Timing (Onset, duration, frequency)
Setting in which it occurs
Factors aggravating/alleviating
Associated Manifestations
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15
Q

Palpation

A

tactile pressure from palmar fingers or fingerpads

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16
Q

Percussion

A

use of the striking or plexor finger, usually the 3rd, to deliver a rapid tap or blow against the distal pleximeter finger, usually dial 3rd finger of the left hand laid against a body surface

17
Q

recommended patient side for physical exam

A

patient’s right side

18
Q

Head to Toe Exam

A
  • general survey
  • vital signs
  • skin
  • HEENT
  • neck
  • back
  • posterior thorax/lungs
  • breasts/axillae, epitrochlear nodes
  • musculoskeletal throughout or here if needed*
  • anterior thorax and lungs
  • cardiovascular
  • abdomen
  • lower extremities
  • nervous system
  • additional exams (rectal/genital)
19
Q

steps to ID problems and make diagnoses

A
  1. ID abnormal findings
  2. localize findings anatomically
  3. cluster clinical findings
  4. search for probable cause of findings
  5. cluster clinical data
  6. generate hypotheses about causes of pt problems
  7. test hypotheses and establish working diagnosis
20
Q

helpful clinical characteristics to cluster clinical findings

A
  • pt age (younger - 1 disease, older - multiple)
  • timing of symptoms (related or unrelated)
  • involvement of different body systems (1 disease may explain)
  • multisymptom conditions (explore risk factors)
    key questions (steers thinking)
21
Q

steps for generating clinical hypotheses

A
  1. select more specific and critical findings to support your hypothesis
  2. match your findings against all conditions that can produce them
  3. eliminate diagnostic possibilities that fails to explain findings
  4. weigh competing possibilities and select most likely diagnosis
  5. give special attention to potentially life threatening conditions
22
Q

Problem List

A

list most active and serious problems first w/ date on onset (can have active vs. inactive lists)

N507 Exam 1 (10 decks)

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