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1 NCM 101 LEC > Consultation and History Taking > Flashcards

Consultation and History Taking Flashcards

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1
Q

Gather the necessary information to form a tentative diagnosis

A

Interviewing and health history

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2
Q

Main reason why the patient is seeking advice

A

Chief complaint

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3
Q

Amplifies the chief complaint by giving a full, clear, chronological account of each symptom and what events were related to them

A

History of present illness

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4
Q

Principal symptom: where the pain occurs

A

Location

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5
Q

Principal symptom: adjective describing the pain

A

Quality

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6
Q

Principal symptom: degree of the pain

A

Quantity/Severity

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7
Q

Principal symptom: onset, duration, frequency of the pain

A

Timing

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8
Q

Principal symptom: the ways that the patient employs that amplify the pain

A

Aggravating factors

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9
Q

Principal symptom: the ways that the patient employs that ease the pain

A

Relieving factors

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10
Q

Principal symptom: signs or symptoms that occur along with the pain

A

Associated symptoms or manifestations

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11
Q

Principal symptom: e.g. laboratory results

A

Relevant data

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12
Q

Principal symptom: what the patient doesn’t have or isn’t experiencing

A

Significant negatives

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13
Q

Patient’s prior illnesses, injuries, medical interventions

A

Past medical history

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14
Q

Patient’s present state of health, environmental conditions, personal habits, health related conditions

A

Current health status

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15
Q

Pattern of familial illness

A

Familial history

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16
Q

Family tree of diseases

A

Genogram

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17
Q

Patient as a person

A

Psychosocial history

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18
Q

To identify problems which the patient did not mention

A

Review of systems

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19
Q

AIL: Urinating too much in a day

A

Polyuria

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20
Q

AIL: can’t stop the urge to urinate

A

Urinary incontinence

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21
Q

T/F: Review charts before interviewing the patient

A

True

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22
Q

T/F: Environment doesn’t affect communication

A

False

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23
Q

T/F: There’s no need to consider privacy when interviewing the patient

A

False

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24
Q

T/F: The setting must be free from interruptions

A

True

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25
Q

T/F: Speak to the patient at eye level

A

True

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26
Q

T/F: Dress cleanly and appropriately

A

True

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27
Q

T/F: Don’t watch your demeanor

A

False

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28
Q

T/F: When asking the patient questions, don’t inquire several times

A

False

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29
Q

T/F: Allow the patient to recount their own stories

A

True

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30
Q

T/F: Incorporate passive listening

A

False

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31
Q

T/F: Don’t incorporate facilitative listening

A

False

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32
Q

T/F: Repeat words to encourage the patient to give more details

A

True (this technique is called reflection)

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33
Q

T/F: Ask the patient to clarify unclear and ambiguous words

A

True (this technique is called clarification)

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34
Q

T/F: Show understanding and acceptance by making the patient feel secure and encouraging them to continue

A

True (this technique is called emphatic response)

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35
Q

T/F: Observe the patient for clues of anger, anxiety, depression

A

True (this technique is called confrontation)

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36
Q

T/F: Don’t mind your posture

A

False

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37
Q

T/F: Show signs of panic and hurriedness

A

False

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38
Q

T/F: Take note of posture, gestures, eye contact

A

True

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39
Q

T/F: Ask the patient indirect questions

A

False

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40
Q

T/F: Ask the patient questions from general to specific

A

True

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41
Q

T/F: Avoid questions answerable by yes or no when taking HPI

A

True

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42
Q

T/F: Use language that is inappropriate and hard to understand

A

False

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43
Q

Gathering data: coffee, drugs, liquor, prescription drugs, marijuana, illicit use of drugs

A

Alcohol and drug history

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44
Q

T/F: Orient the patient with brief and transitional phrases

A

True

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45
Q

T/F: Ask the patient if there is anything else they want to talk about

A

True (this technique is called closing)

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46
Q

T/F: During note taking, it is okay to divert your attention from the patients

A

False (do not divert your attention from the patient)

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47
Q

T/F: During note taking, jot down long phrases and words that will guide you in making the final report

A

False (only use short phrases and words)

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48
Q

T/F: Take notes when the patient is talking about sensitive information

A

False (it is best not to take notes when the patient is talking about sensitive information)

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49
Q

T/F: Ask the patient about their weight changes

A

True

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50
Q

AIL: Increase in body fats or accumulation of fluid

A

Weight gain

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51
Q

AIL: Loss of energy, sense of weariness, withdrawal from activities

A

Fatigue

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52
Q

AIL: Caused by musculoskeletal or neurologic disorders

A

Weakness

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53
Q

AIL: Feelings of coldness, gooseflesh, shivering, rising temperature, hot feelings and sweats, defervescence, shaking, or chills

A

Fever

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54
Q

What should you investigate when a person has fever?

A

Travel and contact with a sick person

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55
Q

Change in hair distribution may be a sign that there is a problem with the patient’s _______

A

Skin

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56
Q

AIL: High level of urea in the blood

A

Uremia

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57
Q

AIL: Yellowish skin that may be caused by a problem in the liver or gall bladder

A

Obstructive jaundice

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58
Q

AIL: Parasitic insect that live on clothing and bedding used by an infected person

A

Body lice

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59
Q

AIL: Redness of the skin

A

Erythema

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60
Q

A type of headache that is felt only on one side of the head

A

One-sided headache

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61
Q

A type of headache that is felt on both sides of the head

A

Bilateral headache

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62
Q

A type of headache that has been occurring for a few hours or days

A

Acute headache

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63
Q

A type of headache that has been occurring for several months or years

A

Chronic headache

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64
Q

A type of headache that is recurrent

A

Tension headache or migraine

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65
Q

An acute and severe headache may suggest..

A

Subarachnoid hemorrhage

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66
Q

A headache that is progressively becoming severe may suggest..

A

Presence of tumor

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67
Q

A headache accompanied by nausea and vomiting may suggest..

A

Brain tumor

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68
Q

A type of headache that suggests problem in the eyes

A

Frontal headache

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69
Q

AIL: Blurring of vision

A

Error of refraction or refractive error

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70
Q

AIL: A sudden blurring of vision may suggest..

A

Retinal detachment

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71
Q

AIL: Blurring at near

A

Hyperopia

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72
Q

AIL: Blurring at far

A

Myopia

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73
Q

AIL: Visual disturbance when reading at near

A

Presbyopia

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74
Q

AIL: What causes a defect in the central visual field?

A

Development of cataract

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75
Q

AIL: Slow peripheral loss due to an increase in intraocular pressure

A

Glaucoma

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76
Q

AIL: One-sided visual field; loss of vision in one-half of the visual field

A

Hemianopsia

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77
Q

AIL: Loss of vision in one quadrant of the visual field

A

Quadrantanopia

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78
Q

AIL: Inflammation of the conjunctivita which causes redness of the eyes

A

Conjunctivitis (sore eyes)

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79
Q

Visible moving strands

A

Muscae volitantes or floaters

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80
Q

AIL: Fixed areas of blindness

A

Scotoma or lesion of visual pathways

81
Q

AIL: Caused by the obstruction of the lacrimal canal

A

Excessive tearing

82
Q

AIL: Double vision due to the weakness or paralysis of an extraocular muscle or tumor at the back of the eyeball

A

Diplopia

83
Q

AIL: Change of color in the eye

A

Scleral icterus or conjunctival icterus

84
Q

AIL: Which organs may be affected if the patient is icteric?

A

Liver or gall bladder

85
Q

AIL: Another term for dizziness

A

Vertigo

86
Q

AIL: Perceived sound without external stimuli or ringing of the ears

A

Tinnitus

87
Q

AIL: Patient is complaining that people are mumbling

A

Sensorineural hearing loss

88
Q

AIL: Hearing loss and vertigo may suggest..

A

Meniere’s disease

89
Q

AIL: May be caused by an inflammation of the ear canal or perforation/rupture of the ear drum

A

Ear discharge

90
Q

AIL: Inflammation of the middle ear

A

Otitis media

91
Q

AIL: May be caused by pollen, contacts with the environment, allergic rhinitis

A

Nasal discharge

92
Q

AIL: Pain in the sinus area

A

Sinusitis

93
Q

AIL: Nasal stuffiness on one side

A

Nasal deviation

94
Q

AIL: Another term for nosebleed

A

Epistaxis

95
Q

AIL: Inflammation of the gums or bleeding gums

A

Gingivitis

96
Q

AIL: Sore tongue

A

Apthous ulcers

97
Q

AIL: Sore throat may suggest a problem with which body system ?

A

Respiratory

98
Q

AIL: Over usage of voice

A

Hoarseness

99
Q

AIL: Acute infection in the mouth may result to..

A

Laryngitis

100
Q

AIL: Swollen glands in the neck may be due to..

A

Goiter, lymphadenitis, or lymphomas

101
Q

AIL: Pain in the myocardium (heart attack)

A

Myocardial infarction

102
Q

AIL: Pain in the myocardium (chest pain)

A

Angina pectoris

103
Q

AIL: Pain in the aorta

A

Dissecting aneurysm

104
Q

AIL: Pain in the trachea and large bronchi

A

Heartburn that may cause esophagus reflux esophagitis

105
Q

AIL: Painful deep breathing due to an inflammation in the cartilage

A

Costochondritis

106
Q

AIL: Chest heaviness may suggest..

A

Cardiac problems

107
Q

AIL: Skipping, pounding, and occasional stopping of heartbeat; heartbeat is felt by the patient

A

Palpitation

108
Q

AIL: Heart rate is over 100bmp

A

Tachycardia

109
Q

AIL: Heart rate is below 60bmp

A

Bradycardia

110
Q

AIL: Non-painful but uncomfortable awareness of breathing; shortness of breath

A

Dyspnea

111
Q

AIL: Breathing quicky

A

Hyperventilation

112
Q

AIL: Difficulty in breathing when lying down

A

Orthopnea

113
Q

AIL: Difficulty in breathing at night

A

Paroxysmal nocturnal dyspnea

114
Q

Sound produced that is caused by partial air obstruction

A

Wheezing

115
Q

AIL: Accumulation of excessive fluid

A

Edema

116
Q

AIL: Edema in lower extremities

A

Bipedal edema

117
Q

AIL: Edema in the face

A

Facial edema

118
Q

AIL: Edema in the abdomen causing enlarged wasitline

A

Ascites

119
Q

AIL: Edema with puffy eyelids may suggest a severe problem in what organ?

A

Kidney

120
Q

AIL: Edema with renal problems

A

Hypoalbuminemia

121
Q

AIL: Edema all over the body

A

Anasarca

122
Q

AIL: Cough with no phlegm

A

Dry cough

123
Q

AIL: Cough with phlegm

A

Productive cough

124
Q

AIL: A white colored phlegm may suggest..

A

Viral infection

125
Q

AIL: A green colored phlegm may suggest..

A

Bacterial infection

126
Q

AIL: Coughing with blood suggests that there is a problem in which organ?

A

Lungs

127
Q

AIL: A build up of mucus in the lungs

A

Bronchiectasis

128
Q

AIL: Coughing up or spitting out blood

A

Hemoptysis

129
Q

AIL: Difficulty in swallowing

A

Dysphagia

130
Q

AIL: Difficulty in swallowing liquid may suggest a disorder of what muscle?

A

Esophageal muscle

131
Q

AIL: Feeling of burning or warmth that is felt retrosternal from the epigastric area to the neck

A

Heartburn that may cause reflux esophagitis

132
Q

Causes abdominal bloating, distention, or flatus (farting)

A

Excessive gas

133
Q

Medication used to prevent farting

A

Anti-flatulent medication

134
Q

(Visceral/Parietal) Pain felt from hollow organs

A

Visceral pain

135
Q

(Visceral/Parietal) Pain caused by inflammation

A

Parietal pain

136
Q

(Visceral/Parietal) Pain that is more localized

A

Parietal pain

137
Q

(Visceral/Parietal) Pain that is poorly localized

A

Visceral pain

138
Q

(Visceral/Parietal) Pain that is aggravated by coughing or movement

A

Parietal pain

139
Q

(Visceral/Parietal) Pain that is burning, cramping, aching

A

Visceral pain

140
Q

(Visceral/Parietal) Pain that is associated with nausea and vomiting

A

Visceral pain

141
Q

Pain that travels from an initial site; radiating pain

A

Referred pain

142
Q

Colicky pain suggests a problem with what muscle contraction?

A

Peristalsis

143
Q

AIL: Vomitus with blood

A

Hematemesis

144
Q

AIL: loss or lack of appetite

A

Anorexia

145
Q

AIL: Stomach is feeling sick

A

Nausea

146
Q

AIL: Spasmodic movement of the chest and diaphragm that proceeds and culminate to vomiting

A

Retching

147
Q

AIL: Forceful expulsion of gastric contents through the mouth

A

Vomiting

148
Q

AIL: Raising of esophageal and gastric contents in the absence of nausea and vomiting

A

Regurgitation that may be caused by an incompetent gastroesophageal sphincter

149
Q

AIL: May result to brownish or blackish vomitus

A

Duodenal and gastric ulcers

150
Q

AIL: Presently grey stool

A

Acholic stool

151
Q

AIL: Passage of hard or painful stools; incomplete defacation

A

Constipation

152
Q

AIL: Passage of excessively frequent stools

A

Diarrhea

153
Q

AIL: Greasy foul smelling stool

A

Steatorrhea

154
Q

AIL: Inability to absorb enough nutrients

A

Malabsorption syndrome

155
Q

A discoloration of the skin and eyes is caused by high levels of _____ in the blood

A

Bilirubin

156
Q

A discoloration of the skin and eyes may suggest a problem in the _____

A

Liver, gallbladder, or bile duct

157
Q

Jaundice may be caused by an obstruction of the _____ or obstruction of the _____

A

Common bile duct or pancreas

158
Q

Dark urine suggests impaired excretion of _____

A

Bilirubin

159
Q

Color of the stool of someone with obstructive jaundice

A

Acholic or light colored

160
Q

Pain caused by a sudden distention of the renal capsule

A

Kidney pain

161
Q

Pain in the ureter

A

Urethral pain

162
Q

Pain in the ureter may be caused by stones in the _____

A

Urinary tract

163
Q

AIL: Condition of having kidney stones

A

Nephrolithiasis

164
Q

AIL: Condition of having gallstones

A

Cholelithiasis

165
Q

Where is prostatic felt?

A

Perineum

166
Q

Pain during urination may be caused by the presence of _____ or _____

A

Stones or tumors

167
Q

AIL: Presence of blood in urine

A

Hematuria

168
Q

Pain during urination with blood may be caused by the presence of…

A

Tumor

169
Q

Urination with blood in the absence of pain may be caused by…

A

Cancer

170
Q

AIL: Caused by an infection of the bladder that comes with a sudden urge to urinate

A

Urinary urgency

171
Q

AIL: An urge to urinate but unable to

A

Urinary hesitancy

172
Q

AIL: The need to strain in order to urinate

A

Straining to void

173
Q

AIL: Urine does not flow smoothly

A

Dribble

174
Q

AIL: Pain during urination without frequency is suggestive of…

A

Urethritis

175
Q

AIL: Excessive thirst or excess drinking

A

Polydipsia

176
Q

AIL: Group of diseases that injures the part of the kidney that filters blood

A

Glomerulonephritis

177
Q

AIL: Intense urge to urinate with straining but little to no result

A

Vesical tenesmus

178
Q

AIL: Intense urge to defecate but little to no result

A

Rectal tenesmus

179
Q

AIL: Swelling of the limbs due to veins having trouble sending blood from the limbs back to the heart

A

Venous disease/Venous insufficiency

180
Q

AIL: An inflammatory process that causes a blood clot to form and block one or more veins, usually in your legs

A

Thrombophlebitis

181
Q

AIL: Caused by weak vein walls and valves or an increase blood pressure in veins

A

Varicose veins

182
Q

AIL: Inflammation of the tendons

A

Tendonitis

183
Q

AIL: Inflammation of the bursa

A

Bursitis

184
Q

AIL: Causes joint pain throughout the body

A

Rheumatoid arthritis

185
Q

AIL: Joint pain

A

Arthralgia

186
Q

AIL: Muscular pain

A

Myalgia

187
Q

AIL: Butterfly rash is commonly associated with what condition

A

Systemic lupous erythematosus

188
Q

AIL: Appears as the body’s reaction to allergy or drug reactions

A

Urticaria or hives

189
Q

AIL: Low blood sugar level

A

Hypoglycemia

190
Q

AIL: Low blood pressure caused by a sudden change in position

A

Postural hypotension

191
Q

AIL: Paroxysmal disorder with or without loss of consciousness; change in brain’s electrical activity

A

Seizure

192
Q

AIL: Sudden temporary loss of consciousness when blood flow to the brain is insufficient

A

Syncope (fainting)

193
Q

AIL: Involuntary movement/shaking of one or more parts of the body

A

Tremors

194
Q

AIL: Tingling sensation of the skin

A

Paresthesia

195
Q

AIL: Occurs when your body does not produce enough hormones

A

Hypothyroidism

196
Q

AIL: Hypothyroidism can result to _____ due to a deceleration of the body’s metabolism

A

Obesity

197
Q

AIL: Occurs when your body produces too much hormones

A

Hyperthyroidism

198
Q

AIL: Hyperthyroidism can result to _____ due to an acceleration of the body’s metabolism

A

Weight loss

199
Q

Another term for black stool

A

Melena

1 NCM 101 LEC (8 decks)

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