Exam 1 Flashcards
Sept 9
What is subjective information?
What the patient says
What is objective information?
What you can measure
What is the purpose of a health history?
Collect subjective data and complete a picture of the person’s past and present health
What guidelines are there for an effective interview?
Use therapeutic communication, minimize distractions, use understandable language, avoid rushing, eye level
What are the goals of an interview?
Discover information, provide information, negotiate, counsel
When does history taking begin?
With your realtionship with the pt
What to avoid when taking history
Medical jargon, overtire the pt and leading questions
What to do when taking history
Introduce yourself, adress pt properly, be courteous, make eye contact, be flexible, take notes sparingly, start with general concerns then move to specific, clarify with WWWHW questions, verify and summarize
What are sensitive issues?
alcohol and drug use, religion, sexual history and orientation
How to approch sensitive issues
Ensure privacy, be direct and firm, don’t apologize, don’t preach, use understandable language, don’t push too hard, therapeutic communication
What are the categories of history taking?
Biographical data
Reson for seeking care
present and past illness
past history
family history
review of systems
functional assessment/ ADL’s
Reson for seeking care questions
What problems or symptoms brought you here?
How long has this problem been present?
Where did these symptoms begin?
Present problem or illness
Chronology of events
health state prior
first symptom
exposure
typical attack
impact on illness
stability of problem
immediate reason for visit
review of involved systems
medication listt
chronology review
problem list
8 charateristics of each patient symptom
location
charater or quality
quantity or severity
timing
setting
aggravating or reliving factors
associated factors
pt’s perception
WILDCATS
w- words to describe
i- intensity
l- location
d- duration
c- comfort
a- aggrevating/ alleviating
t- treatment
s- side effects
Past medical histoy
Overall health before and past medical and surgical history
Past medical history includes
Childhood illness
accidents or injuries
serious or chronic illnesses
hospitalization
operations
obstetric hisoty
immunizations
last exam date
allergies
current medications
Purpose of review of systems
Evaluate the past and present health state of each body system with subjective information
Factors impacting history taking
self esteem. acceptance by peers, tension with parents
Cover issues of concern
HEEADSSS
home
education
eating
activities
drugs
sexuality
suicide
safety
Older adults history taking
Cormorbities (overlapping health issues)
Chronic symptoms might not be reported
complete drug assessment essential
assessment of functional capacity (getting up from a chair, making own food)
prep for physical exam
enviroment, equipment, client
Physical exam organization
compare side to side
offer rest periods
perform painful procedures last
use common language
record quick notes
logical sequence (head to toe)
Client approch
Wash hands
Introduce youself
begin with vital signs
perform from head to toe
explain everything to client (what your doing and findings)
Physical exam in infants
sit in parents lap
Physical exam in toddlers
play with equpiment
fast and quick
Physical exam in preschool
Demonstrate
Physical exam in school age
may want to be alone
Physical exam in adolescent
may want to be alone
tell normal findings
physical exam sequence
general survey
vital signs
skin, hair, nails
head and neck
thorax and lung
heart
vascular system
abdomen
female and male reproductive systems
musculoskeletal
sensory neuro
Physical exam in aging adult
can they see and hear
attention span
4 techniques
inspection
palpation
percussion
auscultation
palpation
sensation of hands
palmar palpation
Surface of fingers
ulnar surface palpation
back of hand
direct percussion
striking fingers/ hands directly on body
indirect percussion
both hands required
percussion tympany sound
lough high pitched (abdomen)
percussion sound resonance
lung
percussion sound hyperresonance
hyper inflated lung
percussion sound dullness
liver
percussion sound flatness
bone/muscle
