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Clinical Medicine > Exam 1 Material > Flashcards

Exam 1 Material Flashcards

1
Q

Comprensive Assessment

A

new patient, Complete history, develop relationship

Baseline

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2
Q

Focused Assessment

A

Urgent care, established patient, focused concerns

-Problem orientated/basic

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3
Q

Inventory

A

like complete but not as detailed

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4
Q

INterim

A

chronicle event between visits

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5
Q

4 C’s of Communication

A

Courtesy, Comfort, Connection, Comformation

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6
Q

3 Methods of assessment

A

Ask Me 3, Teach Back, 4 C’s

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7
Q

Ask Me 3

A

What is my main problem?
What do I need to do?
Whis is it important for me to do this?

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8
Q

Teach Back

A

Tell me what I told you/check understanding

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9
Q

4 C’s

A

Call: what do you call the problem
Cause: What caused it do you think?
Concern: what concerns you most?
Cope: what are you doing to cope?

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10
Q

Depression

A 
SIGECAPS
Sleep          Cognition
Interest       Appetite
Guilt            Psychomotor
Energy        Suicide
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11
Q

NIAA Recommended Low Risk

A

Men < 7 drinks/week <3 on one occassion

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12
Q

NIAA Moderate Risk

A

Less likely to experience alc disorder

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13
Q

NIAA High Risk

A

Higher than low risk

Binge=getting above 0.08 in 2 hours or less

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14
Q

Alcohol

A

CAGE TACE
Concern Take-how many does it take
Annoyed (criticized) Annoyed
Guilty Cut-cut down?
Eye opener Eye opener

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15
Q

CRAFFT

A

Car Relax Alone Forget Familly/Friend Trouble

-Substance absuse for adol

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16
Q

HITS

A

Hurt Insult Threaten Scream

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17
Q

Death and Dying Patient

A 
End of life convo
Advanced Directive
Living Wills
Power of Attorney
DNR
Health Proxy
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18
Q

Outline for Adult Assessment

A 
Patient Name DOB
CC
HPI/PROS
MEDS
ALLERGY
PMHx
PSHx
FMHx
SHx
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19
Q

HPI

A 
Have you ever had this?
When
up, down, left, right, back and forth
1-10
Quality/Quantity
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20
Q

PROS-Constitution

A

Fevers, chills, weight loss/gain, night sweats, fatigue

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21
Q

PROS (head to toe)

A 
Eye
Ears,nose, throat
Cardio
GI
Uro
Musculo
Neuro
Psych
Endocrine (heat cold intolerances)
Hemato/lymph (anemic,bruising?)
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22
Q

MEDS

A

Name dosage frequency number route

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23
Q

Allergy

A

Medicine/Drug
Environment
Food
**if positive ask what kind of reaction

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24
Q

PMHx

A

THECHADS

Immunizations: TFP = tet flu pneumonia

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25
PSHx
Type and reason Date/Location Complications?
26
FMHx
Mom Dad Sib Kids
27
SocHx
``` Occupation Significant Other Tabacco Alcohol Illiicit Drugs Diet Exercise Travel Military ```
28
Objective
Temp Pulse: Radius or brachial BP
29
Basic Examination
tests function of system
30
Expanded Examination
if CC involves system...has co-morbidity in that system | -fails basic test
31
Assessment (A part of SOAP)
Differential diagnoses | -diagnostic findings, preexisting, risk factors, CC is first problem
32
Plan
what you intend to do. | -Meds, OT, tests, holistic/humanistic. referrals, return plan
33
Sports Physical Ultimate Goal
ensure safe participation without restricting unecessarily
34
Step 1 of Sports Physical
Medical History/standardized forms for each state
35
Step 2 of Sports Physical
Physical Exam Too challenging? (freshman playing varsity, ? eating disorder?) -90 second eval=duck walk, movments -Garrick "2 minute" screening orthopedic eval=movements
36
Contact/Collision Sport
basketball, boxing, cheering, diving, football, gymnastics, hockey, skiing, soccer, wrestling
37
Limited Contact
Baseball, field events, skating, skiing (cross country), softball, volleyball
38
Non-Contact
Arcery, body building, canoeing, crew, dancing, field events, golf, running, sailing, swimming, tennis, track, weight lifting
39
Clearance Forms
- Unrestricted - Clearance w/ notification of coach, trainer, and team physician (may need special treatment on occasion) - Deferred clearance (need further eval) - Disqualification
40
Iowa Sports Forms
- Full and unlimited - Limited (may not participate in checked sports) - Clearance pending - Not Cleared due to...
41
7 Major reasons for disqualification
``` Dizzininess w/ exercise Asthma Unfavorable body mass index Systolic BP elevation Visual acuity defect Presence of Heart murmer Musculoskel abnor ```
42
Non-qualified or not qualified with explanation
- CARDITIS - Diarrhea - FEVER - Structural heart disease
43
Qualified or qualified with explanation or special requirements
- Asthma - Congenital heart disease - eating disorders - hep or HIV - loss of eye - malabsorption syndromes - obesity - seizure disorder - sickle cell disease
44
Female Athlete Triad
At risk sports=gymnastics, skiers, diving, cheer - EATING DISORDER - AMENORRHEA (primary, secondary or oligomenorrhea) - OSTEOPOROSIS
45
Vital Signs
Temp Pulse Respiration BP
46
Temperature
add 32 to C for F
47
Oral Temp Norm
37 C | 98.6 F
48
Axillary Temp Norm
lower than oral | 0.6 C or 1.0 F
49
Rectal Temp Norm
Higher than oral | 0.4-0.5 C or 0.7 to 0.9 F
50
Tympanic Tem Norm
Higher than oral | 0.8 C or 1.4 F
51
Temp for elderly and ill children
RECTAL
52
Afebrile
97F-100.4F rectal | 36C-38C rectal
53
Febrile
>100.4 F or 38 C rectal
54
Fever or pyrexia
elevated body temp
55
Hyperpyrexia
Extreme elevation | Avove 41.1 C or 106 F rectal
56
Hypothermia
abnormally low | 35 C or 95 F rectal
57
Pulse
Radial or apical (chest wall) | -30 sec and double
58
Irregular
less than 60=bradycardia | greater than 100=tachycardia
59
Standard resting
60-100
60
Pulse Scale
4+=bounding, aneurysmal (fever cocaine, fear, strenuous exercise) 3+= full, increased (caffeine, fear, anxiety) 2+= expected 1+= diminished 0= absent, not palpable Asytole, occlsion or thrombosis 2/4, 2+, chart, stick figures
61
Pulse Ox
measures percent hemoglobin saturated with O2 | -need translucent cite with good flow
62
Doppler
ultrasonic=detect blood flow | Uses: systolic bp, fetal heart sounds, locate lood vessels, weak pulses, and assess vessel patency
63
Respirations
30 seconds and double - auscultation for full cycle - note easy, relaxed, or labored
64
Standard (eupnea) breathing
12-20 breaths per min
65
Bradypnea
<12 per min | Athletic conditioning, hyperthermia, depressent meds/drugs
66
Hyperpnea/Hyperventilation
> 20 per min | pain, respiratory distress, acidosis, hysteria
67
Tachypnea
> 20 per min | Fever, exertion, acidosis, anxiety, fear, CO poison
68
Diaphragm of Steth
Side w/ cover | High pitched sounds (S1 and S2)
69
Bell
Open side Low pitched sound (S3 and S4, arteries) Use light pressure
70
Blood Pressures
True blood pressures=measured over days/weeks (home, office and ambulatory) - Validity of Office=observer and measurement error, natural fluctuations, anxiety, white coat hyper - Home and Ambulatory more accurate
71
Sphygmanometer
Electronic senses vibrations converts to # | -can get pulse reading but not characteristic
72
Standard Adult BP
<80
73
Hypertension
3 readings over 3 days
74
JNC8 >60 years of age
systolic <90
75
JNC8 <60 years of age
systolic <90
76
JNC8 18 w/ Chronic kidney disease or diabetes
systolic <90
77
Orthostatic Vital Signs
Used if suspect hypovolemia, blood loss, or anemia - Positions: 3 minutes (lying sitting and standing) - Systolic drop 20 mmHg - Diastolic drop 10 mmHg - Pulse increases 15 beats
78
Proper Cuff Size
Adults=1/3 to 1/2 limb circumference -bladder length twice the width (does not quite encircle (80%)) Children=2/3 -bladder length 80-100%
79
BP Technique
Ideal= chair 5 minutes, Nicotine/coffee 30 min, direct skin, palpate artery, rest arm @ heart level, estimate systolic, wait 15-30 sec -Read to nearest 2 mmHG
80
Height
2. 54 cm = 1 in | - length for infants
81
Weight
2.2 lbs= 1 kg
82
Head Circumference
birth - 24 mos | cm and do this on all well child visits
83
Opthalmoscope
- Large: Dilated eye and general exam - Small: undilated eye, start here before going to micro in small or sensitive - Micro: very small, undilated
84
Red-free Filter
Green light, obsere optic disc for pallow and minute vessel changes, retinal vasculature hemorrhages
85
Slit
anterior chamber and elevation of lesions
86
Grid
Measurement of lesions
87
Blue
To observe corneal scratches, foreign bodies after staining with fluoescein
88
Diopters
eual to magnification - Black numbers: positive or plus lenses - red number: negative or minus lenses - Numbers range from +/-20 to +/-140 - more + focuses anteriorly-superficially - more - focuses posteriorly--deeper
89
Opthalmoscope Technique
diopter at 0, dark room - 15 inches away-15 degree angle - red reflex - thumb to eyebrow - slowly move inward with both eyes open - optic disc and retina
90
Visual Acuity
Normal= 20/20 example: 20/200 normal can read at 200 ft, larger the number poorer - top number is distance of chart from patient - bottom number distance at which a person with normal vision can read
91
Otoscope
Pneumatic Bulb | Technique: hold it like pencil
92
Tympanometer
measures ear drum movement/energy
93
Tuning Forks
Vibratory function: 100-400 Hz -circular knobs on ends Auditory function: 500-1000 Hz -plain tool
94
Reflex Hammer
Larger tendons=flattened end, patellar and achilles Smaller tendons=sharpers end, triceps, biceps, brachioradialis
95
Monofilament
tests for loss of sensation for patients with diabetes
96
Standard Precautions
Needles: Do not recap, one handed technique, safety containers PPE Hand Hygiene: after contact with fluids, immediately after removing gloves, and between patients Respiratory hygiene: any patient with a cough at initial point of contact
97
Standard Precautions apply to??
ALL Patients regardless of the diagnosis or infectious status -Applies to: Blood, bodily fluids (except sweat), non intact skin, mucous membrane
98
Target Method
Used in problem-oriented (focused/basic) - Absolute area=primary concern - Adjacent areas=anatomic proximity, complaint requiring inclusion - Associated areas=outside adjacent, related to diagnoses or disease
99
Examination Technique
Inspection, Palpation, Percussion, Auscultation
100
Inspection
observation, game, detail in your notes
101
Palpation
``` palmer surface of fingers and pads -dorsal surface of hand and fingers -ulnar surface of hand and fingers -Light=up to 1 cm depth -Deep= about 4 cm depth NAILS ```
102
Percussion
One object against another: vibration | -direct and indirect
103
Ausultation
ON SKIN practice characteristic sound
104
Order of Physical Exam
Inspection-->Palpation-->Percussion-->Auscultation May vary= abdominal, musculoskeletal

Clinical Medicine (2 decks)

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