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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
Q

PSHx

A

Type and reason
Date/Location
Complications?

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26
Q

FMHx

A

Mom
Dad
Sib
Kids

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27
Q

SocHx

A 
Occupation
Significant Other
Tabacco
Alcohol
Illiicit Drugs
Diet
Exercise
Travel
Military
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28
Q

Objective

A

Temp
Pulse: Radius or brachial
BP

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29
Q

Basic Examination

A

tests function of system

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30
Q

Expanded Examination

A

if CC involves system…has co-morbidity in that system

-fails basic test

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31
Q

Assessment (A part of SOAP)

A

Differential diagnoses

-diagnostic findings, preexisting, risk factors, CC is first problem

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32
Q

Plan

A

what you intend to do.

-Meds, OT, tests, holistic/humanistic. referrals, return plan

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33
Q

Sports Physical Ultimate Goal

A

ensure safe participation without restricting unecessarily

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34
Q

Step 1 of Sports Physical

A

Medical History/standardized forms for each state

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35
Q

Step 2 of Sports Physical

A

Physical Exam
Too challenging? (freshman playing varsity, ? eating disorder?)
-90 second eval=duck walk, movments
-Garrick “2 minute” screening orthopedic eval=movements

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36
Q

Contact/Collision Sport

A

basketball, boxing, cheering, diving, football, gymnastics, hockey, skiing, soccer, wrestling

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37
Q

Limited Contact

A

Baseball, field events, skating, skiing (cross country), softball, volleyball

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38
Q

Non-Contact

A

Arcery, body building, canoeing, crew, dancing, field events, golf, running, sailing, swimming, tennis, track, weight lifting

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39
Q

Clearance Forms

A
  • Unrestricted
  • Clearance w/ notification of coach, trainer, and team physician (may need special treatment on occasion)
  • Deferred clearance (need further eval)
  • Disqualification
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40
Q

Iowa Sports Forms

A
  • Full and unlimited
  • Limited (may not participate in checked sports)
  • Clearance pending
  • Not Cleared due to…
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41
Q

7 Major reasons for disqualification

A 
Dizzininess w/ exercise
Asthma
Unfavorable body mass index
Systolic BP elevation
Visual acuity defect
Presence of Heart murmer
Musculoskel abnor
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42
Q

Non-qualified or not qualified with explanation

A
  • CARDITIS
  • Diarrhea
  • FEVER
  • Structural heart disease
43
Q

Qualified or qualified with explanation or special requirements

A
  • Asthma
  • Congenital heart disease
  • eating disorders
  • hep or HIV
  • loss of eye
  • malabsorption syndromes
  • obesity
  • seizure disorder
  • sickle cell disease
44
Q

Female Athlete Triad

A

At risk sports=gymnastics, skiers, diving, cheer

  • EATING DISORDER
  • AMENORRHEA (primary, secondary or oligomenorrhea)
  • OSTEOPOROSIS
45
Q

Vital Signs

A

Temp Pulse Respiration BP

46
Q

Temperature

A

add 32 to C for F

47
Q

Oral Temp Norm

A

37 C

98.6 F

48
Q

Axillary Temp Norm

A

lower than oral

0.6 C or 1.0 F

49
Q

Rectal Temp Norm

A

Higher than oral

0.4-0.5 C or 0.7 to 0.9 F

50
Q

Tympanic Tem Norm

A

Higher than oral

0.8 C or 1.4 F

51
Q

Temp for elderly and ill children

A

RECTAL

52
Q

Afebrile

A

97F-100.4F rectal

36C-38C rectal

53
Q

Febrile

A

> 100.4 F or 38 C rectal

54
Q

Fever or pyrexia

A

elevated body temp

55
Q

Hyperpyrexia

A

Extreme elevation

Avove 41.1 C or 106 F rectal

56
Q

Hypothermia

A

abnormally low

35 C or 95 F rectal

57
Q

Pulse

A

Radial or apical (chest wall)

-30 sec and double

58
Q

Irregular

A

less than 60=bradycardia

greater than 100=tachycardia

59
Q

Standard resting

A

60-100

60
Q

Pulse Scale

A

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
Q

Pulse Ox

A

measures percent hemoglobin saturated with O2

-need translucent cite with good flow

62
Q

Doppler

A

ultrasonic=detect blood flow

Uses: systolic bp, fetal heart sounds, locate lood vessels, weak pulses, and assess vessel patency

63
Q

Respirations

A

30 seconds and double

  • auscultation for full cycle
  • note easy, relaxed, or labored
64
Q

Standard (eupnea) breathing

A

12-20 breaths per min

65
Q

Bradypnea

A

<12 per min

Athletic conditioning, hyperthermia, depressent meds/drugs

66
Q

Hyperpnea/Hyperventilation

A

> 20 per min

pain, respiratory distress, acidosis, hysteria

67
Q

Tachypnea

A

> 20 per min

Fever, exertion, acidosis, anxiety, fear, CO poison

68
Q

Diaphragm of Steth

A

Side w/ cover

High pitched sounds (S1 and S2)

69
Q

Bell

A

Open side
Low pitched sound (S3 and S4, arteries)
Use light pressure

70
Q

Blood Pressures

A

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
Q

Sphygmanometer

A

Electronic senses vibrations converts to #

-can get pulse reading but not characteristic

72
Q

Standard Adult BP

A

<80

73
Q

Hypertension

A

3 readings over 3 days

74
Q

JNC8 >60 years of age

A

systolic <90

75
Q

JNC8 <60 years of age

A

systolic <90

76
Q

JNC8 18 w/ Chronic kidney disease or diabetes

A

systolic <90

77
Q

Orthostatic Vital Signs

A

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
Q

Proper Cuff Size

A

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
Q

BP Technique

A

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
Q

Height

A
  1. 54 cm = 1 in

- length for infants

81
Q

Weight

A

2.2 lbs= 1 kg

82
Q

Head Circumference

A

birth - 24 mos

cm and do this on all well child visits

83
Q

Opthalmoscope

A
  • Large: Dilated eye and general exam
  • Small: undilated eye, start here before going to micro in small or sensitive
  • Micro: very small, undilated
84
Q

Red-free Filter

A

Green light, obsere optic disc for pallow and minute vessel changes, retinal vasculature hemorrhages

85
Q

Slit

A

anterior chamber and elevation of lesions

86
Q

Grid

A

Measurement of lesions

87
Q

Blue

A

To observe corneal scratches, foreign bodies after staining with fluoescein

88
Q

Diopters

A

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
Q

Opthalmoscope Technique

A

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
Q

Visual Acuity

A

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
Q

Otoscope

A

Pneumatic Bulb

Technique: hold it like pencil

92
Q

Tympanometer

A

measures ear drum movement/energy

93
Q

Tuning Forks

A

Vibratory function: 100-400 Hz
-circular knobs on ends

Auditory function: 500-1000 Hz
-plain tool

94
Q

Reflex Hammer

A

Larger tendons=flattened end, patellar and achilles

Smaller tendons=sharpers end, triceps, biceps, brachioradialis

95
Q

Monofilament

A

tests for loss of sensation for patients with diabetes

96
Q

Standard Precautions

A

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
Q

Standard Precautions apply to??

A

ALL Patients regardless of the diagnosis or infectious status

-Applies to: Blood, bodily fluids (except sweat), non intact skin, mucous membrane

98
Q

Target Method

A

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
Q

Examination Technique

A

Inspection, Palpation, Percussion, Auscultation

100
Q

Inspection

A

observation, game, detail in your notes

101
Q

Palpation

A 
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
Q

Percussion

A

One object against another: vibration

-direct and indirect

103
Q

Ausultation

A

ON SKIN
practice
characteristic sound

104
Q

Order of Physical Exam

A

Inspection–>Palpation–>Percussion–>Auscultation

May vary= abdominal, musculoskeletal

Clinical Medicine (2 decks)

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