health history, interview, teqniques, 4 assessment, safety, documentation, skin, hair, nails Flashcards

1
Q

Chief complaint

A

reason for seeking care

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2
Q

history of present illness

A

OLDCARTS

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3
Q

past medical history

A

past illnesses
childhood illness
surgical hx
obstetric hx
current meds
family hx
allergies

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4
Q

ROS

A

all subjective data
-review of each system to determine in patient experiencing s/s or illness within that system

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5
Q

subjective

A

what the patient says

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6
Q

objective

A

what you see

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7
Q

order of assessment

A

inspection, palpation, percussion, auscultation

except abdomin: inspect, auscultation, palpation

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8
Q

inspection

A

observing pt visually

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9
Q

palpation

A

touching of specific areasto assess

use back of hand for temp
use pads of finger for pulse and edema
use palmar surface for contour, position, pain

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10
Q

percussion

A

tapping technique with hands to determine condition of solid or air-filled body areas

flat: bone
dull: liver
Resonant: lungs
Tympany: abdomen

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11
Q

auscultation

A

using sethoscope to assess movement of air or fluid

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12
Q

standard precautions

A

prevent disease transmission during contact

gloves are standard precaution.

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13
Q

ophthalmoscope

A

visual interior eye

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14
Q

visual acuity tests

A

snellen: far
Rosenbaum: near

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15
Q

otoscope

A

ear canal and tympanic membrane

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16
Q

tuing fork

A

conductive vs sensorineural hearing loss

17
Q

goniometer

A

measure angle of joint

18
Q

skinfold caliper

A

body fat percent

19
Q

SBAR

A

situation
background
assessment
recommendations

20
Q

ABCDE for suspicious lesions

A

asymmetry
border
color
diameter >6mm
evolution

21
Q

clubbing

A

chronic hypoxia: low oxygen

22
Q

risk assessment and health promotion

A

reduce rate of melanoma cancer deaths:
-avoid sun between 10a-4p, wear protective clothing, sunscreen
-avoid artificial UV lights
-skin self exams
-dermatology visits

23
Q

macule, papule, nodule, pustule

A

macule: flat, circumscribed, <1cm

papule: raised <1cm

nodule: solid palpable <1cm

pustule: purulent, fluid filled, any size