HISTORY & PHYSICAL EXAM Flashcards
definition: what the patient tells you; the history, from the chief complaint through review of systems
subjective data
definition: what you detect during the exam; all physical exam findings
objective data
name two things that, if deviant from the norm, should be documented in the source of the history
- if the source is someone other than the patient
2. if the reliability of the source is questionable
definition: the reason the patient is here to see you, in the patient’s own words
chief complaint
definition: a complete clear, and chronological account of the problems prompting the pt to seek care
history of present illness
List the seven attributes of a symptom
CHLORIDE
- Character or quality
- Location
- Onset
- Radiation
- Intensity
- Duration
- Exacerbating or alleviating factors/ associated manifestations
definition: includes general health and strength of patient, adult and childhood illnesses, past surgeries, hospitalizations and serious injuries, recent screening tests, immunizations, emotional status, and disabilities
past medical history (PMH)
includes things such as marital status, stress, occupation/job history, level of schooling, activities of daily living, alcohol, drug, and tobacco use, pack-year smoking history, diet and exercise
personal & social history
include bathing, dressing, toiling, transfers, continence, feeding, managing money
physical ADLs
include using the telephone, shopping, preparing food, housekeeping, laundry, transportation, taking medicine
instrumental ADLs
purpose: gain understanding of overall health of the patient and prevent missing any important history that might have been missed in HPI
review of symptoms
ROS component: recent weight changes, weakness, fatigue, fever
general
ROS component: rashes, lumps, sores, itching, dryness, color change, changes in hair or nails
skin (integumentary)
ROS component: headache, injury, dizziness, vision changes, glasses or contact lenses, last eye exam, hearing, hearing aids, infection, discharge, frequent colds, nasal stuffiness, hay fever, nosebleeds, sinus trouble, condition of teeth and gums, dentures, last dental exam, sore throats, horseness
HEENT
ROS component: lumps, ‘swollen glands’, goiter, pain, stiffness
neck
ROS component: lumps, pain or discomfort, self-exams
breasts
ROS component: cough, sputum (color, quality), hemoptysis, dyspnea, wheezing, asthma, COPD, TB, smoking history
respiratory
ROS component: HTN, rheumatic fever, heart murmurs, ches pain or discomfort, palpitations, dyspnea, ortophnea, paroxysmal nocturnal dyspnea, edema, EKGs, other heart test results
cardiovascular
ROS component: trouble swallowing, heartburn, nausea, changes in bowel habits, rectal bleeding or black or tarry stools, hemorrhoids, constipation, diarrhea, abdominal pain, food intolerance, excessive belching or flatulence, jaundice, liver or gallbladder trouble, hepatitis
gastrointestinal
ROS component: polyuria, nocturia, urgency, burning or pain with urination, hematuria, UTIs, kidney stones, incontinence, in males decreased force of urinary stream, hesitancy, dribbling
urinary
ROS component: STDs, sexual habits, exposure to HIV; in females, menarche, regularity, frequency, duration of periods, number of pregnancies, deliveries, abortions (spontaneous and induced), complications with pregnancy, birth control method
genital
ROS component: intermittent claudication, leg cramps, varicose veins, history of blood clots
peripheral vascular
ROS component: muscle or joint pain, arthritis, gout, backache, swelling, redness, limitation of motion or activity, history of trauma
musculoskeletal
ROS component: fainting, blackouts, seizures, weakness, paralysis, numbness or loss of sensation, tingling, tremors, involuntary movements
neurologic
ROS component: anemia, bruising or bleeding, history of transfusions and any reactions with those, sickle-cell disease or trait
hematologic
ROS component: h/o thyroid disease (heat or cold intolerance, excessive sweating), excessive thirst or hunger, polyuria-associated with new onset diabetes
endocrine
ROS component: nervousness, tension, mood, depressive feelings, memory changes, suicide attempts, past diagnosis of any psychiatric problems
psychiatric
name two things you should do to begin a physical examination
- WASH YOUR HANDS in the presence of the pt
2. clean your stethoscope
name the four cardinal techniques of examination
- inspection
- palpation
- percussion
- auscultation
definition: observe details of patient’s appearance, behavior, facial expression, mood, skin conditions, odor, gait, etc
inspection
definition: tactile pressure from the palmar fingers/finger pads to assess skin elevation, depression, warmth, & tenderness. assess lymph nodes, pulses, counter and size of organs/masses, and crepitus in joints
palpation
definition: use of striking finger (plexor) to the distal pleximeter finger against chest or abdomen, to evoke a sound wave of resonance/dullness of underlying tissue/organs
percussion
definition: use diaphragm/bell of stethoscope to detect characteristics of heart, lung and bowel sounds
auscultation
conversion rate in to cm
1in = 2.54cm
calculate BMI
kg/m^2
what is a normal BMI?
19-25
what BMI is considered overweight?
> 25
what BMI is considered obese?
> 30
which test is used to check lateralization of hearing?
the weber test
which test is used to compare air and bone conduction of hearing?
the rinne test
list the 5 segments of the nervous system exam
- mental status
- cranial nerves.
- motor system
- sensory system
- reflexes
which segment of the nervous system exam is defined as:
Assess pt’s orientation, mood, thought process, thought content, abnormal perceptions, insight an judgment, memory and attention, information and vocabulary, calculating abilities, abstract thinking and constructional ability
mental status
which segment of the nervous system exam is defined as:
Check sense of smell, strength of the temporal and master muscles, corneal reflex, facial movements, gag reflex, and strength of the trapezia and sternomastoid muscles
cranial nerves
which segment of the nervous system exam is defined as:
asses muscle bulk, tone, and strength of major muscles groups. assess cerebellar function with rapid alternating movements (RAMs)
motor system
which segment of the nervous system exam is defined as:
asses pain, temperature, light touch, vibration, and discrimination
sensory system
which segment of the nervous system exam is defined as:
assess biceps, triceps, brachioradialis, patellar, achilles deep tendon reflexes, plantar and babinski reflex
reflexes
what electrolyte lab test is described?
used to monitor salt/water balance and evaluate fluid and electrolyte balance/therapy
sodium (Na)
what is the normal range for Na?
136-145mEq/L
what electrolyte lab test is described?
important electrolyte of cardiac function. it is tested as part of complete routine evaluations, especially in pts who take diuretics or heart medications
Potassium (K)
what is the normal range for K?
3.5-5.0mEq/L
what electrolyte lab test is described?
interpreted with the other electrolytes to investigate acid-base balance and proper balance of body fluids
chloride (Cl)
what is the normal range for Cl?
90-110mEq/L
what electrolyte lab test is described? most of (this substance) is in the form of bicarbonate, therefore, this test is really a measure of the blood bicarbonate level. changes may suggest fluid imbalances, which causes an imbalance in the body's electrolytes
carbon dioxide (CO2)
what is the normal range for CO2?
23-29mEq/L
what electrolyte lab test is described?
reveals important information about how well the kidneys and liver are working. measures the amount of urea nitrogen in the blood
blood urea nitrogen (BUN)
what is the normal range for BUN?
10-20mg/dl
what electrolyte lab test is described?
a chemical waste product produced by muscle metabolism. kidneys filter this and other waste products from blood. used to diagnose impaired renal function. if kidney function is impaired, an increased level of this electrolyte may accumulate in blood
creatinine (Cr)
what is the normal range for Cr
0.6-1.2mg/dl
what electrolyte lab test is described?
measures the amount of sugar in a sample of blood. used to diagnose diabetes or monitor existing diabetics
glucose (Glu)
what is the normal range for Glu?
70-100mg/dl
what is the normal range for WBC?
4.5-10.8 X10^3 cells/mm^3
what is the normal range of Hgb?
13-18g/dl (men); 12-16g/dl (women)
what is the normal range of Hct?
45-52% (men); 37-48% (women)
what is the normal range of platelets?
150-400 X10^3/mcL
function: destroy and ingest bacteria. first at the site of inflammation; therefore their numbers will increase greatly immediately after an injury or during the inflammatory process
neutrophils
function: fight viral infections; B cells and T cells are two major types. play a key role in the formation of immunoglobins (humoral immunity) and also provide cellular immunity
lymphocytes
function: arrive at the site of injury in about five hours. phagocytic cells that remove foreign materials such as injured and dead cells, microorganisms and other particles from the site of injury, particularly during viral or bacterial infections
monocytes
function: found in such areas as skin and the airway in addition to the bloodstream. they increase in number during allergic and inflammatory reactions and parasite infections.
eosinophils
function: also known as mast cells when found in tissues. they are found in the tissues of the GI and respiratory tracts, and the skin. contain heparin and histamine and are believed to be involved in allergic and stress situations. may contribute to prevention of clotting in microcirculation
basophils
definition: measure the extrinsic pathway to assess the clotting ability of blood. used to monitor pts taking certain medications as well as to help diagnose clotting disorders
prothrombin time (PT)
what is the normal range for PT?
11-15sec
definition: established by WHO and the international committee on thrombosis and hemostasis for reporting the results of blood coagulation tests. allows for standardization of the value no matter where the test is done
international normalized ratio (INR)
what is the normal range for INR?
1.0-1.5
definition: a performance indicator measuring the efficacy of both the intrinsic and common coagulation pathways. apart from detecting abnormalities in blood clotting, it is also used to monitor the treatment effects with heparin
partial thromboplastin time (PTT)
what is the normal range for PTT?
30-50sec
