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IMM > Intro to Clinical Assessment & Head-to-Toe Approach > Flashcards

Intro to Clinical Assessment & Head-to-Toe Approach Flashcards

1
Q

Vital signs

A
  • Temp
  • Heart rate
  • Respiratory rate
  • Blood Pressure
    -Height
  • Weight
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2
Q

Psychiatric (Psych)

A
  • Insomnia
  • Nervousness or anxiety
  • Changes in insight, orientation, memory, or judgement
  • Changes in attention or mood
  • Unusual or disturbing thoughts
  • Hallucinations or delusions
  • Suicidal thoughts or attempts
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3
Q

Neurological (Neuro)

A
  • Headache
  • Dizziness or vertigo
  • Weakness or paralysis
  • Numbness or loss of sensation, tingling, or “pins and needles”
  • Change in level of consciousness (LOC)
  • Tremors or other involuntary movements
  • Convulsions or seizures
  • Rigidity
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4
Q

What does DERM include?

A
  • Skin
  • Hair
  • Nails
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5
Q

Skin hair and nails

A

Rashes
Bruises
Dryness or moistness
Itching
Hair loss or growth
- Lesions, masses, ulcers, sores, wounds
- Changes in hair or nails
- Changes in skin colour (ex. erythema), texture
- Changes in mole colour, texture, size

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6
Q

HEENT

A

Head, ears, eyes, nose, throat

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7
Q

Head and neck

A

Pain or headache
Dizziness
Light-headedness
Fainting spells
Swollen glands

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8
Q

Eyes

A

Visual acuity
Pain
Spots, specks, flashing lights
Double or blurred vision
Tearing or dryness
Itching
Redness
Discharge
Blind spots

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9
Q

Ears

A

Auditory acuity
Tinnitus
Vertigo
Earaches
Disharge

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10
Q

Nose and Sinuses

A

Itchiness
Nasal congestion
Discharge or runny nose
Nosebleeds
Sinus pain or pressure

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11
Q

Throat and Mouth

A

Gum sorenesss and sore throat
Mouth or tongue sores
Bleeding gums
Dry mouth
Hoarseness of voice
Loss of taste
Condition of teeth and gums
Use of dentures

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12
Q

Respiratory

A

Difficulty breathing
Pain on breathing
Dyspnea - shortness of breath
Cough
Wheezing
Sputum - Saliva and mucus coughed up
Hemoptysis - Coughing up blood
Snoring or apnea
Chest wall abnormalities
Chest pain or chest tightness

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13
Q

Cardiovascular

A

Rapid or irregular heart beat
Palpitations or flutters
Chest pain or pressure
High or low blood pressure
- Orthostatic hypotension - BP suddenly drops when you stand
Heart murmur - extra noise during heart beat

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14
Q

Gastrointestinal

A

Difficulty or pain on swallowing
Heartburn, acid reflux
Changes in appetite
Nausea
Vomiting
Abdominal pain
- Hematemesis - significant amount of blood in vomit
Excessive belching or gas
Diarrhea
Constipation
Change in bowel habits
Pain on defecation
Rectal bleeding
- Blood in stools or black/tarry stools
Hemorrhoids
Jaundice

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15
Q

Genitourinary

A

Freq. of urination
- Polyuria - urinate more than normal
- Nocturia - Need for patients to get up at night on a regular basis and urinate
- Anuria - Failure of kidneys to produce urine
Urgency or dribbling
Burning or pain during urination
Hematuria - Blood in urine
Kidney or flank pain
Enlarged prostate
- Dysmenorrhea - pain with menstruation
Menstrual regularity and freq.
Vaginal dryness or itching
- Changes in sexual interest & function
Discharge or sores

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16
Q

Peripheral vascular system

A

Temperature change (e.g. cold or warm extremities)
* Discolouration (e.g. cyanosis, pallor)
* Leg cramps
* Varicose veins
* Pain or numbness
* Edema or swelling
* Erythema
* Tenderness
* Reduced pulses

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17
Q

List the steps to a clinical assessment

A
  1. History taking
  2. Physical exam
  3. Develop working diagnosis
  4. Obtain lab studies
  5. Develop final diagnosis
  6. Initiate treatment
  7. Ongoing evaluation
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18
Q

What 9 steps of a comprehensive health history invovle?

A

1) Identifying data (ID)
2) Chief concern/complaint (CC)
3) History of present illness (HPI)
4) Past medical history (PMHx)
5) Medication history (MHx)
6) Allergies & intolerances
7) Family history (FHx)
8) Social history (SHx)
9) Review of systems (ROS)

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19
Q

1) Identifying data (ID)

A

Date and time of history
* Age, gender identity/pronouns, occupation, marital status

20
Q

Chief complaint (CC

A

The symptoms causing the patient to seek care
* Quote patient’s own words

21
Q

History of present illness (HPI)

A

Complete, clear, chronologic account of presenting problem
* Detailed description of symptoms, treatments & risk factors

22
Q

Past medical history (PMHx)

A

Medical, surgical, obstetric/gynecologic, psychiatric
* Immunizations

23
Q

Medication history (MHx)

A

Prescription and non-prescription medications; vitamins and
supplements; alternative health products

24
Q

Allergies and intolerances

A

Date of reaction, symptoms of reaction

25
Q

Family history (FHx)

A

Presence or absence of specific illnesses

26
Q

Social history (SHx)

A

Education level, ethnicity, current home situation, support system,
personal interests, lifestyle (smoking, alcohol, illicit drugs), activities
of daily living, exercise, diet

27
Q

Review of systems (ROS)

A

Documents presence or absence of common symptoms related to
each major body system
* Detailed, systematic, and complete review of a patient’s symptoms
* Organizes information head-to-toe according to major body
systems
* Takes a patient-centered approach (vs. a product-centered
approach)

28
Q

Order of ROS

A

VS
PSYCH OR NEURO
DERM
HEENT
RESP
CV
GI
GU
PVS
MSK

29
Q

What does scholar stand for?

A

Symptoms
Characteristics
History
Onset
Location
Aggravating Factors
Remitting Factors

30
Q

Symptoms

A

What are the main & associated symptoms

31
Q

Characterists?

A

What are the symptoms like?

32
Q

History

A

What has been done so far? Happened in the past?

33
Q

Onset

A

When did it start

34
Q

Location

A

Where is the problem

35
Q

Aggravating Factors

A

What makes it worse

36
Q

Remitting Factors

A

What makes it better

37
Q

What you ask in your ROS should be based on…

A

Patient History

38
Q

Best way to assess new patients

A

Comprehensive

39
Q

Provides fundamental knowledge about patients

A

Comprehensive

40
Q

Helps identify or rule out physical causes related to patient

A

Comprehensive

41
Q

Strengthens pharmacist-patient relationship

A

Comprehensive

42
Q

Efficient way to assess established patients

A

Focused

43
Q

Addresses specific concerns and symptoms

A

Focused

44
Q

Assesses symptoms restricted to a specific body system

A

Focused

45
Q

Applies examination methods relevant to assessment of target problem

A

Focused

IMM (1 decks)

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