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Medical History > Med History Exam > Flashcards

Med History Exam Flashcards

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1
Q

What are the objectives of a medical interview?

A

Gather info about illness
Establish rapport
Instruct and educate
Support and Direct treatment

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2
Q

What are the 5 good clinician traits?

A 
Objective
Precise
Sensitive
Specific
Reliable
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3
Q

What is striving to remove one’s own values, personal beliefs, prejudices, and preconceptions from the observation during the patient interview?

A

Objectivity

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4
Q

Of, or relating to the distribution of observations around the mean in known as what?

A

Precision

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5
Q

Precise is found around the mean, but accuracy is clustered around what?

A

Intended goal

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6
Q

Of, or relating to the characteristic of a test to accurately identify, or “pick up” real cases of the disease in question is known as?

A

Sensitivity

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7
Q

Of, or relating to the characteristic of a test to accurately identify non-cases. Thus, ruling out disease refers to what?

A

Specificity

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8
Q

The characteristic of a test, finding, or procedure that allows observers to obtain the same result refers to?

A

Reliable

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9
Q

What are the 3 key characteristics related to Therapeutic Core Qualities?

A

Respect
Genuineness
Empathy

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10
Q

What is the ability to understand the patients experiences and feelings accurately?

A

Empathy

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11
Q

What is the ability to be yourself in a relationship despite your professional role?

A

Genuineness

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12
Q

What is the ability to accept the patient as he or she is despite your personal preferences?

A

Respect

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13
Q

What are the levels of responding?

A

Ignoring
Minimizing
Interchangeable
Additive

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14
Q

What is xerostomia?

A

Dry mouth

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15
Q

What is borborygmi?

A

Rumbling in the stomach

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16
Q

What is dysphasia?

A

Difficulty speaking

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17
Q

What is dysphagia?

A

Difficulty swallowing

18
Q

What is typically added to a medical word to indicate number, measurement, position, direction, negative, and color?

A

Prefixes

19
Q

Where should an interpreter be in relation to the patient and provider in needed?

A

Seated next to the provider, facing the patient

prevents interviewing interpreter and not the patient

20
Q

The Chief Complaint MUST answer what?

A

Mandatory: primary complaint and duration

Optional: age and sex

21
Q

What is the thorough elaboration of the chief complaint?

A

History of Present Illness (HPI)

22
Q

What type of questions provide a sketch of the patients problem?

A

Non-directive questions

Open-ended

23
Q

What type of questions fill in the details about the sketch and are generally more specific questions?

A

Directive questions

(Closed-ended) yes or no

24
Q

What are the 7 characteristics of a major symptom?

A

Onset
Location
Duration

Character (Quality, Severity)
Alleviating/Aggravating factors
Radiation
Timing (triggers, frequency)

OLD CART

25
Q

What are the 2 techniques for clarifying complaints?

A

Summarization

Confrontation

26
Q

When taking a Past Medical History what pneumonic do you use?

A 
A - Allergies
H - Hospitalizations
I - Immunizations
S - Surgeries
S - Screening Procedures (paps, colon)
T - Trauma or major illness
O - Oral Meds
R - Reproductive History (females)
Y - Youth/Childhood illness

“A HISSTORY”

27
Q

When asking about allergies what should you ask?

A

Food allergies
Environmental allergies

What kind of reaction

  • Hives
  • GI intolerance/sensitivity
  • Anaphylaxis (DON’T MISS THIS!!)
28
Q

How should you record hospitalizations when taking a history?

A

Most recent working back in time

29
Q

When recording oral medications you MUST include what?

A

Dose
Route
Reason

30
Q

What is the pneumonic to help gather a Social History?

A 
F - Family/Food
L - Lifestyle
A - Abuses of substances
M - Martial or relationship
E - Employment
S - Support System

“FLAMES”

31
Q

What pneumonic is used for substance abuse?

A

C - Cut down?
A - Annoyance when asked
G - Guilty about it
E - “Eye-Opener” in the morning

32
Q

If you have a ROS that is positive, it must be included where?

A

Assessment portion

33
Q

What is the single factor that is most indicative of whether a symptom goes into the Subjective or Review of Systems?

A

Diagnosis

34
Q

How many recommendations are required at every encounter and documented on every note?

A

Minimum of 2

35
Q

What does SOAP-P stand for?

A

Subjective
Objective
Assessment
Plan

Prevention

36
Q

Your plan for your proposed “Plan” in your SOAP notes should be written in what order?

A 
Additional lab or diagnostic studies
Consults to specialty providers
Therapeutics: pharm - non-pharm
Patient education
Disposition/Follow-up

“ACT PD”

37
Q

Drug schedule 1 has high potential for abuse with no accepted use. What are some examples?

A 
Heroin
LSD
Ecstasy
Meth
Peyote
38
Q

Class 2 drugs have high potential for abuse and can also be considered dangerous. What are some examples?

A 
Vicodin
Cocaine
Methadone
Oxycodone
Adderall
Ritalin
39
Q

Class 3 drugs have a moderate to low potential for physical and psychological dependence. What are some examples?

A

Codeine
Anabolic Steroids
Testosterone
Ketamine

40
Q

Class 4 drugs have low potential for abuse and low risk of dependence. What are some examples?

A 
Xanax
Soma
Valium
Ativan
Ambien
Tramadol
41
Q

Class 5 drugs have lower potential for abuse than class 4 and consist of preparations containing limited quantities. What are some examples?

A

Robitussin
Lomotil
Lyrica

Medical History (1 decks)

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