Midterm Flashcards
Midterm sample questions
what is HIPAA and when was it started?
Health Insurance Portability and Accountability Act - 1996
Designed to provide privacy standards for patients.
Created by the dept. of health and human resources
What CANNOT be included in a case presentation?
any identifiers:
Names
Numbers of any sort (DOB, phone, MRN, SS, etc)
Identifying Photos
what happens if you do not safeguard the patients information?
you get kicked out
What is on the identification sheet (aka registration form)?
demographics
employment
insurance
emergency contact
what is included in the patient’s history?
Date & Time Identifying Data Chief Complaint History of Present Illness incl. medications, allergies, habits Past History: both medical and surgical Family History: narrative or diagram Personal/Social History: Review of Systems (ROS)
what is included in the physical exam?
Vital Signs: Blood Pressure, Heart rate, Respiration rate, Temp(C), O2 Saturation (SpO2)
Exam of all systems:
Skin, HEENT(incl. thyroid and lymph nodes), Thorax/lungs, breasts/axillae, musculoskeletal, cardiovascular, abdomen, peripheral vascular/nervous system & genital/rectal exam
what are the components of a consent form?
Patient Name & Date
Name and Description of Surgery
Indication for Surgery
Risks & Benefits of Procedure
Alternatives to Procedure
Patient’s Signature, printed name, date, and time/Surgeon’s signature
*Patient must be competent to make medical decisions
what is the SOAP format?
Subjective: what the patient tells you
Objective: found as part of your physical exam
Assessment: Problem list
Plan: Management
what are the normal ranges for vital signs for a patient at rest?
Blood Pressure: 90/60- 120/80
Heart Rate: 60-100 beats per minute (BPM)
Respiratory Rate: 12-20 breaths per minute
Temperature: 97.8-99.1 F (ave. 98.6)
Pulse Oximetry: 95-100%
what is the difference between systolic and diastolic pressure?
Systolic BP (SP): the pressure exerted on the walls of the arteries during heart contraction (systole) (top number) Diastolic BP (DP): the pressure exerted on the walls of the arteries during heart relaxation (diastole) (bottom number)
what is MAP and how does it effect perfusion?
Mean Arterial Pressure (MAP): aka perfusion pressure
MAP= DP+ 1/3 PP (pulse pressure= SP-DP)
MAP > 60 mmHg to perfuse organs
MAP > 70 mmHg to perfuse organs in hypertensive patient.
what are the classifications of HTN?
Normal: Systolic:119 or lower Diastolic: 79 or lower
Prehypertension: Systolic: 120-139 Diastolic 80-89
Stage 1 Hypertension: Systolic: 140-159 Diastolic: 90-99
Stage 2 Hypertension: Systolic: 160 or higher Diastolic: 100 or higher.
are body temperatures uniform wherever they are taken?
No,
Axillary temperatures - 1 C lower than oral
Rectal temperatures + 1 C higher than oral
what is pulse oximetry?
Non-invasive means of measuring the saturation of hemoglobin
What is the CAGE questionnaire and what is it used for?
CAGE Questionnaire
Have you ever felt the need to CUT DOWN on drinking?
Have you ever felt ANNOYED by criticism of your drinking?
Have you ever felt GUILTY about drinking?
Have you ever had an EYE-OPENER to steady your nerves or get rid of a hangover?
what are the stages of the kubler-ross response?
Kubler-Ross: 5 stages in a person’s response to death.
Denial & Isolation Anger Bargaining Depression or Sadness Acceptance
what is the difference between subjective and objective data?
Subjective Data: What the patient tells you.
Objective Data: What you detect during the exam.
what is the chief complaint?
The reason the patient is here to see you.
Make every attempt to use the patient’s own words.
If the patient has NO complaints, report their GOALS instead.
what are the seven attributes of a symptom?
Seven Attributes of a Symptoms (Chloride)
Character or Quality Location Onset Radiation Intensity Duration Exacerbating or Alleviating factors
what is included in the past medical history?
General health and strength of the patient Adult illnesses Childhood illnesses Past surgeries or hospitalizations Recent tests Immunizations
what is the review of systems?
Series of questions from “head to toe” in a system based approach
(General, skin, HEENT, Neck, Breasts, Resp. Cardio, GI, Urinary, Genitals, Perif. Vasc., MS, Neuro, Hematologic, Endocrine, Psych)
what are the cardinal techniques of examination?
Inspection, Palpation, Percussion, Ascultation
what are the BMI ranges and how is it calculated?
Weight (kg)/height (meters squared)
25 overweight
>30 is obese
what are the 5 segments when doing a neuro exam?
mental status cranial nerves motor function sensory system reflexes