Midterm Exam Flashcards by Ashley Anderson

What is the importance of properly documented patient medical record (4 reasons)?

Assists in providing the best patient care possible
Offers legal protection to those who provide care to the patient
Research purposes
Financial reimbursement

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What are the 6 components of a focused (SOAP) note?

Identifying data
Reliability
Subjective data (symptoms given by patient)
Objective data (what the provider finds upon examination)
Assessment (what is wrong with the patient)
Plan

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What are the components of a complete history and physical exam?

Identifying data
Reliability
Chief concern
Present illness
Allergies
Medications
Past medical history
Past surgical history
Family and social history
Review of systems
Health maintenance
Physical exam
Completed lab/diagnostic tests
Assessment/plan
Education

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What components are involved in the “identifying data” portion of a complete history and physical exam?

Date
Time
Patient name and how they would like to be addressed
Age
DOB
Medical record number
Gender

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When is it important to document reliability?

Important to document if the reliability of the information is uncertain due to impairment in the patient’s memory, mood, clinical situation, etc.

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What is a chief concern/complaint?

The reason the patient is seeking medical care (in patient words)

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What is an example of a question to elicit a chief complaint?

“What brings you in today?”

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What is an example of a chief complaint?

“Mrs. Smith is a 70 year old man who presents with “crushing chest pain” for the past 30 minutes.”

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What is a history of present illness?

Complete, clear, chronological account of the problem for which the patient is seeking care for

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What are the 7 attributes of a symptom?

O - onset
L - location
D - duration
C - character
A - aggravating/alleviating factors
R - radiation
T - timing
S - severity

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T/F? We should use a left-side approach when completing a physical exam.

False. Right-side approach

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What is a normal height and weight dependent on?

A normal growth chart

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How do we obtain a height in an adult? A child?

Adult - firm, flat surface
Child - laying on a flat and firm horizontal surface

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What is a normal BMI?

18.5-24.9 kg/m2

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What is the calculation for BMI?

[Weight (lbs) x 704.5] / Height (in)

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What is a normal blood pressure?

Systolic <120 mmHg and diastolic <80 mmHg

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Identify key components of obtaining a blood pressure.

Width of bladder is about 40% of the upper arm circumference
Have patient sit in a chair for 5 minutes with feet on floor
Arm free of clothing
Brachial artery at heart level
Repeat BP after two minutes

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What is a normal heart rate for adolescents and adults?

60-100 bpm

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What is a normal respiratory rate for adults?

14-20 breaths/min

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What is a normal pulse oximetry?

95-100%

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What is a normal temperature?

37 C (98.6 F)

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What are the two pain scales?

Visual analog scale and Wong-Baker FACER

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What is the visual analog scale?

A pain scale that ranks pain from 0-10

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What is the Wong-Baker scale?

A pain scale that uses emoji-like characters to describe pain for patients who are young or have verbal communication difficulties

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What are the components of the general survey?

- Apparent state of heath - Level of consciousness - Orientation - Signs of distress - Body habitus - Dress, grooming, personal hygiene - Mood - Affect - Facial expression - Odors of body and breath - Posture, gait, motor activity

What are the levels of consciousness?

Alert - opens eyes, looks at you, responds fully and appropriately to stimuli Lethargic - patient appears drowsy but opens eyes and looks at you, responds to questions and falls asleep Obtunded - patient opens eyes and looks at you but responds slowly and is confused Stupor - patient arouses from sleep only after painful stimuli, verbal responses are slow or absent (patient lapses into unresponsive state when the stimulus ceases) Coma - patient remains unarousable with eyes closed

What does it mean when a patient is alert and oriented x 3-4?

Orientated to person, place, time, and situation/event

What are some specific odors we look for during the general survey?

Fruity breath and the scent of alcohol

What is vellus hair?

Short, fine, inconspicuous and relatively unpigmented hair

What is terminal hair?

Coarser, thicker, more conspicuous, pigmented hair found on the scalp and eyebrows

How is normal skin described?

Pink in color, warm and moist, no abnormalities

What is peripheral cyanosis?

Blue coloring of the fingers and toes

What is central cyanosis?

Bluish color on the face

What is jaundice?

Yellowing of the skin and eyes

What is carotenemia?

Yellowing of the skin only

What is erythema?

Reddened skin

What is pallor?

Pale appearance

What does it mean when skin is blanchable?

Lesions are erythematous and suggest inflammation but when pressed can show pallor

What does it mean when skin is non-blanchable?

Lesions are not erythematous but are bright red, purple, or violet and remains same color when pressed

What is a linear pattern of lesions?

Lesions appear as a straight line

What is a clustered pattern of lesions?

Small lesions in a clump

What is a geographical lesion?

A lesion with a sharply-defined border

What is a serpiginous lesion?

A lesion with a wavy margin

What is an annular lesion?

A ring-like lesion

What is an arciform lesion?

An advancing outer erythematous edge with a trailing (inner) scaly edge

How are moles screened?

ABCDE screening tool

What does A stand for in the ABCDE screening tool of moles?

Asymmetry

What does B stand for in the ABCDE screening tool of moles?

Borders

What does C stand for in the ABCDE screening tool of moles?

Change in color (especially blue or black)

What does D stand for in the ABCDE screening tool of moles?

Diameter (Greater than or equal to 6 mm)

What does E stand for in the ABCDE screening tool of moles?

Elevation or enlargement

What is a macule?

A small (<1 cm), flat, non-palpable spot with a change in skin color

What is a patch?

A flat, non-palpable spot with a change in skin color that is greater than 1 cm

What is a papule?

An elevated, superficial skin lesion less than 1 cm in diameter

What is a plaque?

An elevated superficial skin lesion greater than 1 cm in diameter

What is a nodule?

A marble-like lesion less than 0.5 cm and is often deeper and firmer than a papule

What is a cyst?

A nodule filled with expressible material

What is a wheal?

A somewhat irregular, relatively transient, superficial area of localized skin edema

What is a vesicle?

A palpable skin elevation less than 1 cm filled with serous fluid

What is a bulla?

A palpable skin elevation greater than 1 cm filled with serous fluid

What is a pustule?

A palpable skin elevation filled with pus

What is a scale?

A thin flake of dead exfoliated epidermis

What is a crust?

A dried residue of skin exudates

What is lichenification?

A visible and palpable thickening of the epidermis and roughening of the skin with increased visibility of the skin furrows (often occurs with chronic rubbing)

What is a scar?

Connective tissue that arises from injury or disease

What are striae?

Stretch marks

What are keloids?

Hypertrophic scarring that extends beyond the borders of the initiating injury

What is an erosion?

A depressed lesion of non-scarring loss of superficial epidermis where the surface is moist but does not bleed

What is an excoriation?

A linear erosion caused by scratching

What is a fissure?

A linear crack in the skin, often resulting from excessive dryness

What is an ulcer?

A deeper loss of epidermis and dermis which may bleed and scar

What cranial nerve is being assessed when asking patient to puff cheeks, raise eyebrows, etc.?

Trigeminal (CN 5)

What cranial nerve is being assessed when asking patient to clench jaw?

Trigeminal (CN 5)

What cranial nerve is being assessed when doing light touch testing during HENT?

Trigeminal (CN 5)

What cranial nerves are being assessed when testing for nystagmus?

Oculomotor, Trochlear, Abducens (CN 3, 4, 6)

What cranial nerve is being assessed with confrontational testing of the eyes?

Optic (CN 2)

What cranial nerve is being assessed with direct and consensual reactions?

Optic (CN 2)

What cranial nerve is being assessed with the whisper test?

Vestibulocochlear (CN 9)

Is diminished hearing is seen during the whisper test, what would be indicated?

Weber and Rinne test

What cranial nerve is being assessed with the smell test?

Olfactory (CN 1)

What cranial nerve is being assessed when we watch for the symmetrical rise of the soft palate?

Vagus and glossopharyngeal (CN 9 and 10)

What cranial nerve is being assessed when we have the patient move their tongue side to side?

Hypoglossal (CN 12)

What cranial nerve is being assessed when we have the patient swallow?

Vagus and glossopharyngeal (CN 9 and 10)

What are the normal findings of a pulmonary exam?

Resonant percussion note, vesicular auscultation

What is normal diaphragmatic excursion?

4 cm bilaterally

What does S1 represent?

Mitral and tricuspid valve closure (LUB) - systole (high frequency)

What does S2 represent?

Aortic and pulmonic valve closure (DUB) - diastole (high frequency)

What is a normal grading of arterial pulses?

What does S3 represent?

Beginning of ventricular filling (low frequency)

What does S4 represent?

Atrial systole (low frequency)

What is the correct order of the abdominal exam?

Inspection, auscultation, palpate, percuss

What are we listening to when we auscultate the abdominal, renal, and iliac arteries in the abdominal exam?

Venous hums

What is the normal width of the abdominal aorta?

3 cm

T/F. The kidneys are retroperitoneal and are usually not palpable unless enlarged.

True

What is a normal spleen sound?

Tympanic

What is a normal percussion sound of the abdomen?

Tympanic

What is a normal liver span?

Around 7 cm

What are some physical exam findings for scoliosis?

Head is to one side of the natal cleft and not in a straight line, shoulders uneven, hump in the right thoracic or left lumbar region

What are the dermatomes present in the upper extremity?

C5-T2

What are the dermatomes present in the lower extremity?

L1-S5