Midterm Exam Flashcards
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
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
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
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
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.
What is a chief concern/complaint?
The reason the patient is seeking medical care (in patient words)
What is an example of a question to elicit a chief complaint?
“What brings you in today?”
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.”
What is a history of present illness?
Complete, clear, chronological account of the problem for which the patient is seeking care for
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
T/F? We should use a left-side approach when completing a physical exam.
False. Right-side approach
What is a normal height and weight dependent on?
A normal growth chart
How do we obtain a height in an adult? A child?
Adult - firm, flat surface
Child - laying on a flat and firm horizontal surface
What is a normal BMI?
18.5-24.9 kg/m2
What is the calculation for BMI?
[Weight (lbs) x 704.5] / Height (in)
What is a normal blood pressure?
Systolic <120 mmHg and diastolic <80 mmHg
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
What is a normal heart rate for adolescents and adults?
60-100 bpm
What is a normal respiratory rate for adults?
14-20 breaths/min
What is a normal pulse oximetry?
95-100%
What is a normal temperature?
37 C (98.6 F)
What are the two pain scales?
Visual analog scale and Wong-Baker FACER
What is the visual analog scale?
A pain scale that ranks pain from 0-10
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
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?
2+
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
