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Clinical Applications > Midterm Exam > Flashcards

Midterm Exam Flashcards

1
Q

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

A
  • 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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2
Q

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

A
  • 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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3
Q

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

A
  • 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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4
Q

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

A
  • Date
  • Time
  • Patient name and how they would like to be addressed
  • Age
  • DOB
  • Medical record number
  • Gender
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5
Q

When is it important to document reliability?

A

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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6
Q

What is a chief concern/complaint?

A

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

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7
Q

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

A

“What brings you in today?”

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8
Q

What is an example of a chief complaint?

A

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

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9
Q

What is a history of present illness?

A

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

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10
Q

What are the 7 attributes of a symptom?

A

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

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11
Q

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

A

False. Right-side approach

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12
Q

What is a normal height and weight dependent on?

A

A normal growth chart

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13
Q

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

A

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

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14
Q

What is a normal BMI?

A

18.5-24.9 kg/m2

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15
Q

What is the calculation for BMI?

A

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

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16
Q

What is a normal blood pressure?

A

Systolic <120 mmHg and diastolic <80 mmHg

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17
Q

Identify key components of obtaining a blood pressure.

A
  • 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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18
Q

What is a normal heart rate for adolescents and adults?

A

60-100 bpm

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19
Q

What is a normal respiratory rate for adults?

A

14-20 breaths/min

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20
Q

What is a normal pulse oximetry?

A

95-100%

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21
Q

What is a normal temperature?

A

37 C (98.6 F)

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22
Q

What are the two pain scales?

A

Visual analog scale and Wong-Baker FACER

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23
Q

What is the visual analog scale?

A

A pain scale that ranks pain from 0-10

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24
Q

What is the Wong-Baker scale?

A

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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25
Q

What are the components of the general survey?

A
  • 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
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26
Q

What are the levels of consciousness?

A

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

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27
Q

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

A

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

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28
Q

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

A

Fruity breath and the scent of alcohol

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29
Q

What is vellus hair?

A

Short, fine, inconspicuous and relatively unpigmented hair

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30
Q

What is terminal hair?

A

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

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31
Q

How is normal skin described?

A

Pink in color, warm and moist, no abnormalities

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32
Q

What is peripheral cyanosis?

A

Blue coloring of the fingers and toes

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33
Q

What is central cyanosis?

A

Bluish color on the face

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34
Q

What is jaundice?

A

Yellowing of the skin and eyes

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35
Q

What is carotenemia?

A

Yellowing of the skin only

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36
Q

What is erythema?

A

Reddened skin

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37
Q

What is pallor?

A

Pale appearance

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38
Q

What does it mean when skin is blanchable?

A

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

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39
Q

What does it mean when skin is non-blanchable?

A

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

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40
Q

What is a linear pattern of lesions?

A

Lesions appear as a straight line

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41
Q

What is a clustered pattern of lesions?

A

Small lesions in a clump

42
Q

What is a geographical lesion?

A

A lesion with a sharply-defined border

43
Q

What is a serpiginous lesion?

A

A lesion with a wavy margin

44
Q

What is an annular lesion?

A

A ring-like lesion

45
Q

What is an arciform lesion?

A

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

46
Q

How are moles screened?

A

ABCDE screening tool

47
Q

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

A

Asymmetry

48
Q

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

A

Borders

49
Q

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

A

Change in color (especially blue or black)

50
Q

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

A

Diameter (Greater than or equal to 6 mm)

51
Q

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

A

Elevation or enlargement

52
Q

What is a macule?

A

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

53
Q

What is a patch?

A

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

54
Q

What is a papule?

A

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

55
Q

What is a plaque?

A

An elevated superficial skin lesion greater than 1 cm in diameter

56
Q

What is a nodule?

A

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

57
Q

What is a cyst?

A

A nodule filled with expressible material

58
Q

What is a wheal?

A

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

59
Q

What is a vesicle?

A

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

60
Q

What is a bulla?

A

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

61
Q

What is a pustule?

A

A palpable skin elevation filled with pus

62
Q

What is a scale?

A

A thin flake of dead exfoliated epidermis

63
Q

What is a crust?

A

A dried residue of skin exudates

64
Q

What is lichenification?

A

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)

65
Q

What is a scar?

A

Connective tissue that arises from injury or disease

66
Q

What are striae?

A

Stretch marks

67
Q

What are keloids?

A

Hypertrophic scarring that extends beyond the borders of the initiating injury

68
Q

What is an erosion?

A

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

69
Q

What is an excoriation?

A

A linear erosion caused by scratching

70
Q

What is a fissure?

A

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

71
Q

What is an ulcer?

A

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

72
Q

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

A

Trigeminal (CN 5)

73
Q

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

A

Trigeminal (CN 5)

74
Q

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

A

Trigeminal (CN 5)

75
Q

What cranial nerves are being assessed when testing for nystagmus?

A

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

76
Q

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

A

Optic (CN 2)

77
Q

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

A

Optic (CN 2)

78
Q

What cranial nerve is being assessed with the whisper test?

A

Vestibulocochlear (CN 9)

79
Q

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

A

Weber and Rinne test

80
Q

What cranial nerve is being assessed with the smell test?

A

Olfactory (CN 1)

81
Q

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

A

Vagus and glossopharyngeal (CN 9 and 10)

82
Q

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

A

Hypoglossal (CN 12)

83
Q

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

A

Vagus and glossopharyngeal (CN 9 and 10)

84
Q

What are the normal findings of a pulmonary exam?

A

Resonant percussion note, vesicular auscultation

85
Q

What is normal diaphragmatic excursion?

A

4 cm bilaterally

86
Q

What does S1 represent?

A

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

87
Q

What does S2 represent?

A

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

88
Q

What is a normal grading of arterial pulses?

A

2+

89
Q

What does S3 represent?

A

Beginning of ventricular filling (low frequency)

90
Q

What does S4 represent?

A

Atrial systole (low frequency)

91
Q

What is the correct order of the abdominal exam?

A

Inspection, auscultation, palpate, percuss

92
Q

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

A

Venous hums

93
Q

What is the normal width of the abdominal aorta?

A

3 cm

94
Q

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

A

True

95
Q

What is a normal spleen sound?

A

Tympanic

96
Q

What is a normal percussion sound of the abdomen?

A

Tympanic

97
Q

What is a normal liver span?

A

Around 7 cm

98
Q

What are some physical exam findings for scoliosis?

A

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

99
Q

What are the dermatomes present in the upper extremity?

A

C5-T2

100
Q

What are the dermatomes present in the lower extremity?

A

L1-S5

Clinical Applications (1 decks)

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