Mod 3 Flashcards
close-ended question
questions with yes/no answers
crepitation
sound or feeling of broken bones rubbing together
detailed physical exam (DPE)
head to toe exam
diagnosis
label for patients
differential diagnosis
list of potential diagnosis
distention
stretched, inflated, or larger than normal
history of present illness (HPI)
information regarding the patients current condition
jugular vein distention (JVD)
bulging of the neck vein
medical patient
patient with one or more conditions/disease
open-ended question
requires more than yes/no
OPQRST
onset, provocation, quality, radiaton, severity, time
paradoxical motion
one side moves without the other
past medical history (PMH)
information regarding the patients past
priapism
persistent erection caused by spinal injury or medical problems
rapid truama assessment
a rapid assessment from head to toe to detect signs and symptoms of injury
reassessment
detecting changes in the patients condition
SAMPLE
symptoms, allergies, medicine, past history, last oral intake, events
sign
something you can see on the patient
stoma
permanent opening in the neck
symptom
something the patient tells you
tracheostomy
surgical incision held open by a metal or plastic tube
trauma patient
patient suffering from one or more physical injuries
trending
changes in a patients condition of time
orthopnea
shortness of breath that only happens when you lie down
components of the secondary assessment
physical examination, patient history, vital signs
what is physical examination
use sense to examine patient
what is HPI?
history of present illness
what is PMH?
psst medical history
what vital signs do you take?
pulse, respiration, blood pressure, pulse oximetry, skin (color, temp, and condition) and pupils
physical examination techniques
observe, auscultate, palpate
observe
looking at the patient for an overall sense of condition
auscultate
listening for signs of abnormal condition
palpate
feeling the area for deformities and abnormal findings
respiratory assessment history
dyspnea on exertion, weight gain, orthopnea, sleep on pillows, have a cough
dyspnea on exertion
difficult to catch breath after exertion
orthopnea
difficulty breathing when laying down
what to check in respiratory exam
pedal and sacral edema, lung sounds, pulse oximetry
respiratory specific history
dyspnea on exertion, orthopnea, weight gain
cardiovascular exam
check pulse (presence/rate/regularity), skin color/ temperature/condition) blood pressure, orthostatic blood pressure changes, JVD
neurological exam
use Cincinnati prehospital stroke scale (or other approved), pupils, monitoring mental status changes over time
endocrine exam
blood glucose, skin color/temperature/conditions, breath odors, excessive hunger, thirst, or urination, pupils, monitoring mental status changes over time
diabetic specific history
oral intake, medication history/use, recent illness
GI/GU (gastrointestinal/urinal)
palpation of abdominal quadrants