Module 1 Flashcards
(163 cards)
1
Q
patient assessment
A
Chief Complaint (CC) History of Present Illness (HPI) Past Medical History Medical Surgical Health Maintenance Family History Social History Medications Allergies Review of Systems (ROS) Physical Examination Laboratory Data Problem List/Assessment Plan
2
Q
Comprehensive Assessment
A
includes ALL information for pt assessment
Useful for new patients
Pre-operative evaluations
Work/School physicals
3
Q
Problem-focused Assessment
A
includes the PERTINENT information for pt assessment
As related to a particular issue/complaint
Established patients coming in for specific complaint
ex) pt in the ER w/ Fx
4
Q
taking pt’s history
A
Utilize Open-ended questions
Avoid leading questions
Let the patient tell their story
-May need to direct them if they are going on tangents
ex) pts that get distracted and ramble
*always include worst case scenario (leads to life threatening DiffDx)
5
Q
chief complaint
A
Why the patient is seeking care
Can be one or more complaints
Try to address one at a time
6
Q
HPI
A
Additional information regarding the Chief Complaint
Subjective information provided by the patient, family member, guardian, etc.
document who is providing the information
ex) mother providing hx for peds pt
Onset of the problem, setting in which it occurred, manifestations associated with
problem
*OPQRST or OLDCARTS
7
Q
onset
A
How symptoms began
time when sx started (qualitative)
-suddenly vs. gradually
8
Q
duration
A
how long symptoms have been occurring (hours, minutes, etc)
-ongoing for 1 day, 1 week, etc.
9
Q
character
A
description of sx
ex)burning, pressure, pulling
cannot get full breath in (pt w/ SOB)
10
Q
timing
A
how often sx is occurring
- constant
- intermittent
- waxing/waning
- most of the day
- constant at night
11
Q
associated symptoms
A
Tailor to chief complaint
Symptoms that can be tied to the complaint
ex) pt presents w/ abdominal p and c/o assoc. n/v and dysuria
ex) presents w/ chest pain and c/o dyspnea on exertion and diaphoresis
12
Q
past medical history
A
Childhood illnesses Adult illnesses Hospitalizations Surgical history OB/GYN history Health maintenance: -Immunizations -Screening exams
13
Q
family history
A
Helps establish risk factors First degree relatives Parents, siblings, children Grandparents Age of onset, age of death
14
Q
social history
A
Marital Status Occupation Education Level Alcohol use Tobacco Use Illegal Drug Use Military Service Sexual Preference explain to pt why you need this info as they are sensitive topics
15
Q
sexual history
A
Determine risks: pregnancy, STDs, AIDS
Sexual preference
Men, women or both
Number of partners: current and past
16
Q
mental health
A
History of emotional or mental illnesses
Diagnoses, hospitalizations, treatments
Depression screenings
-being done at PCP during annual exams
17
Q
medications
A
Prescription Over-the-counter (OTC) Vitamins/supplements
Dosage, route, frequency
18
Q
allergies
A
Medication Environmental Food Insects/Animals Describe reaction
19
Q
review of systems
A
includes all systems, not as specific as associated sx > ask if there are any additional problems beyond CC > used to help clarify HPI w/ pertinent positives and negatives Constitutional HEENT: Eyes, Ears, Nose, Throat Cardiac Pulmonary Gastrointestinal Genitourinary Musculoskeletal Neurologic Skin Psychiatric Hematologic
20
Q
initial differential diagnosis
A
-considered after obtaining CC, HPI, ROS (after you obtain
the subjective data)
*typically should be formulated after obtaining history/chief complaint
-use as guide to determine which parts of PE to be performed -> PE used to r/o possible dx
21
Q
comprehensive/full physical exam
A
General Survey Vital signs Skin HEENT Pulmonary Cardiovascular Musculoskeletal
Physical Examination Areas
Neurologic Abdominal Breasts Genitourinary Psychiatric
22
Q
problem-focused physical exam
A
geared more to the complaint and focused on areas in the
differential
> all objective data
23
Q
working differential diagnosis
A
formulated after PE & obtaining objective data
24
Q
assessment & plan
A
developed after determined working differential diagnoses
- consider best interest of pt
ex) cost/insurance
25
vital signs
provide initial critical information regarding the patient
```
hallmarks:
• Blood pressure
• Heart Rate
• Respiratory Rate
• Temperature
```
also includes:
• Height • Weight
• BMI
make sure VS are accurate, repeat manually if abnormal
26
pain
```
• Considered 5th vital sign
• Chronic pain is leading cause of disability and impaired performance
at work
• Has effects on:
• ADL (Activities-of-daily-living)
• Mood
• Sleep
• Work
• Sexual activity
```
27
nociceptive pain
aka somatic pain
-linked to tissue damage of skin, musculoskeletal system or
viscera
-Sensory system in intact
-involved afferent nociceptors can be sensitized by inflammatory mediators
ex) pt w/ arthritis or spinal stenosis
28
neuropathic pain
related to direct effect to somatosensory system
- pain persists beyond healing from the initial injury
- due to PNS causing entrapment or pressure on spinal nerves, plexuses, or peripheral nerves = increased/prolonged response to pain
ex) shingles -> skin intact but painful
ex) spinal cord injury from stroke or trauma
29
psychogenic pain
no obvious factors contributing to pain, cannot be found until everything is ruled out
• Psychiatric conditions
• Personality/coping styles
• Cultural influences
30
idiopathic pain
pain w/ no identifiable etiology
| -cannot be discovered until everything is ruled out
31
pain scale
every pt's threshold of pain is different
- quantify severity of pain as much as possible
* observe if pain scale matches pt's body language & facial expressions
ex) chronic pain pts -> ask staff about behavior prior to your exam
32
attempting to treat pain (4 As)
```
• Analgesia - how to modify pain
• Activities of daily living
• Adverse effects - meds or ADLs that may cause problem
• Aberrant drug-related behaviors
ex) dependence, tolerance buildup
```
33
types of BP cuffs
```
• Sphygmomanometer
-Aneroid
-Electronic
-Hybrid
• Mercury Blood Pressure Cuffs
• Home Blood pressure Monitoring
• Ambulatory Blood Pressure
```
34
when to check BP
after pt has been sitting quietly for 5 minutes
Ideal to have patient avoid exercise, tobacco products and caffeine for
30 minutes prior to measurement
Room should be warm and quiet
-arm is unclothed
35
PE findings and factors that change vascular resistance in arm for BP
- fistula
- scarring
- lymphedema
- incorrect cuff size
36
level of arm when taking BP
brachial artery should be at heart level
| -at elbow, arm should be raised slightly over AC fossa (on medial portion)
37
BP reading when cuff is too small
causes falsely elevated reading
38
BP reading when cuff is too large
causes falsely low reading
39
BP reading when cuff is too loose
causes falsely high reading
40
best indicator for elevated BP readings
ambulatory readings & home BP readings
- better predictors of
cardiovascular disease and end-organ damage
41
venous congestion effect on BP
can cause
falsely low systolic and high diastolic reading due to less audible sounds
ex) from slow or repetitive inflations of the cuff
42
minimum inflation for BP cuff
at least 30mmHg above when systolic pulse disappears
~ at least 200mmHg
-for pt w/ HTN, pump higher
43
Systolic pressure
Level when you hear sound of at least 2 consecutive beats
44
Diastolic pressure
The level when sounds become muffled and disappear
45
5mmHg difference in BP
normal for difference in BP in both arms
46
Pressure differences in arms >10-15 mmHg
suggest pathology
• Subclavian steal syndrome
• Aortic Dissection
• Supra-valvular aortic stenosis
47
Subclavian steal syndrome
artery of pt is not pliable -> causes low BP reading
48
estimation of BP
palpation of systolic pressure
• Find radial pulse
• Inflate cuff until you feel radial pulse disappear
ex) use for pts with pain in arm that cannot handle full pump of cuff
49
auscultatory gap
Silent interval that may be present between systolic and diastolic
pressures
• Can lead to under-estimation of systolic pressure or over-estimation of diastolic pressure
-occurs if the cuff is not pumped up high enough when initially listening for the BP
50
when auscultatory gap is present
Associated with arterial stiffness and atherosclerotic disease
ex) elderly pts w/ HLD, comorbidities, 60+
51
gold standard for
| confirmation of elevated BP
24 hour Ambulatory blood pressure monitoring
| • Limited availability • Insurance coverage is poor
52
statistic for elevated BP readings not confirmed
5-65%
| -must be confirmed by ambulatory & home BP readings
53
diagnosis of HTN
diagnosed after 2 office readings >140/90 on 2 separate occasions
• Home readings >135/85
• Ambulatory automated BP 24 hour average >130/80, or daytime >135/85,
sleep readings >120/70
54
white coat HTN
```
• BP > 140/90 in medical setting
ex) office, clinic, ER
• Ambulatory BP monitoring is < 135/85
• Linked to an anxiety response
• Seen in 20% of patients
• No change in risk of cardiovascular disease
```
55
masked HTN
BP in medical setting <140/90
-appears normal in office or ER
• Elevated daytime ambulatory BP measurements >135/85
• Seen in 10-30% of patients
Associated with increased risk of cardiovascular and end-organ damage
** must be treated **
56
JNC-8 classification for normal BP in adults
< 120/80
57
JNC-8 classification for pre-HTN BP in adults
120 - 139 / 80 - 89
-pt may present as masked HTN
consider risk factors such as smoking and family history
58
JNC-8 classification for stage 1 HTN BP in adults
140 – 159/90 – 99
-if pt > 60 y/o :
150 – 159/90-99
(vascular system changes over time due to elasticity)
59
JNC-8 classification for stage 2 HTN BP in adults
> 160 / > 100
60
evaluate for end-organ damage when
```
.. there is persistent elevation in BP
• Eyes- look for retinopathy changes in fundoscopic exam
• Heart- obtain EKG
• Brain- evaluate MMSE, Neuro exam
• Kidneys- check labs, urinalysis
```
61
contributing factors to low BP readings
- medications
- recent changes to medications
- internal bleeding
62
Normal Orthostatic Blood Pressure Changes
Change in position from laying to sitting to standing have normal changes
- decrease in systolic reading
- decrease in diastolic reading
* * about 5 mmHg change is normal
63
indication of orthostatic hypotension
BP with decreased systolic reading >20 mmHg or decreased diastolic reading of > 10 mmHg
64
causes of orthostatic BP changes
* Drugs
* Blood Loss
* Prolonged Bed rest
* Diseases of autonomic nervous system
65
postural hypotension
a drop of > 20mmHg systolic and > 10mmHg diastolic accompanied by 10-20% increase in HR
66
types of pulses in the body
* Radial pulse
* Brachial Pulse
* Femoral Pulse
* Cardiac apex
* Carotid pulse
67
pulses to assess in peds patients
• Femoral Pulse
since radial pulse is small in babies, this is the first pulse detected in BLE
• Cardiac apex
-L hand side of thorax, lowest part of heart -> mid clavicular line 5th intercostal under L breast
68
normal HR in adults
60-90bpm
69
factors that can alter HR
* Anxiety
* Pain
* medication effect
* cardiac conditions
* pulmonary conditions
* thyroid disease
* anemia
70
effect of anemia on HR
low blood count -> HR increases
| -decreased volume in circulatory system results in heart working faster to move O2 around the body
71
pulse deficit occurs with...
atrial fibrillation
heart failure
detects weak heart contractions
72
peripheral pulses
```
Distal pulses
• Radial pulse
• Posterior tibial
• Dorsalis pedis
Smaller pulse = DP and PT pulses - > habitus varies
```
73
diminished pulses seen in..
patients with arteriosclerotic peripheral vascular
disease, low cardiac output
ex) severe anemia -> decreased periphery = weaker pulse
74
asymmetry of pulses indicates..
coarctation of the aorta or aortic
dissection
• Different in lower extremities compared to the upper extremities
75
bounding pulse
aka Water hammer pulse
-can be seen with aortic
regurgitation or patent ductus arteriosis
> valve has extra amount of blood -> asystole -> stronger push out
76
pulsus alternans
amplitude of pulse alternatives every other beat
| associated with pericardial effusions
77
normal respiratory rate in adults
14 - 20 breaths per minute
| -Occasional sigh is normal
78
when assessing respiratory rate
count for at least 20 seconds
- Assess without informing patient what you are looking for
• Watch chest raise
• Place hand on shoulder and feel for chest wall movement
79
sighing respirations
frequent sighs occurring every other breath
• May be associated with hyperventilation syndrome
• Causes dyspnea and dizzines
80
bradypnea
slow breathing
81
causes of bradypnea
```
• Physiologic
-good fitness level = lower RR & HR
• Diabetic Coma
-elevation of glucose > 500 -> slow HR
• Drug-induced respiratory depression
• Increased intracranial pressure
ex) pt s/p TBI with SAH or SDH causes body to breathe slowe
```
82
tachypnea
• Rapid, shallow breathing
Causes:
• Restrictive lung disease (asthma, COPD)
• Pleuritic chest pain
• Elevated diaphragm
83
Pleuritic chest pain effect on breathing
pt w/ URI and painful cough due to pulling of intercostal muscles = increased respiratory rate
84
elevated diaphragm effect on breathing
diaphragm muscle is paralyzed - > decreased chest wall movement = increased respiratory rate
85
Obstructive Breathing
• Expiration is prolonged due to narrowing of airways that increase
resistance of air flow
Causes:
• Asthma
• Chronic Bronchitis
• COPD
86
hyperpnea/hyperventilation
```
• Rapid, deep breathing
Causes:
• Exercise
• Anxiety
• Metabolic acidosis
• Kidney Failure • DKA
```
87
type of breathing in comatose patient
hyperpnea/hyperventilation
| ex) infarction, hypoxia, hypoglycemia (blood sugar of 40)
88
Cheyne-Stokes Breathing
Period of deep breathing alternating with periods of apnea
```
Causes:
• Normal in children and elderly when sleeping
• Heart failure
• Uremia
• Drug-induced respiratory depression
• Brain damage
```
89
red flag of Cheyne-Stokes breathing
pt using abdomen to breathe
90
Kussmaul’s Respirations
pt is in no respiratory distress that is obvious
- breathing is labored and deeper
* nares/nasal passages are flared
ex) common in pt with DKA
91
ataxic breathing
Unpredictable breathing irregularity
• Breaths may be shallow or deep, with periods of apneas
Causes:
• Respiratory depression
• Brain damage
92
normal temperature
37 degrees C, 98.6 degrees F
93
Celsius to Fahrenheit Formula
(°C * 1.8) + 32 = °F
94
Fahrenheit to Celsius Formula
(°F - 32) / 1.8 = °C
95
fluctuation in temp throughout the day
~1 degree C or 1.8 degree F over the course of a
day
* temp is lower in the morning & higher at night
96
Hyperprexia
> 41.1 degrees C or >106 degrees F (severely abnormal)
97
Hypothermia
< 35 degrees C or <95 degrees F
• Can be associated with decreased movement
ex) pt that is very sedentary or bed bound have lower temps
• Interference with vasoconstriction
• Hypothyroidism
• hypoglycemia
98
gold standard in obtaining temperature
pulmonary artery = most accurate as it is closest to the heart
99
non-invasive temperature checks
* Oral
* Rectal
* Axillary
* Tympanic
* Temporal
100
axillary temperature
obtained in neonates due to need for good seal
101
rectal temperature
most accurate way to obtain temp outside of pulmonary artery
102
differentials associated with fever
* Infection
* Trauma
* Malignancy
* Drug reactions
* Immune disorders
103
vitals for a pt in significant pain from acute trauma
elevated HR
shallow & elevated respirations
-elevated BP
-temp is normal to high
104
fatigue
common symptom of depression and anxiety
*also consider infections: hepatitis, infectious mononucleosis, and tuberculosis
> endocrine disorders: hypothyroidism, adrenal insufficiency, diabetes mellitus)
> heart failure
> chronic disease of the lungs, kidneys, or liver
> electrolyte imbalance
> moderate to severe anemia
> malignancies
> nutritional deficits
> medications
105
Weakness
sx in pt showing demonstrable loss of muscle power
| > If localized in neuroanatomical pattern = neuropathy or myopathy
106
recurrent shaking chills
sx that suggest more extreme swings in temperature and systemic bacteremia
- Feel cold, goosebumps, shivering = rising temp
- Feel hot and sweaty = lowering temp
107
night sweats
occur in tuberculosis and malignancy
108
fever in immunocompromised patients with sepsis
fever may be absent, low-grade, or drop below normal (hypothermia)
109
rapid changes in weight over a few days suggest ...
changes in body fluid, not tissue
110
drugs associated with weight gain
tricyclic antide- pressants; insulin and sulfonylurea; contraceptives, glucocorticoids, and progestational steroids; mirtazapine and paroxetine; gabapentin and valproate; and propranolol
111
causes of weight loss
loss of 5% or more of usual body weight over 6 mo period
- GI diseases
- endocrine disorders (diabetes mellitus, hyperthyroidism, adrenal insufficiency)
- chronic infections, HIV/AIDS;
- malignancy
- chronic cardiac, pulmonar y, or renal failure
- depression
- anorexia nervosa or bulimia
112
weight loss with high food intake
indication of diabetes mellitus, hyperthyroidism, or malabsorption
-Consider also binge eating (bulimia) with clandestine vomiting.
113
risk factors for malnutrition
Poverty, old age, social isolation, physical disability, emotional or mental impairment, lack of teeth, ill-fitting dentures, alcoholism, and drug abuse
114
Four Steps to Promote Optimal Weight and Nutrition
1. Measure BMI – identify risk of overweight and obesity, est other risk factors
2. Assess dietary intake
3. Assess patient motivation to change
4. Provide counseling about nutrition and exercise
Set reasonable goals – realistic weight, helps to lose even 5-10% of their weight (0.5-2 lbs per week)
115
promoting weight loss in patients
```
Realistic diet
Walk 30-60 mins, 5 or more days a week
Total calorie goal
Behavioral change
Pharmacologic tx if conventional does not work
```
116
counseling for pt with low BMI < 18.5
encourage Nutrient dense foods and beverages
| 10 tips to a great plate
117
dietary sodium
half a teaspoon of salt per day for pts with borderline BP
118
obesity can lead to increased risk of
```
heart disease
cancers
type II DM
stroke
arthritis
sleep apnea
infertility
depression
-may also increase death
```
119
calorie deficit goal for weight loss
500-1000 kilocalories/day
| *this is more important than the type of diet
120
behavioral habits for weight loss
portion-controlled meals
meal planning
food diaries
activity records
121
goal of the general survey
describe distinguishing features of the pt so clearly that colleagues can spot pt in a crowd of strangers
-avoid cliches like middle aged man and in no acute distress
122
factors that affect body habitus
```
socioeconomic status
nutrition
genetic make up
physical fitness
modd state
early illnesses
gender
geographic location
age cohort
```
123
features of the skin exam that should be pursued
```
pallor
cyanosis
jaundice
rashes
bruises
mottling of the extremities
```
124
Edema from extravascular fluid retention is visible in patients with...
heart failure
nephrotic syndrome
liver failure
venous stasis
125
Run-down shoes can contribute to..
foot and back pain
calluses
falls
infection
126
copper bracelets suggest...
joint pain in RA
| -folklore remedy with little evidence of effectiveness to alleviate inflammation/pain
127
facial expression in hyperthyroidism
pt exhibits exaggerated stare
128
facial expression in parkinsonism
pt exhibits immobile facies
- "masked"
- pt can also exhibit anxiety, depression, apathy, anger, elation
129
breath odor of acetone or fruity odors
present in diabetic pts (sugary smell)
| -acetone breath -> pt in DKA
130
Decreased eye contact
can be cultural or suggest anxiety, fear, or sadness
131
posture in pt that prefers sitting upright
indication of left-sided heart failure
132
posture in pt that is leaning forward with arms braced
indication of COPD
133
avoidance of movement indicates
pt in pain
134
very short stature present in pts with
- Turner syndrome
- childhood renal failure
- achondroplastic and hypopituitary dwarfism
135
pt's height in hypogonadism and Marfan syndrome
long limbs in proportion to the trunk
136
Cushing syndrome
truncal fat with relatively thin limbs
| -also present in metabolic syndrome
137
if the brachial level is below heart level...
blood pressure reading will be higher
138
if the brachial artery is above heart level...
BP reading will be lower
139
target end organs affected by HTN
eyes- retinopathy
heart- LVH
brain-neuro deficits
kidneys- labs must be done for eval
140
guidelines for selecting correct BP cuff size
width of inflatable bladder of cuff should be ~ 40% of upper arm circumference
-length of cuff should be ~ 80% of upper arm circumference
141
Takayasu arteritis
rare type of vasculitis in which pts are pulseless in limbs
142
causes of hypothermia
```
exposure to cold
> other causes include:
-reduced movement as in paralysis
-interference with vasoconstriction from sepsis or excess alcohol
-starvation
-hypothyroidism
-hypoglycemia
```
143
rapid resp rate can increase...
discrepancy between oral and rectal temperatures -> In these situations, rectal temperatures are more reliable
144
behaviors seen in mood disorders
Compulsions, obsessions, phobias, and anxieties
145
lethargic patients
appear drowsy but open their eyes and look at you, respond to questions, and then fall asleep
146
obtunded patients
slow to respond, somewhat confused
| -patients can still open eyes and look at you
147
movements of depression
slow, hopeless & slumped posture
148
behaviors of agitated depression
crying
pacing
hand wringing
149
behaviors of manic episodes
agitation
| expansive movements
150
one sided neglect in patients is an indication of...
lesion in the opposite parietal cortex, usually the nondominant side
151
behaviors of paranoid patients
anger
hostility
suspiciousness
evasivenes
152
affect of schizophrenic patients
typically flat and remote
| > with manic episodes -> elation and euphoria
153
expressions in patients with dementia
apathy
| -dulled affect with detachment and indifference
154
hallucinations occur in patients with...
schizophrenia
alcohol withdrawal
systemic toxicity
155
dysarthria
defective articulation of words
156
aphasia
disorder of language, testing for aphasia includes
1. word comprehension - ask pt 1 stage command
2. repetition- ask pt to repeat a phrase of one syllable words (ex- "no ifs, ands, or buts") ** most difficult rep task
3. naming- ask pt to name parts of a watch
4. reading comprehension- ask pt to read paragraph aloud
5. writing- ask pt to write a sentence
157
Broca's aphasia
expressive aphasia
-broken, non-fluent speech in which wordcomprehension is intact
-speech is slow, few words, & effort is laborious
impaired features include:
-repetition
-naming (pt still recognizes objects)
-writing
158
Wernicke aphasia
```
receptive aphasia: impaired comprehension with fluent speech
-words are malformed or invented -> speech may be incomprehensible
impaired features include:
-word comprehension
-repetition
-naming
-reading comprehension
-writing
```
159
indications for mental health screening
- medically unexplained physical sx
- multiple physical or somatic sx ("high sx count")
- high severity of presenting somatic symptom
- chronic pain
- sx > 6 weeks
- physician rating as a "difficult encounter"
- recent stress
- low self-rating of overall health
- frequent use of health care services
- substance abuse
160
tangential speech (derailment)
speech with shifting topics that are
loosely connected or unrelated
-pt is unaware of the lack of association
- seen in schizophrenia, manic episodes, and other psychotic disorders
161
neologisms
invented or distorted words
| -words w/ new & highly idiosyncratic meanings
162
circumstantiality
mildest thought disorder
- speech w/ unnecessary detail, indirection, delay in reaching point
- seen in pts with mental disorders
163
Stuperous
Responsive to painful stimuli
