Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

Advanced Health Assessment > Module 2: Physical Exam > Flashcards

Module 2: Physical Exam Flashcards

Module 2: 1. Demonstrate communication skills to collect an organized and patient history for both focused and comprehensive examinations. 2. Record the patient history in a problem-oriented format. 3. Develop an initial problem list based on history.

1
Q

All data is either ________ or _________.

A

Subjective, Objective

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

What is subjective?

A

What the patient tells you.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

What is objective?

A

What you observe.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

What is included with subjective data?

A

CC, HPI, ROS, PSFH

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

What is included with objective data?

A

What is in the chart and what you find out in the physical exam.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

What is the chief complaint?

A

This is what the patient states. It contains the concern and duration. IN THEIR OWN WORDS.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

HPI?

A

This is what the patient tells you and what you ask the patients. (OLDCARTS, PQRST)
It has both the pertinent positive and negatives.
It helps you to verify the Diagnosis and to exclude the Differentials

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

What is in the ROS?

A

The past history organized by systems
Complete ROS only done on new patients!
Focused done on acute or chronic focused visits-
Should contribute to the differentials or the DX
Should include both pertinent positives and negatives

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

PSFH should include?

A 
Hospitalizations 
Current Medications
Allergies
Alcohol, drugs, tobacco
Diet, exercise, leisure 
Sexual activity and preferences
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

Family History?

A

Home situation and significant others
Religious/ Cultural practices
Family Health History

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

What should be the main focus in the episodic encounter and contribute to the potential diagnosis and the differential diagnosis?

A

Chief Complaint.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

How much of the diagnosis is within the history?

A

90%

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

CC+HPI+PSFH+PE & DX Testing =

A

Correct Diagnosis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

What is the correct sequence when performing PE?

A

Inspection, Palpation, Ausculation, Percussion

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

What is PE best practice?

A

Tell what you see not what you do not see, be specific, paint a picture

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Words to not use include?

A

Normal, Good, Strong, Nice

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

When ever you have a chance to grade a finding try to use it. Which findings can be graded?

A

Pulses, tonsils, DTR’s all have standard grading scales.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

HISTORY OF PRESENT ILLNESS
PQRST
What does the P stand for?

A

PROVOCATIVE OR PALLIATIVE - What
causes the symptom? What makes it better
or worse? Question examples: What were you
doing when you first experienced or noticed the
symptom? What seems to trigger it? What
relieves the symptom? What makes the symptom
worse?

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

HPI
PQRST
What does the Q stand for?

A

QUALITY OR QUANTITY - How does the
symptom feel, look, or sound? How much
of it are you experiencing? How would you
describe the symptom? How much are you
experiencing? Is it so much that it prevents you
from performing any activities?

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

HPI
PQRST
What does the R stand for?

A

REGION OR RADIATION - Where is the

symptom located? Does it spread?

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

HPI
PQRST
What does the S stand for?

A

SEVERITY SCALE - How does the symptom
rate on a severity scale of 1 to 10, with 10
being the most extreme?

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

HPI
PQRST
What does the T stand for?

A

TIMING - When did the symptom begin?
How often does it occur? Is it sudden or
gradual?

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

How will you get the differential diagnosis?

A

To get to your differential diagnosis, you will need to combine your Subjective data (history) with your Objective data (physical findings and laboratory reports) to then form your assessment of what the problem for the patient happens to be. This will give you your diagnoses. Forming the diagnoses will require you to make judgments about the situation.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

_______ ________ _________ involves the application of the practitioner’s knowledge and skills to identify and distinguish normal from abnormal findings.

A

Basic Health Assessment

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Q

_______ _________ builds on basic health assessment yet is performed more often using an inductive or inferential process, that is, moving from a specific physical finding or patient concern to a more general diagnosis or possible diagnoses based on history, physical findings, and lab/diagnostic tests.

A

Advanced Assessment

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
26
Q

_______ _________ is a scientific process in which the practitioner suspects the cause of a patient/s symptoms and signs based on previous knowledge, gathers relevant information, selects necessary tests, and recommends therapy.

A

Diagnostic Reasoning

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
27
Q

What 5 things are accomplished with diagnostic reasoning?

A
  1. Determines and focuses on what needs to be asked and what needs to be examined.2. Performs examinations and diagnostic tests accurately.3. Clusters abnormal findings.4. Analyzes and interprets the findings.5. Develops a list of likely or differential diagnoses.
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
28
Q

What does the process of assessment start with?

A

The patient stating a reason for the visit or chief concern

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
29
Q

What is demographic information?

A

gender, age, occupation, and place of residence

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
30
Q

What can routine vital sign info include?

A

height, weight, temperature, pulse, respiratory rate, blood pressure, last menstrual period, and smoking status.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
31
Q

One useful mnemonic for gathering information for symptom analysis is COLDSPA. What do the letters represent?

A

COLDSPA:Character- How does it feel, look, smell?Onset- When did it start?Location- Be specific- Where is it? Does it radiate?Duration- How long does it last? Does it recur?Severity- How do they rate the pain?Pattern- What makes it better? Worse? Does anything help?Associated factors- What other symptoms do you have? How much does it interfere with your activities?

32
Q

Another mnemonic is OLDCARTS, What do the letters represent?

A

OLDCARTS:OnsetLocationDurationCharacterAggravating/associated factorsRelieving factorsTemporal factors: severity.

33
Q

What is subjective data?

A

What the patient tells you

34
Q

What is objective data?

A

What you detect during the examination

35
Q

What are the sections of the adult health history?

A

Identifying dataReliabilityChief ComplaintPresent illnessPast HistoryFamily historyPersonal and social historyReview of systemsSee Bates page 7 for details

36
Q

How do you prepare for the physical examination?

A
  1. Reflect on your approach with the patient.2. Adjust the lighting and the environment.3. Make the patient comfortable.4. Check your equipment.5. Choose the sequence of the examination/
37
Q

On bates page 17 there is a physical examination suggested sequence.

A

review to help the assessment flow

38
Q

What is the cardinal techniques of examination?

A

Inspection, Palpation, Percussion, and Auscultation

39
Q

Tips for ensuring the quality of patient data

A
  1. Ask open ended questions and listen carefully and patiently to the patient’s story.2.Craft a thorough and systematic sequence to history taking and physical examination.3. Keep an open mind toward both the patient and the data.4.Always include “the worst-case scenario” in your list of possible explanations of the patient’s problem, and make sure it can be safely eliminated.5. Analyze any mistakes in data collection or interpretation.6 Confer with colleagues and review the pertinent medical literature to clarify uncertainties.Apply principles of data analysis to patient information and testing.
40
Q

What is reliability?

A

Indicates how well pepeated measurements of the same relatively stable phenomenon will give the same result, also known as precision. Reliability may be measured fo one oberver or for more than one observer. (like measuring liver border dullness, edema, heart sounds, etc)

41
Q

What is validity?

A

Indicates how closely a given observation agrees with “the true state of affairs” or the best possible measure of reality.(mercury BPs < valid then intra-arterial pressure tracings)

42
Q

What is sensitivity?

A

Identifies the proportion of people who test positive in a group of people known to that the disease or condition, or the proportion of people who are TRUE positives compared with the total number of people who actually have the disease. When the observation or test is negative in people with the disease, the result is termed FALSE negative.(good observations or tests have a sensitivity of greater than 90%)

43
Q

What is Specificity?

A

Identifies the proportion of people who test negative in a group of people known to be WITHOUT a given disease or condition, or the proportion of people who are “true negatives” compared with the total number of people without the disease. Then the observation or test is positive in people without the dease the result is termed false positive.. Good observations or tests have a specificity of more than 90% and help “rule in” disease because the test is rarely positive when disease is absent, and there are few false positives.

44
Q

SnNout

A

When the SeNsitivity of a symptom or sigh is high, a Negative response rules OUT the target disorder.

45
Q

SpPin

A

When the SPecificity is high, a Positive test result rules IN the target disorder.

46
Q

What is predictive value?

A

Indicates how well a given symptom, sign, or test result- either positive or negative predicts the presence or absence of disease.

47
Q

What is Positive predictive value?

A

It is the probability of disease in a patient with a positive (abnormal) test, or the proportion of “true positives” out of the total population tested.

48
Q

What is negative predictive value?

A

It is the probability of not having the condition or disease when the test is negative, or normal, or the proportion of “true negatives” out of the total population tested.

49
Q

What is the formula for Sensitivity?

A

Sensitivity= a/ a+c x 100 True positive observations (a)/ total persons with the disease (a+c) x 100= sensitivity percent Bates page 46

50
Q

What is the formula for specificity?

A

Specificity= d/b+dTrue negative observations (d) / total persons with the disease (b+d) x 100= specificity percentbates page 46

51
Q

Positive predictive value

A

Positive predictive value+ a/ a+btrue positives (a)/ total postives (a+b) x 100bates page 46

52
Q

Negative predictive value

A

Negative predictive value= d/c+dtrue negative observations (d)/ total negative observations (c+d) x100bates page 46

53
Q

What is the Likelihood Ratio?

A

Conveys the odds that a finding occurs in a patient with the condition compared to a patient without the condition. When the LR is greater than 1.0 the probability of the condition goes up; when the LR is less than 1.0 the probability of the condition goes down.

54
Q

What is the formula for likelihood ratio

A

A positive LR= sensitivity/(1-specificity)A negative LR= specificity/ (1-sensitivity)see Bates page 49 for more detail

55
Q

What is the kappa measurement of inter observer agreement?

A

Measures the degree of observer agreement, or precision, of a clinical finding compared to agreement by chance alone, similar to a correlation coefficient.

56
Q

What are the conventional levels of Kappa (k)?

A

0.0-0.2=slight agreement0.2-0.4= fair agreement0.4-0.6= moderate agreement0.8-1.0= substantial agreement

57
Q

Learning about the Patient: The sequence of the interview

A

Greeting the patient and establishing rapportEstablishing the agenda for the interview.Inviting the patient’s storyIdentifying and responding to emotional cuesExpanding and clarifying the patient’s storyGenerating and testing diagnostic hypothesesCreating a shared understanding of the problemNegotiating a planPlanning for follow-up

58
Q

What are the seven attributes of a symptom?

A
  1. Location, 2. Quality, 3. Quantity or severity, 4. Timing, 5. Setting in which it occurs, 6. Remitting or exacerbating factors, 7. Associated manifestations
59
Q

OPQRST mnemonic for discovering the seven attributes of a symptom

A

OPQRSTOnsetPalliating/Provoking gactorsQUalityRadiationSite TIming

60
Q

Exploring the Patient’s perspective: FIFE

A

Feelings, Ideas effect on Function, and Expections.

61
Q

The techniques of skilled interviewing. Review starting on page 69 any you don’t understand.

A

Active listening, guided questions, nonverbal communication, empathic responses, validation, reassurance, partnering, summarization, transitions, and empowering the patient.

62
Q

How to do guided questioning.

A

Start with open-ended questions and move to focused, Using questioning that elicits a grades response, Ask a series of questions (one at a time), Offer multiple choices for answers, encourage patient to clarify answers, encourage with continuers, and use echoingBates page 71

63
Q

Guidelines for sensitive topics.

A
  1. Do not judge2. Explain why you need to know.3. Find opening questions for sensitive topics and learn the specific kinds of information needed for your assessment. 4. Consciously acknowledge the discomfort you are feeling and don’t avoid topics just because they make you uncomfortable.
64
Q

The CAGE questions for alcohol

A

Have you ever felt the need to CUT down on drinking?Have you ever felt Annoyed by criticism of your drinking?Have you ever felt Guilty about drinking?Have you ever taken a drink first thing in the morning (Eye-openers) to steady your nerves or get rid of a hangover?CAGE=Cutting down, Annoyance, Guilt, and Eye-openers.

65
Q

The three dimensions of cultural humility:

A
  1. Self awareness- learn about your own biases2. Respectful communication, work to eliminate assumptions about what is “normal”. Learn directly from your patients- they are experts on their culture and illness.3. Collaborative partnerships- build your patient relationships on respect and mutually acceptable plans.
66
Q

Building blocks of professional ethics in patient care:

A

Nonmaleficence or primum non nocere, beneficence, Autonomy, and confidentiality

67
Q

What is Nonmaleficence or primum non nocere?

A

It is commonly stated as, “first, do no harm”. In the interview giving false information or avoiding topics can do harm.

68
Q

What is beneficence?

A

It is the dictum that the clinician needs to “do good” for the patient. As clinicians, your actions need to be motivated by what is in the patient’s best interest.

69
Q

What is Autonomy?

A

Reminds us that patients have the right to determine what is in their own best interest.

70
Q

What is confidentiality?

A

This can be one of the most challenging principles. As a clinician, you are obligated to not repeat what you learn from or know about a patient. They choose who stays during interviews and always ask.

71
Q

What are the Tavistock principles?

A

The tavistock principles is a guideline that provides ethical principles for guiding health care. The first document came in 1998 when a group met at the Tavistock Square in London.

72
Q

List some of the Tavistock principles:

A

Rights: People have a right to health and health care.Balance: care of the individual patient is central, but the health of the population is also a concern.Comprehensiveness: in addition to treating illness, we have an obligation to ease suffering, minimize disability, prevent disease, and promote health. Cooperation: health care succeeds only is we cooperate with those we serve, each other, and those in other sectors.Improvement: Improving health care is a serious and continuing responsibility.Safety: Do no harmOpenness: being open, honest, and trustworthy is vital in health care.

73
Q

What is the most significant variable in narrowing the probabilities of a problem?

A

Age

74
Q

What is the goal of a clinical decision?

A

To choose an action that most likely results in the health outcomes the patient desires.

75
Q

What is the goal for a novice practitioner?

A

To aim for competence and expertise!

76
Q

When should you perform a comprehensive assessment?

A

When you are seeing a patient for the first time in the office or hospital. This will include all the elements of a health history and the complete physical exam.

77
Q

When should you perform a problem oriented or focused exam?

A

When you see patients that you know very well who are returning for routine office follow up care or for patients with specific “urgent care” concerns like sore throat or knee pain.

Advanced Health Assessment (12 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions