Module 3 Patient Intake and Vitals P1

Question 1

What are vital signs?

Answer 1

metrics used to evaluate a patient’s overall health

Question 2

What is something that you need to do and obtain during every office visit?

Answer 2

Obtain vital signs
Perform measurements (Height, weight)
Review pain scale

Question 3

What is a chief complaint?

Answer 3

is the primary reason for visiting the office. It is subjective info documented in the patient’s MR in their own words.

Question 4

What is medication reconciliation?

Answer 4

it is when a ma compares a patient’s list of meds to the MR as a safety measure to reduce risk of prescribing wrong medications.

Question 5

What is the difference between subjective and objective information?

Answer 5

objective information is info that can be measured and observed whereas subjective info is what the patient says and cant be measured

Question 6

What are the two section of a patient’s health record and what do they include?

Answer 6

Administrative section;
patient demographics
financial/ insurance info
Clinical section:
past medical history, social, occupational, family

Question 7

Describe what is found in each subpart of the clinical section of a patient’s MR?
1. Medical History:
2. Social History:
3. Family:
4. Occupational:

Answer 7

1. past illnesses or surgeries
2. diet, exercise, caffeine intake smoking, lifestyle, etc.
3. illnesses or diseases relevant to the current family
4. past injuries both work and non work- related.

Question 8

What should you do if you ask a patient about their tobacco/ alcohol/ drug use to be able to provide them with greater care and they refuse to answer?

Answer 8

you should document “patient refused to answer” in their medical record

Question 9

What is the purpose of a mental health screening?

Answer 9

assess a patient’s safety and mental status. EX- depression screening

Question 10

What is a PHQ-Z and what is it used for?

Answer 10

it is a patient health questionnaire that focuses on patient frequency of depressed mood throughout two weeks

Question 11

What are some common symptoms of depression?

Answer 11

difculoity sleeping, staying asleep, or getting up in the morning.
profound sadness/ fatigue
change in appetite and loss of energy

Question 12

what is anxiety and some common symptoms?

Answer 12

a common response to perhaps fear. Symptoms include:
Heightened ability to observe or make connections
difficulty focusing
a sense of panic
irritability feeling
cold/ sweaty
shortness of breath
heart palpations, whether skipped, irregular, or extra beat.

Question 13

What is Blood pressure a measure of and what are the units used to measure bp?

Answer 13

measures force of blood circulating through arteries. Units are MM Hg.

Question 14

What is the equipment used to measure blood pressure?

Answer 14

sphygomomanometer
stethscope

Question 15

What is auscultation

Answer 15

is the process of listening with a stethoscope to the sounds of the body

Question 16

What is systolic pressure and what is diaystolic pressure?

Answer 16

systolic pressure is the first phase of the kotkoff sounds and it is recorded whne th e first tapping sound is heared.
Diaystolic pressure is the last phase and is recorded when the last sound appears

Question 17

What are Korotkoff sounds?

Answer 17

distinct sounds that are heard throughout the cardiac cycle

Question 18

Describe the four phases of the Korotkoff cycle?

Answer 18

phase 1- loud, with a clear-cut snapping tone
Phase 2- sounds have a murmur-like quality
Phase 3- sounds are similar in character to phase I sounds;
Phase 4- sounds have a dull or fading away tone

Question 19

How is Bp taken and what are some common errors/

Answer 19

Bp is taken in a sitting position, common errors include:
using wrong cuff size- can impact both S and D by 6-9 mm hg
Patients crossing their legs- the S may be raised by 2-8 mm hg
postioning of arm- arm above heart level= reading lowered. Arm belw right atrium= reading elevated

Question 20

Where should a patient’s arm be positioned during a bp procedure?

Answer 20

arm should be resting on a table as the same level as their heart

Question 21

What effects Bp?

Answer 21

age, internal conditions, external environments, genetics, etc.

Question 22

What are factors that influence bp and cause hypertension: abnormally high bp)

Answer 22

increase in blood volume= increase in bp and opposite is true
peripheral resistance= when the tube of the blood veins become smaller making it harder to pump blood through the vessels= bp goes up
overall conditon of the heart muscles
overworked and weakened heart muscles= high bp