Module 3 Patient Intake and Vitals P1 Flashcards
What are vital signs?
metrics used to evaluate a patient’s overall health
What is something that you need to do and obtain during every office visit?
Obtain vital signs
Perform measurements (Height, weight)
Review pain scale
What is a chief complaint?
is the primary reason for visiting the office. It is subjective info documented in the patient’s MR in their own words.
What is medication reconciliation?
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.
What is the difference between subjective and objective information?
objective information is info that can be measured and observed whereas subjective info is what the patient says and cant be measured
What are the two section of a patient’s health record and what do they include?
Administrative section;
patient demographics
financial/ insurance info
Clinical section:
past medical history, social, occupational, family
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:
- past illnesses or surgeries
- diet, exercise, caffeine intake smoking, lifestyle, etc.
- illnesses or diseases relevant to the current family
- past injuries both work and non work- related.
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?
you should document “patient refused to answer” in their medical record
What is the purpose of a mental health screening?
assess a patient’s safety and mental status. EX- depression screening
What is a PHQ-Z and what is it used for?
it is a patient health questionnaire that focuses on patient frequency of depressed mood throughout two weeks
What are some common symptoms of depression?
difculoity sleeping, staying asleep, or getting up in the morning.
profound sadness/ fatigue
change in appetite and loss of energy
what is anxiety and some common symptoms?
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.
What is Blood pressure a measure of and what are the units used to measure bp?
measures force of blood circulating through arteries. Units are MM Hg.
What is the equipment used to measure blood pressure?
sphygomomanometer
stethscope
What is auscultation
is the process of listening with a stethoscope to the sounds of the body
What is systolic pressure and what is diaystolic pressure?
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
What are Korotkoff sounds?
distinct sounds that are heard throughout the cardiac cycle
Describe the four phases of the Korotkoff cycle?
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
How is Bp taken and what are some common errors/
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
Where should a patient’s arm be positioned during a bp procedure?
arm should be resting on a table as the same level as their heart
What effects Bp?
age, internal conditions, external environments, genetics, etc.
What are factors that influence bp and cause hypertension: abnormally high bp)
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
