Overview of History Taking, Physical Exam, Documentation, and Oral Presentations

Question 1

Something the patient feels or observes themselves. These are discovered by taking a medical history.

Answer 1

symptoms

Question 2

Physical or functional abnormalities found on physical examination

Answer 2

signs

Question 3

__% of the time diagnosis can be based on _____ _____ alone

Answer 3

70% of the time diagnosis can be based on health history alone

Question 4

__% of the time diagnosis can be made when ______ ________ is added

Answer 4

90% of the time diagnosis can be made when physical examination is added

Question 5

Identifies the chief complaint and provides a full, clear, chronological account of the symptoms

Answer 5

HPI

Question 6

Use the patient’s own words to capture their thoughts/feelings about the illness

Answer 6

HPI

Question 7

details that highlight features associated with the chief complaint and your differential diagnoses, that the patient admits having.

Answer 7

pertinent positives

Question 8

details that might be expected based on the chief complaint that the patient denies having

Answer 8

pertinent negatives

Question 9

optimal for inspecting a number of structures such as the jugular venous pulse, the thyroid gland, and the apical impulse of the heart. It casts light across body surfaces that throws contours, elevations, and depressions, whether moving or stationary, into sharper relief

Answer 9

tangential lighting

Question 10

Always palpate the area _______ ______ the location of pain.

Answer 10

Always palpate the area FARTHEST FROM the location of pain.

Question 11

voluntary muscle spasm

Answer 11

guarding

Question 12

___________ of a body part produces a sound that indicates the tissue composition (dependent on air/tissue ratio)– important in chest and abdomen exam

Answer 12

Percussion of a body part produces a sound that indicates the tissue composition (dependent on air/tissue ratio)– important in chest and abdomen exam

Question 13

percussion over a structure with air, high amplitude, low pitch (the lung) – lung resonant to percussion

HOLLOW

Answer 13

resonance

Question 14

percussion over a hollow air-containing structure, high pitch, hollow quality (the stomach) – stomach tympanic to percussion

DRUM-LIKE

Answer 14

tympany

Question 15

sound is between resonance and tympany (children, emphysema)

BOOMING

Answer 15

hyperresonance

Question 16

sound is dull, low amplitude, short duration without resonance (the liver) – liver dull to percussion

THUD-LIKE

Answer 16

dullness

Question 17

very short, high pitched, no air in the tissue (over the arm muscle)

FLAT

Answer 17

flatness

Question 18

firm pressure

detects high pitched sounds

Answer 18

diaphragm

Question 19

Bowel sounds
Normal heart sounds
Lung sounds

Answer 19

diaphragm

Question 20

light pressure

detects low pitched sounds

Answer 20

bell

Question 21

Blood pressure
Abnormal heart sounds
bruits

Answer 21

bell