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Patient Assessment > PA exam 1 > Flashcards

PA exam 1 Flashcards

1
Q

Define DDX

A

A list of possible diagnoses from which we must eliminate all other possibilities.

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2
Q

What is the single most important part of patient visit?

A

The history. 80% of the diagnosis

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3
Q

Subjective portion

A

Information we obtain from the patient (the history)

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4
Q

Objective Portion

A

Information we obtain through our own observations (that are reproducible)

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5
Q

Assessment portion

A

DDx or final diagnosis

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6
Q

Plan portion

A

What we will order to help us make the diagnosis or what we will do to tx the pt.

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7
Q

Comprehensive history

A

includes everything

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8
Q

Focused history

A

specific problem based history

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9
Q

Outline of the SOAP note

A

Identifying data
S: (CC) (HPI)(PMH-current med illnesses, allergies, meds, surgical hx, acc/injuries, childhood illnesses, immunizations, habits, psych, OBGYN)(Fam Hx)(Soc HX)(ROS)
O: Physical Exam
A: DDX, and assessment
P: Plan, Tx, orders for additional labs etc.

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10
Q

What do we include in the identifying data?

A

Name, Age, DOB, Hospital/chart no

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11
Q

Chief complaint

A

Part of S: primary reason a pt is seeking medical attention Stated in the patient’s own words

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12
Q

First sentence of the HPI

A

Age of pt, gender of pt, restatement of CC and duration of CC (chronologically)

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13
Q

S: (HPI)

A

elaboration of the chief complaint, the Sacred 7,

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14
Q

S: (PMH)

A 
focuses on the general current (and past) health of the pt.  should include:
Current med problems
allergies
meds
pysch illnesses
childhood illnesses
Prior surgeries/hospitalizations/accidents/injuries
Immunizations
OBGYN
Habits (PMH not social hx)
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15
Q

S: (FH)

A

Age and health of immediate blood relatives, (M, F, Sib, Ch)

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16
Q

S: (Soc hx)

A

Occupation, marital status, Habits (some include here but I do not), psych (can be here or PMH), Sexual Hx (can be here or PMH)

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17
Q

S: (ROS)

A

laudry list of common symptoms organized by organ system.

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18
Q

O: (PE)

A

Physical exam

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19
Q

O: Labs/Xray

A

if available at the time the pt presents they go in O, if ordering they go in P

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20
Q

A:

A

DDX/ the results of tests being ordered

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21
Q

What is the difference between a sign and a symptom

A

A symptom is what the patient tells you, a sign is what you observe that is reproducible

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22
Q

Sign or Symptom? Headache

A

symptom

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23
Q

Sign or symptom? Chest pain

A

symptom

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24
Q

Sign or symptom? Itching

A

symptom

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25
Q

Sign or symptom? Heart murmur

A

Sign

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26
Q

Sign or symptom? Nausea

A

symptom

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27
Q

Sign or symptom? Diarrhea

A

symptom (at least we hope so)

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28
Q

Sign or symptom? double vision

A

Symptom and sign (on exam we can support this)

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29
Q

Sign or symptom? Dizziness

A

Symptom

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30
Q

Sign or symptom? erythematous TM

A

Sign

31
Q

Sign or symptom? Temperature of 102

A

Sign and symptom (the pt can tell you they took it at home and you can see by taking their temp.)

32
Q

Sign or symptom? Weight loss

A

Sign and symptom

33
Q

Sign or symptom? Wheezing

A

sign and symptom

34
Q

The sacred seven

A

S: (HPI)-
Location-Where is the pain?
Quality-sharp, dull, aching, continuous
Quantity (or intensity)-scale of 0-10
Chronology (or duration)-when did it first start, how long has it been going on, better worse or the same?
Setting-what were you doing when it started?
Aggravating (or alleviating factors)-anything make it worse or better?
Associated manifestations-Weight loss, swelling, loss of appetite?

35
Q

Levine sign

A

closed fist on chest description might include MI

36
Q

Medical illnesses should include any hx of….

A

DM, Hypertension, CA, MI, CV DZ, Respiratory, Osteoporosis,

37
Q

Allergies

A

Either NKA (if none at all), NKDA (if no drug allergies but something else) MAKE SURE TO INCLUDE WHAT HAPPENS IF THEY ARE EXPOSED TO THE ALLERGEN

38
Q

CAGE

A

C: have you ever felt you should Cut down on your drinking?
A: Have people Annoyed you about your drinking?
G: Have you ever felt Guilty about your drinking?
E: Have you ever had an Eye opener (first drink in AM)
total score of 2 or higher is considered clinically significant

39
Q

T/F You should include all lab results, X-ray results, CT or MRI results in your Assessment?

A

F-results of labs, CT MRI etc should go in OBJECTIVE data!

40
Q

What is the basis of information for the assessment part of the SOAP note

A

subjective data in the HPI and objective data in physical exam (lab and X-ray results) are used to make the DDX or Dx which goes in the Assessment part of the note

41
Q

What are the important pt issues in the PE

A

Equipment-make sure it’s available and working
Environment-comfortable and private
Identify-yourself and role (last name is PA-S)
Respect-pt’s privacy and modesty at all times
Wash your hands!!!-in fromt of the pt.

42
Q

Which statement about ophthalmic exam is correct?
A. you should always use your right eye to examine the pt’s left eye and your left eye to examine the pt’s right eye.
B. You should always examine the pt’s eye with your dominant eye.
C. You should always use our Right eye to examine the patient’s right eye, and your left eye to examine the pt’s left eye.

A

C. you should always examine the pt’s left eye with your left and right with your right
This way you are not bumping noses and “kissing” the pt when you examine them

43
Q

General survey of the pt should include….

A 
Body language of the pt
Apparent age vs. pt's stated age
overall appearance (robust, emaciated)
Overt signs of distress or dz
Obvious deformities (amputations blindness kyphosis)
Person hygeine
Posture/gait
Level of consciousness
Ht., Wt., VS (temp, BP, HR, Resp, Pain),
44
Q

T/F rectal temps are about 0.5 degrees lower than oral

A

F-Rectal temps are about 0.5 degrees higher than oral

45
Q

What will a cuff that is too small give you for a BP

A

A falsely high BP

46
Q

What will a cuff that is too large give you for a BP

A

A falsely low BP

47
Q

What are the first sounds you hear when you release the pressure on the cuff and what do they represent?

A

Korotkoff sounds - represent the systolic pressure

48
Q

What does the last sound you hear when taking a BP indicate?

A

Diastolic pressur

49
Q

What does NB on a BP stand for

A

noto bene-NB when the beats don’t quit! instead it is where the sound became muffled or changed in tone

50
Q

Parameters for BP normal reading

A

Ideal BP is 120/80, systolic should be <80

51
Q

How do you classify a orthostatic hypotension?

A

difference of 20mmHg lower systolic from lying flat to standing, or a 10mm lower diastolic

52
Q

T/F pain is subjective?

A

T. Pain is subjective. Tenderness is objective

53
Q

What is the ROS

A

review of systems, a systemic approach to the symptoms that may uncover dz. Should be called the review of symptoms :)

54
Q

If you uncover information relevant to the pt’s CC where does that info get recorded?

A

HPI-not the ROS

55
Q

Systemic components of ROS

A

General, skin, HEENT, Neck, breasts, respiratory, CV, GI, GU, Peripheral Vascular, Musculoskeletal, Neuro, Heme, endocrine, psych

56
Q

O: (ROS) (General)

A

Usual state of health, Fever, chills, night sweats, weight changes, fatigue

57
Q

When our temperature is rising we feel ______

A

Cold

58
Q

When our temperature is falling we feel ______

A

Hot

59
Q

What is temp regulated by?

A

The hypothalamus

60
Q

T/F for ROS you should always write negative responses first?

A

F You should always list positive responses first

61
Q

What percentage of malpractice law suits are based on poor communication skills?

A

85%

62
Q

According to the text what are the two central components of doctor-patient interaction

A

Art of speaking, and Active listening

63
Q

mnemonic for working with interpreters

A 
I-introduction
N-Note goals
T-transparency
E-ethics
R-respect beliefs
P-patient focus
R-retain control
E-explain
T-thanks
64
Q

What is Schwartz’s “rule of 5 vowels?”

A

Audition-listening carefully
Evaluation-sorting relevant/irrelevant
Inquiry-probing into significant areas to obtain clarification
Observation-Nonverbal communication regardless of what is said
Understanding-concerns and apprehension of pt in order to be more empathetic

65
Q

What is proxemics?

A

The technical term for personal space

66
Q

When was HIPAA enacted?

A

1996

67
Q

What is an open ended question?

A

A question that cannot simply be answered with a yes/no.

68
Q

What are the four basic principles of PE

A

Inspection, Palpation, Percussion, Auscultation

69
Q

According to the text, in examining the skin of a pt. the examiner must…

A
  1. Identify the primary lesion
  2. Identify it’s distribution
  3. Identify any associated findings
  4. Consider the age of the pt.
70
Q

CC: ear pain, Pt tells you that they are also having some throat pain Where does this belong?

A

(S) (HPI)-under the sacred 7-associated manifestations

71
Q

CC: Ear pain, on exam you notice the pt has a red TM, where does this belong?

A

(O)(HEENT)

72
Q

CC: Nausea. When asked the pt states he does have a history of Upper back pain as well

A

(S)(PMH)(Med illnesses)

73
Q

CC: Bilateral ankle swelling. Pt tells you he takes a daily multivitamin and nothing else.

A

(PMH)(Med list)

74
Q

CC: Bilateral ankle swelling. Pt states that he is allergic to peanuts, when he eats them his throat swells up and he can’t breathe.

A

(PMH)(Allergies)

Patient Assessment (1 decks)

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