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Didactic Year > Patient Assessment 1 > Flashcards

Patient Assessment 1 Flashcards

1
Q

Clinician centered care

A

“The balance of power was centered on the preferences and values of the doctor” reflects
-“find the broken part and fix it”

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2
Q

The biopsychosocial model reflects

A

The complex interaction of biological, psychological and social factors. Not
just bio and medical

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3
Q

Pioneer of patient centered care

A

Harvey picker
“improving healthcare through the patient’s eyes”

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4
Q

Patient centered care

A

Patients want their clinicians to see them as individuals, to understand their concerns, emotions and challenges

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5
Q

Relationship centered care

A

“An expansion of patient centered care”

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6
Q

What is incorporated in relationship centered care?

A

-The relationship between caregivers and patients/families
-relationship among members of the healthcare team
-caregiver’s relationship with one’s self

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7
Q

General steps of patient assessment

A

Preparation
Health history
Physical exam
Assessment
Plan
Documentation/presentation

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8
Q

What are you doing during the preparation for a patient encounter?

A

Review the patient’s name and chief concern
Review past and current medical history
Gather tools
PPE/precautions?
Interpreter?
HIPPA

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9
Q

Components of taking an adult patient’s health history

A

Patient identifiers
Source/reliability
Chief concern
HPI
PMH
SH
FH
ROS

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10
Q

What is a learned skill that requires practice, like any other clinical skill?

A

Medical interview

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11
Q

Two main goals for the medical interview

A

Establish a meaningful and caring relationship with your patient
Be a rigorous diagnostician

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12
Q

How accurate were medical internists at making the correct diagnosis after history only

A

75%

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13
Q

Allowing patients to tell their symptom story is diagnostically helpful, because it will allow us to arrive

A

At the correct diagnosis more often and more quickly

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14
Q

“Listen to the patient. He is telling you the diagnosis” quote by

A

Sir William Osler

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15
Q

The sole use of clinician centered interviewing results in poor

A

Patient satisfaction, physician frustration, and worse health outcomes

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16
Q

Open ended skills are aimed at

A

Getting the patient to tell their story in their own words in a way they want

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17
Q

Examples of non-focusing open ended skills

A

Silence
neutral utterances
Nonverbal encouragement

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18
Q

Focusing open ended skills

A

Echoes
Paraphrasing
Requests

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19
Q

Components of NURS

A

N-name the emotion
U-understanding
R-respect
S-support

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20
Q

Difference between empathy and compassion

A

Empathy = capacity to share/resonate others’ emotional state, suffering, or joy
Compassion = Not “sharing” of suffering, but rather feelings of warmth, concern, and care for the other

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21
Q

Respecting the emotion

A

“thanks for sharing this with me”

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22
Q

Step one, also called

A

Setting the stage

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23
Q

“Small talk before big talk”

A

Stage 1

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24
Q

What % of our communication to others is nonverbal?

A

80%

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25
Q

Examples of positive non verbal communication

A

Forward lean
Eye contact
Uncrossed arms and legs
Nod
Sit level with patient

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26
Q

Chief concern and agenda, step

A

2

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27
Q

Open ended non focusing, step

A

3, just listen!

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28
Q

How long does it take for a physician to interrupt a patient with traditional clinician centered interview?

A

Less than 30 seconds

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29
Q

Focusing the story, obtaining emotional and personal context, step

A

4

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30
Q

What step do we use NURS in?

A

Step 4

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31
Q

Summarize and transition, step

A

5

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32
Q

What are closed ended data gathering skills?

A

Questions that produce yes/no answers
Or
Questions that produce brief answers

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33
Q

A symptom is objective or subjective

A

Subjective
(Ex. Nausea, headache)

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34
Q

A sign is objective or subjective

A

Objective
(Ex. Murmur, perforated TM)

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35
Q

Where are signs identified in the interview?

A

Physical exam

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36
Q

How many systems are there?

A

19

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37
Q

7 symptom descriptors

A

Onset/chronology
Position/radiation
Quality
Quantification
Related symptoms
Setting
Transforming factors

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38
Q

Expand/clarify HPI, step

A

6

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39
Q

“Pertinent positives and negatives” will be uncovered in which step

A

6

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40
Q

Past medical history, step

A

7

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41
Q

Components of PMHx

A

Adult illnesses
Childhood illnesses
Medications
Allergies
Health maintenance

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42
Q

Social history, step

A

8

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43
Q

Review of system, step

A

10

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44
Q

End of interview, step

A

11

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45
Q

SOAP meaning

A

Subjective, objective, assessment, plan

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46
Q

Health history is mostly covered in the ________ and ___________

A

HPI, ROS

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47
Q

Common concerns/symptoms

A

Fatigue
Weakness
Fever, chills, night sweats
Weight change
Pain

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48
Q

Emphasizes physical, psychological, and emotional safety for patients and providers

A

Informed care

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49
Q

Draping and modesty applies to ________ care

A

Informed

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50
Q

What kind of language do we want to use with patients?

A

Simple, not medical

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51
Q

The general survey begins when

A

Any time the patient is in your view

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52
Q

General survey

A

“Study the whole person, covering the general health state and any obvious physical characteristics”

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53
Q

When does the general survey take place in relation to the interview?

A

Before

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54
Q

What are you looking for in the general survey?

A

Apparent state of health
LOC
Signs of distress
Skin color
Grooming, hygiene
Facial expressions
Odor
Body structure, gait, posture

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55
Q

Low grade fever

A

99-100.4

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56
Q

High fever

A

> 103

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57
Q

Extremely high fever

A

> 104

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58
Q

Normal temperature

A

97.8-99

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59
Q

Normal HR

A

60-100

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60
Q

Aside from rate, what else are we assessing with pulse?

A

Rhythm

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61
Q

Abnormal RR could be evident by

A

Prolonged expiration phase

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62
Q

Auscultatory office blood pressure pros and cons

A

Common, cheap
Subject to patient anxiety, observer technique, cuff recalibration

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63
Q

Ambulatory blood pressure monitoring

A

Automated: clinical and research “gold standard”
Average of 24 hr blood pressures
More expensive, may not be covered

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64
Q

Hypertension definition for office manual or automated

A

140/90

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65
Q

Hypertension definition home automated blood pressure

A

<135/85

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66
Q

Hypertension definition ambulatory 24 hr avg? Daytime? Nighttime?

A

> 130/80
135/85
120/70

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67
Q

White coat hypertension

A

A phenomenon in which patients exhibit elevated blood pressure in the hospital or doctor’s office but not in their everyday lives

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68
Q

Masked hypertension

A

Low clinic blood pressure, but elevated ambulatory/home blood pressure

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69
Q

Nocturnal hypertension

A

Nocturnal fall of <10% of daytime values is associated with poor cardiovascular outcomes and can only be identified on 24 hour ambulatory bp monitoring

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70
Q

Width of cuff should be about _____ % upper arm circumference

A

40

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71
Q

Pre-measurement BP reading steps for accuracy

A

-avoid caffeine, smoking, exercise for 30 mins prior
-sits for 5 mins prior
-arm free of clothing
-arm roughly at heart level

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72
Q

Nociceptive pain

A

Somatic

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73
Q

Neuropathic pain

A

Pain from damage to neurons of either the peripheral or central nervous system “burning”

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74
Q

Central sensitization pain

A

Alteration of the CNS processing of sensation amplifying signals
Ex. Fibromyalgia

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75
Q

Psychogenic pain

A

Physical cause for pain cannot be identified (common)

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76
Q

Idiopathic pain

A

Chronic pain in the absence of an identifiable physical or psychological cause or pain perceived as excessive for the extent of an organic pathological condition

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77
Q

Four As of pain monitoring

A

Analgesia
ADLs
Adverse effects
Abberant drug related behaviors

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78
Q

Is MRI ioninzing or non-ionizing?

A

Non-ionizing

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79
Q

How does MRI work?

A

Strong, static magnetic field of radiofrequency energy used to excite free protons (located mainly in water) to a higher energy state

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80
Q

Indications for MRI

A

Soft tissues! (Amongst other things)

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81
Q

Limitations of MRI

A

Size restrictions
Time, availability
Presence of ferrous materials
Pacemaker
Cost

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82
Q

Is ultrasound non-ionizing or ionizing?

A

Non-ionizing

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83
Q

How does ultrasound work?

A

Imaging is made possible by the transmission and return of sound waves of high frequency

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84
Q

With ultrasound, which structures are dark and which are light

A

Fluid, blood = black
Bone = white
Organs = various shades of gray

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85
Q

Anechoic

A

Fluid filled area void of any material

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86
Q

Hypoechoic

A

A darker area compared to surrounding tissue

87
Q

Hyperechoic

A

A brighter area compared to surrounding tissue

88
Q

Fanning

A

Tilting the probe while maintaining some position on skin

89
Q

Acoustic shadow

A

Area on the screen void of ultrasound return due to an overlying obstructive structure

90
Q

Color flow doppler

A

Used in assessing direction of blood flow (Ex. Cardiac ultrasound)

91
Q

Indications for ultrasound

A

Point of care: ocular, lung, soft tissue, vascular access, thorax-abdominal trauma

Gallbladder: stones
Pelvic: uterus, ovaries, fetus
Cardiac: wall motion, valves, effusion
Renal: obstruction
Neurologic: nerve blocks

92
Q

Advantages of ultrasound

A

No radiation
Real-time motion images
Procedural assistance

93
Q

Disadvantages of ultrasound

A

Body habits restrictions
Availability
Interpretation dependent on radiologist/sonographer abilities

94
Q

Nuclear medicine assesses for

A

Physiology not morphology

95
Q

Indications for nuclear medicine

A

Lung: V/Q scan (PE)
Liver: HIDA scan (gallbladder obstruction)
Bone: bone scan
Thyroid: Radioactive iodine uptake
Heart: Myocardial perfusion scintigraphy
PET: Cancer work-ups

96
Q

Advantages of nuclear medicine

A

Cancer treatment
Head-to-toe scanning
Organ function assessment
Less radiation

97
Q

Disadvantages of nuclear medicine

A

Small exposure to ionizing radiation
Potential for allergic reactions
Availability

98
Q

Electrocardiogram

A

Record of the electrical activity of the heart

99
Q

How does x-ray work?

A

Exposure of silver bromide and silver iodide to x-rays causes deposition of metallic silver, which appears darker on film

100
Q

Standard x-rays are referred to as

A

Plain films

101
Q

Digital radiography

A

Uses electronic sensors rather than silver sheets to measure attenuation coefficient of tissue through which x-rays have been passed through.
Data then processed into images on monitor.

102
Q

Fluoroscopy

A

Uses plates covered with phosphor which fluoresces when exposed to x-rays (cardiac Cath)

103
Q

On x-ray, high density structures are ______, while air appears ________

A

Radiopaque, black

104
Q

What is the preferred CXR view?

A

PA view

105
Q

Where is the plate placed in the PA view?

A

Over anterior aspect

106
Q

Contrast studies, mostly used for which systems

A

GI, GU, vascular

107
Q

What is a downside to contrast studies?

A

Reactions
Minor: n/v, flushing
Moderate to severe: pulmonary edema, bronchospasm, apnea

108
Q

What can we do to prevent severe reactions in contrast studies?

A

Prophylax with steroids or benadryl

109
Q

What are plain films good for?

A

Skeletal: Fx, alinements
Chest: mass,fluid, air
ABD: air, stool
Soft tissue neck: soft tissue swelling, air/gas, patency

110
Q

What are plain films not too good for?

A

Ligament/cartilage
Head injury
Non-radiopaque foreign bodies

111
Q

How does a CT scan work?

A

Highly restricted x-ray beams move 360 around desired area

112
Q

Is CT ionizining or non-ionizing?

A

Ionizing

113
Q

CT indications

A

IV and PO contrast
CT angiography
Renal function

114
Q

What is a CT less useful for?

A

Intracranial pathology
Spinal/nerve
Muscle
Cartilage, ligament
Pregnant or pediatric patient

115
Q

No increase risk of cancer below _____ rads

A

5

116
Q

What are some questions you should be asking in the history for the dermatology patient?

A

Why now?
Where did it start?
Does it migrate?
Have you had this before?
Any recent contacts who had something similar?
Associated symptoms?
Medications?
New products?

117
Q

Dermatofibroma

A

Benign fibrous tumor of the skin

118
Q

Keloid

A

Hypertrophic scar, elevated beyond site of original injury

119
Q

Purpura

A

Subdermal bruising

120
Q

Factors that influence severity of burns

A

Rate of heat transfer
Thickness of affected skin
Temperature
Duration of exposure

121
Q

Deep partial thickness

A

Blisters, painful to pressure only
Easily unroofed, waxy

122
Q

Full thickness

A

Not painful
Leathery
May not blanch

123
Q

Moderate burn injury can be treated in what setting

A

Hospital admission, but not burn center

124
Q

Management of thermal burns

A

Cooling
Pain management
Fluid management
Airway
Cleaning/debriding
Dressings
Infection
Tetanus prophylaxis
Referral

125
Q

Avoid examining the ______ and then returning to the ______

A

Feet or pubic area
Face

126
Q

It is conventional for the examiner to be on the patient’s ________ side

A

Right

127
Q

Four cornerstones of the physical exam

A

Inspection
Palpation
Percussion
Auscultation

128
Q

The bell of the stethoscope is best for ______ pitched sounds

A

High

129
Q

The diaphragm of the stethoscope is best for _______

A

Low

130
Q

OLDCARTS

A

Onset
Location
Duration
Character/quality
Associated symptoms
Radiation
Timing
Severity

131
Q

Flesh colored

A

No change from surrounding normal skin

132
Q

Battle’s sign

A

Bruising behind the ears, indicative of a basilar skull fracture

133
Q

Raccoon eyes

A

Bruising around the eyes (indicates skull fracture)

134
Q

What viral etiologies could cause enlargement of the salivary glands?

A

Mumps (parotitis)

135
Q

What bacterial etiologies could cause enlargement of the salivary glands?

A

Acute parotitis
Tuberculosis
Actinomycosis

136
Q

What pulse site do you want to check on the head?

A

Temporal

137
Q

Name the lymph nodes of the head and neck

A

Preauricular
Post auricular
Occipital
Tonsillar
Superficial cervical
Submandibular
Submental
Deep cervical chain
Posterior cervical chain
Supraclavicular

138
Q

What do lymph nodes do?

A

Act as fighters against foreign invasion of bacteria, viruses, cancer cells or toxins

139
Q

Lymphocytes originate from

A

Stem cells

140
Q

Amorosus Fugax

A

Can’t see out of one eye

141
Q

Seat belt sign

A

Can indicate injury to great vessels

142
Q

Ligature marks

A

Indicates strangulation or use of restraints

143
Q

Possible cause for tracheal deviation?

A

Pneumothorax

144
Q

Enlarged supraclavicular node indicative of

A

Advancing gastric cancer
(Virchow’s node)

145
Q

Enlarged pre-auricular associated with

A

Otitis externa

146
Q

Enlarged posterior cervical with sore throat may indicate

A

Mono (EBV)

147
Q

Enlarged epitrochlear node may be early indication of

A

HIV

148
Q

Two approaches to thyroid exam

A

Anterior
Posterior

149
Q

If thyroid is enlarged, you should

A

Auscultate for the presence of a bruit

150
Q

What should you always do before palpating carotid artery?

A

Auscultate! (Exception to the rules)

151
Q

You should palpate carotid pulse at what 3 locations

A

Base
Cricoid level
Mandible

152
Q

CMS

A

Centers for Medicare and Medicaid Services

153
Q

Two components to billing

A

MDM (medical decision making)
Time

154
Q

4 categories of Medical Decision Making

A

Straightforward
Low
Moderate
High

155
Q

HPI is more for _______ visits

A

acute

156
Q

When documenting physical exams, pick either ________ or __________

A

Body areas
or
Organ systems

157
Q

RVU

A

Relative value unit

158
Q

Medicare fraud

A

Providing false information to claim medical reimbursements beyond the scope of payment for actual healthcare services rendered

159
Q

Medicare abuse

A

Describes practices that, either directly or indirectly, result in unnecessary costs to the Medicare program

160
Q

Both fraud and abuse can expose providers to ______ and ________ liability

A

Criminal
Civil

161
Q

The patient’s record is a

A

Legal document

162
Q

The medical record establishes your _______ as a health care provider

A

Credibility

163
Q

Levels of E/M services are based on 4 levels of history

A

Problem focused
Expanded problem focused
Detailed
Comprehensive

164
Q

When does comprehensive typically apply?

A

1st time seeing patient
Inpatient admissions

165
Q

Orders should go under the ______ portion of your SOAP note

A

Plan

166
Q

Problem list:

A

Running list of active, remote, or resolved medical complaints that the patient has been evaluated for in office

167
Q

Gravida

A

G - number of pregnancies

168
Q

Para

A

Births delivered after 20 weeks (viable or non viable) includes multiples

169
Q

Documentation of OB history usually follows short term notation of

A

G-P-A

170
Q

LNMP

A

Last normal menstrual period

171
Q

CAGE questions in context of

A

Alcohol abuse

172
Q

How many systems should be reviewed according to Dr. Geralds?

A

14

173
Q

Assessment aka

A

Differential diagnoses

174
Q

Plan divided into 5 sections

A
  1. Diagnostics
  2. Therapeutics
  3. Patient education
  4. Consents/referrals
  5. Disposition plan
175
Q

Alliance=

A

Compliance!

176
Q

Four steps to a DDx

A
  1. Acquire data
  2. Identify key features
  3. Develop problem list
  4. Create DDx
177
Q

Flourescein stain

A

Pattern of dendrites associated with herpes zoster opthalmicus

178
Q

Gradual hearing loss could be a ______ etiology

A

Viral

179
Q

Sudden hearing loss could be a _______ etiology

A

Vascular or autoimmune

180
Q

Patient will complain of ______ in sensorineural hearing loss

A

People mumbling
Noisy rooms make it worse

181
Q

Ramsey hunt syndrome

A

Herpes Zoster oticus

182
Q

Tinnitus associated with hearing loss, think

A

Meneire’s disease

183
Q

If popping sounds in ear, think

A

TMJ

184
Q

Dizziness while seated=

A

Arrhythmia

185
Q

Dizziness while just moving head

A

Labyrinthitis

186
Q

Dizziness that is worse with movement =

A

Benign positional vertigo

187
Q

Losing balance sensation

A

CVA

188
Q

Dizziness at rest

A

Ménière’s disease

189
Q

Dix-Hallpike maneuver

A

Rapidly moving the PT from a sitting position to the supine position with the head turned 45 degrees to the right = for benign positional vertigo

190
Q

Whisper test is testing which CN

A

CN 8

191
Q

Weber test is testing

A

Lateralization

192
Q

Normal Rinne test

A

Air condition greater than bone conduction

193
Q

What technique should we use on pediatrics for otoscopic exam?

A

Pull down and back

194
Q

Pneumatic otoscope tests for

A

Ability of TM to move
If limited movement = could be fluid/infection etc

195
Q

______ is the most frequent cause of colds

A

Rhinovirus

196
Q

Hutchinson’s sign

A

Tip of nose affected by zoster and usually indicates ocular involvement

197
Q

You must use a _______ when inspecting the nose and mouth

A

Light

198
Q

What can you do to the sinuses to assess for fluid/infection?

A

Percuss
Transillumination

199
Q

Lips observe

A

Color and moisture
Symmetry
Edema

200
Q

Can candidal thrush be scraped off

A

Yes

201
Q

Aphthous ulcers

A

“Canker sores”
Small painful round ulcers in the oral mucosa of unknown cause

202
Q

Trismus

A

Inability to open the jaw, can be associated with peritonsillar abscess

203
Q

Ludwig’s angina

A

Submandibular space infection
Most serious complication is edema of the glottis
Airway compromise can occur

204
Q

Strep throat swab sensitivity

A

90-95%

205
Q

EBV IGG and IGM is more or less sensitive than mono-spot

A

More

206
Q

Sinusitis imaging indications

A

Limited to atypical presentations or treatment failures

207
Q

Soft tissue neck x-ray indications

A

Epiglottitis
Retropharyngeal abscess
Ludwig’s angina
Foreign body
Croup

208
Q

Normal prevertebral measurements

A

<6 mm at C2
<22 mm at C6

209
Q

Flexible laryngoscopy

A

Allows for visualization of airway using a small camera

210
Q

Flexible laryngoscopy indications of

A

GERD, dysphagia
Stridor
Hoarseness
Inhaled foreign object

211
Q

Barium swallow is a type of

A

Contrast fluoroscopy

212
Q

Indications for barium swallow

A

Choking
Dysphagia
Aspiration
Hiatal hernia
GERD
Enlarged veins, tumors, polyps

213
Q

Test for determining the clarity and sensitivity of hearing

A

Audiometry

214
Q

Indications for audiometry

A

Routine adolescent screening
Reported hearing deficit
Screening for high risk pt’s

Didactic Year (24 decks)

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