Patient Encounter Flashcards
What is subjective data?
Involves what the patient tells you, the history
What is objective data?
What you detect during the examination
What is involved in the comprehensive assessment of the adult?
Identifying data and source of history, reliability, chief complaint, HPI, past hx, family hx, personal and social hx, review of systems
What is important to meausure in the general survey of the pt?
Weight and BMI
BMI of obesity class 1
30.0-34.9
BMI of obesity class 2
35.0-39.9
Extreme obesity BMI
> or equal to 40
The risk for heart disease and obesity-related diseases increases significantly if what?
Female waist is 35 in or more and male is 40 in or more
What can breath odors indicate?
Presence of alcohol, acetone (diabetes), pulmonary infections (lung abscess), uremia or liver failure (fetor hepaticus)
What are some examples of posture abnormalities?
Kyphosis, Lordosis, Scoliosis
There is a preference or sitting upright in what?
Left sided heart failure
There is a preference for leaning forward with arms braced in what?
COPD
What are the two most critical portions of a physical exam?
General appearance of patients and the vital signs
What are the 4 vital signs?
BP, heart rate, respiratory rate, temperature
What is the “true blood pressure”
Average blood pressure measured over several office visits or from home over a one week period
Blood pressures should be taken where?
On both arms atleast once
Prehypertension
120-139/80-89
Stage 1 HTN
140-159/90-99
Stage 2 HTN
> 160/>100
Diabetes or renal disease BP
<130/<80
What is more predictive of CVD and end-organ damage?
Home and ambulatory more predictive than conventional office measurements
What is the cut-off for normal home, ambulatory, and office BP?
135/85
White coat HTN
Office blood pressure is high but ambulatory pressures are normal, CVD risk is normal to slightly increased
Masked HTN
Office BP is normal but ambulatory BP is high, indicating high risk of CVD
Nocturnal HTN
Physiologic BP dip which occurs at night
A nocturnal fall of what is associated with poor CV outcomes?
<10% of daytime values
Where should the arm be positioned when taking BP?
At heart level
Width of the inflatable bladder should be about __% of arm circumference
40
Length of the inflatable bladder should be about __% of the arm circumference
80
How far away from the antecubital crease should the BP cuff be
2.5 cm
Auscultatory gap
A silent interval that may be present between the systolic and diastolic pressures
Pressure differences of more than 10-15 mmHg in each arm mean what?
Subclavian steal syndrome and aortic dissection
HTN in upper extremities and low BP in legs
Coarctation of the aorta and occlusive aortic disease
If the cuff is too small…
BP will read high
If the cuff is too big on a small arm..
BP will read low
If the cuff is too big on a big arm..
BP will read high
The average oral temperature
37 degrees C
Rectal temperatures are typically
Higher by an average of 0.4 to 0.5 C
Axillary temperatures are typically
Lower than oral by approximately 1 degree C, considered less accurate than other measurements
What core temp is most reliable?
Rectal
Oral temperatures is not recommended when?
When pts are unconscious, restless, or unable to close their mouths
What is pain called when found on a physical exam?
Tenderness
What are the 4 classic techniques of physical exam
- Inspection
- Palpation
- Percussion
- Auscultation
What is percussion used for?
Utilized to evoke a sound wave such as resonance or dullness from the underlying tissue or organs
What are bruits?
Turbulent sounds that can be auscultated over arterial vessels
What side is preferred to exam the patients from?
Patients right side is standard
Comprehensive assessment
For pts your seeing for the fist time, includes all elements of the health hx and complete physical exam
Focused or problem oriented assessment
Routine care or pts with specific urgent care concerns
What is important to do when preparing for physical exams?
Most important: check the equipment ahead of time
What are the 3 general goals of a physical exam?
- Maximize pts comfort
- Avoid unnecessary changes in postion
- Enhance clinical efficiency
Major function of the skin
Keep body in homeostasis
Central cyanosis
Low level of oxygen in the arterial blood, very ominous
Peripheral cyanosis
When cutaneous blood flow decreases and slows, can be a normal response to anxiety or cold environments
Approximately __ of melanomas are initially detected by the patient
50%
The average pt has how many moles?
15-30
What are some common types of moles or nevi?
Junctional, Intradermal, or Compound
Mobility
How easily the skin lifts up
Turgor
How quickly the skin returns into place
