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History and Physical 1 > Patient Encounter > Flashcards

Patient Encounter Flashcards

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1
Q

What is subjective data?

A

Involves what the patient tells you, the history

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2
Q

What is objective data?

A

What you detect during the examination

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3
Q

What is involved in the comprehensive assessment of the adult?

A

Identifying data and source of history, reliability, chief complaint, HPI, past hx, family hx, personal and social hx, review of systems

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4
Q

What is important to meausure in the general survey of the pt?

A

Weight and BMI

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5
Q

BMI of obesity class 1

A

30.0-34.9

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6
Q

BMI of obesity class 2

A

35.0-39.9

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7
Q

Extreme obesity BMI

A

> or equal to 40

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8
Q

The risk for heart disease and obesity-related diseases increases significantly if what?

A

Female waist is 35 in or more and male is 40 in or more

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9
Q

What can breath odors indicate?

A

Presence of alcohol, acetone (diabetes), pulmonary infections (lung abscess), uremia or liver failure (fetor hepaticus)

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10
Q

What are some examples of posture abnormalities?

A

Kyphosis, Lordosis, Scoliosis

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11
Q

There is a preference or sitting upright in what?

A

Left sided heart failure

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12
Q

There is a preference for leaning forward with arms braced in what?

A

COPD

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13
Q

What are the two most critical portions of a physical exam?

A

General appearance of patients and the vital signs

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14
Q

What are the 4 vital signs?

A

BP, heart rate, respiratory rate, temperature

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15
Q

What is the “true blood pressure”

A

Average blood pressure measured over several office visits or from home over a one week period

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16
Q

Blood pressures should be taken where?

A

On both arms atleast once

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17
Q

Prehypertension

A

120-139/80-89

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18
Q

Stage 1 HTN

A

140-159/90-99

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19
Q

Stage 2 HTN

A

> 160/>100

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20
Q

Diabetes or renal disease BP

A

<130/<80

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21
Q

What is more predictive of CVD and end-organ damage?

A

Home and ambulatory more predictive than conventional office measurements

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22
Q

What is the cut-off for normal home, ambulatory, and office BP?

A

135/85

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23
Q

White coat HTN

A

Office blood pressure is high but ambulatory pressures are normal, CVD risk is normal to slightly increased

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24
Q

Masked HTN

A

Office BP is normal but ambulatory BP is high, indicating high risk of CVD

25
Q

Nocturnal HTN

A

Physiologic BP dip which occurs at night

26
Q

A nocturnal fall of what is associated with poor CV outcomes?

A

<10% of daytime values

27
Q

Where should the arm be positioned when taking BP?

A

At heart level

28
Q

Width of the inflatable bladder should be about __% of arm circumference

A

40

29
Q

Length of the inflatable bladder should be about __% of the arm circumference

A

80

30
Q

How far away from the antecubital crease should the BP cuff be

A

2.5 cm

31
Q

Auscultatory gap

A

A silent interval that may be present between the systolic and diastolic pressures

32
Q

Pressure differences of more than 10-15 mmHg in each arm mean what?

A

Subclavian steal syndrome and aortic dissection

33
Q

HTN in upper extremities and low BP in legs

A

Coarctation of the aorta and occlusive aortic disease

34
Q

If the cuff is too small…

A

BP will read high

35
Q

If the cuff is too big on a small arm..

A

BP will read low

36
Q

If the cuff is too big on a big arm..

A

BP will read high

37
Q

The average oral temperature

A

37 degrees C

38
Q

Rectal temperatures are typically

A

Higher by an average of 0.4 to 0.5 C

39
Q

Axillary temperatures are typically

A

Lower than oral by approximately 1 degree C, considered less accurate than other measurements

40
Q

What core temp is most reliable?

A

Rectal

41
Q

Oral temperatures is not recommended when?

A

When pts are unconscious, restless, or unable to close their mouths

42
Q

What is pain called when found on a physical exam?

A

Tenderness

43
Q

What are the 4 classic techniques of physical exam

A
  1. Inspection
  2. Palpation
  3. Percussion
  4. Auscultation
44
Q

What is percussion used for?

A

Utilized to evoke a sound wave such as resonance or dullness from the underlying tissue or organs

45
Q

What are bruits?

A

Turbulent sounds that can be auscultated over arterial vessels

46
Q

What side is preferred to exam the patients from?

A

Patients right side is standard

47
Q

Comprehensive assessment

A

For pts your seeing for the fist time, includes all elements of the health hx and complete physical exam

48
Q

Focused or problem oriented assessment

A

Routine care or pts with specific urgent care concerns

49
Q

What is important to do when preparing for physical exams?

A

Most important: check the equipment ahead of time

50
Q

What are the 3 general goals of a physical exam?

A
  1. Maximize pts comfort
  2. Avoid unnecessary changes in postion
  3. Enhance clinical efficiency
51
Q

Major function of the skin

A

Keep body in homeostasis

52
Q

Central cyanosis

A

Low level of oxygen in the arterial blood, very ominous

53
Q

Peripheral cyanosis

A

When cutaneous blood flow decreases and slows, can be a normal response to anxiety or cold environments

54
Q

Approximately __ of melanomas are initially detected by the patient

A

50%

55
Q

The average pt has how many moles?

A

15-30

56
Q

What are some common types of moles or nevi?

A

Junctional, Intradermal, or Compound

57
Q

Mobility

A

How easily the skin lifts up

58
Q

Turgor

A

How quickly the skin returns into place

History and Physical 1 (6 decks)

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