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Physical Diagnosis > PD3- Midterm > Flashcards

PD3- Midterm Flashcards

1
Q 
goals of pt documentation:
provide ? thru accurate doc
capture ? of pt illness/improve security levels
assure appropriate ? to institutions 
justify ? consumed
assure appropriate ?
A 
quality of care
severity
comparisons
hospital resources
reimbursement
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2
Q

comorbid cond is secondary dx when:

  • pt receives ? at time of admission
  • list under ?
  • do not use ?
  • develops subsequent to?
  • affects ? and/or ?
A 
Tx
PMH of H&P
has a history of
hospital admission
tx received/LOS
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3
Q

for dictation you must write a ? in pt chart

A

short note

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4
Q

admissions discharges and operative notes- can report via?

A

dictation

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5
Q

? must be countersigned with in 24h

A

admission orders

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6
Q

admission orders - mneumonic?

A 
adc vaandilm
admit to
dx
condition
vitals
activities
allergies
nursing orders
diet
iv
labs
meds
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7
Q

condition - 2 statuses?

A

condition

code

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8
Q

vitals
every hr on ?
do NOT write
freq of ? status assessment

A

unstable pt
per nursing order
neuro

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9
Q

don’t write ? orders

A

STAT

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10
Q

include ? under assessment of admission H&P

A

risk factors

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11
Q

each DRG is give a ?

1.0 = lump sum ?

A 
relative weight (RW)
$4500
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12
Q

discharge note similar to a ?

A

daily progress note

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13
Q

discharge orders- MUST indicate that pt is ?

A

being discharged

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14
Q

discharge SUMMARY is a ? that summarizes pt’s ? hospital stay/ complete w/in ?

A

SEPARATE, entire

30D of discharge

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15
Q

complete h&p, nfo on labs, tests, assessment & plan ?

A

admission NOTE

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16
Q

adc vaandilm?

A

admission ORDER

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17
Q

SOAP note, specify all discharge info and instructions in plan

A

discharge NOTE

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18
Q

medical order to discharge pt to where and with whom, discontinuation orders

A

discharge ORDERS

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19
Q

written form or dictation summarizing pts hospital stay, w/in 30 days

A

discharge SUMMARY

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20
Q

acute abdomen w/out pain

A

geriatrics
diabetes
steroids

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21
Q

capsular swelling- type of ?

A

pain

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22
Q 
pain
gripping?
dull, aching?
crampy, contricting?
biliary usually starts as?
A

intestinal obstruction
pyelonephritis
biliary or renal colic
epigastric

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23
Q

pain after eating- possible ? of and viscera

A

vascular dz

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24
Q

green vomit- obstruction distal to ?

A

ampulla of vater

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25
Q

periodic peritonitis in?

A

familial mediteranean fever

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26
Q

malabsorption syndrome?

A

CF, celiacs

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27
Q

aganglionic megacolon

A

hirschsprungs dz

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28
Q

liver 4-8cm at ?
6-12cm at?
hepatomeg when percussed ? below costal margin?

A

midsternal line
midclavicular line
2-3cm

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29
Q

f/e of cervical spine?

lateral flexion?

A

70 degrees

50 degrees

30
Q

right shoulder pain? 3

A

GB dz, peptic ulcer, liver abscess/tumor

31
Q

in alley’s (shoulder) document level of ?

A

thoracic vertebra reached

32
Q

cross chest/horizontal adduction test for ?

A

ac joint impingement

33
Q

arm extended and forearm supinated w/ elbow slightly flexed, resists shoulder forward flexion

A

speeds test- biceps tendonitis

34
Q 
thoracic outlet syn test?
head rotated to face tested shoulder
extend and laterall rotate head 
examiner extends pt shoulder
pt takes a deep breath and pos = ?
A

adson maneuver

loss of radial pulse

35
Q

anterior and superior dislocation of radial head

A

nursemaid’s elbow

36
Q

test this by resisting wrist flexion and pronation?

A

golfer’s elbow

37
Q

hoffman’s dz tested via ? ; tests ? tendons

A

finkelsteins; APL,EPB

38
Q

pt makes fist, hcp pressing radial and ulnar artery and releases one at a time; delay/ absence of flushing = ?

A

allen test

partial/complete occlusion

39
Q

inflammation of flexor tendon and synovial sheath, finger catches as it extends

A

trigger finger

40
Q

avulsion of flexor tendon of 4/5 finger

A

jersey finger

41
Q

collaterals of knee

A

apley’s distraction

42
Q

neuromata of knee

A

tinel’s sign

43
Q

ballottment- tapping/clicking, patella ‘floats’ outward when pressure released = ?

A

effusion

44
Q

lachman’s pulls tibia anteriorly and stabilizes femus; lax its of ? indicates ?

A

> 5cm, ACL injury

45
Q

thickening on posterosuperior aspect of calcaneus?

A

pump bump - Haglund’s deformity

46
Q

flexion deformity of PIP joints toes 2-5; causes hyperextension of MTP

A

hammertoes

47
Q

hyperextension of MTP joint of great toe w/ possible tearing of flexor tendon?

A

turf toe

48
Q

geri pt may be lucid but ?

A

disoriented

49
Q

~4+ dz in 70% greater than?

A

65

50
Q

ADLs- primary responsibility?

A

promoting safety

51
Q

polypharmacy- 13% US population but takes almost ? of all meds Rx

A

30%

52
Q

to prevent poly pharm, ? is key!

A

communication

53
Q

refusal or failure to provide elderly person with life necessities i.e. food water, comfort, safety, etc

A

elder neglect

also abandonment, financial or material exploitation

54
Q

decubitus ulcer- final common p/w? irreversible changes in ?

A

ischemia, 2 hrs uninterrupted pressure

55
Q

prevent decubitus ulcers- pressures less than ?

A

30 mm Hg

56
Q

leading cause of institutionalization in elderly

A

urinary incontinence

57
Q

goal of palliative care?

A

best QOL

58
Q

high rates of depression in ? and ? geri pts

A

dementia, PD

59
Q

psychotherapy ? in geri depression

A

underutilized

60
Q

associated with sig medical and psych morbidity

A

grief

61
Q

MCC of suicide in geri

A

physical illness

lost loved one

62
Q

collaborative
person centered form
elicits and strengthens motivation for change?

A

motivational interviewing

63
Q 
MI:
express ?
support?
roll with ?
develop ?
A

empathy
self-efficacy
resistance
discrepancy

64
Q

key to lifestyle changes?

A

motivation

65
Q

4 concepts in adult learning

  1. selfconcept moves from ? to ?
  2. use ? as a resource for learning
  3. motivation is influenced by ?
  4. ? of knowledge
A

dependency»>self-direction
life experience
societal roles
immediate application

66
Q

colorectal ca study- pt perception of working well with dr- ?

A

commitment skills and relationship

67
Q

SEGUE framework can also be used as ?

A

assessment tool

68
Q

improved outcomes in smoking cessation and pos results in obesity counseling?

A

5 As

69
Q 
5 As
? risk
? change
? and collaborate on set goals
? in addressing challenge
? for f/u
A 
assess
advise
agree
assist
arrange
70
Q

in adult edu, HCP doesn’t consider?

A

lifespan development

Physical Diagnosis (4 decks)

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