Phys exam and Hx taking (Ch. 1) - Bates Flashcards
What are the 7 components to a comprehensive adult hx?
1) identifying data/source of the hx
2) CC
3) Present illness (HPI)
4) Past hx (PMH)
5) Family hx
6) Personal/Social hx
7) ROS
Meds should include ___, ___, ___, and ___ of use.
name, dose, route, frequency
Allergies must include ___ to the med/food.
reaction
Pack-year is calculated by multiplying the # of ___ times the # of ___ the pt has smoked.
packs, yrs
The ___ hx captures the pt’s personality and interests, sources of support, coping style, strengths, and fears.
social
The ___ comes at the end of the interview and should go from ___-to-___.
ROS, head-to-toe
In the ROS, ___ includes, weakness, fatigue, low energy, wt changes, fever.
general
Thyroid trouble, heat/cold intolerance, excessive sweating, excessive thirst/hunger, and polyuria all fall under what category?
Endocrine
What equipment will you need for a physical exam?
opthalmoscope/otoscope, flashlight/pen light, tongue depressors, thermometer, watch w/second hand, sphygomanomater (b/p), stethoscope, gloves, lubricant for pelvic/rectal exams, vaginal specula (female), reflex hammer, tuning forks, Q-tips/cottonball
Visualize ___ area of the body at a time.
one
The physical exam relies on 4 techniques including:
inspection, palpation, percussion, auscultation
___ precautions include hand hygiene and gloves and deal w/bld, body fluids, secretions, excretions, nonintact skin, mucous membranes.
Standard
___ precautions are used to prevent HIV, hepatitis, and other bld-borne pathogens. Protective barriers include gloves, gowns, aprons, masks, and protective eyewear.
Universal
It’s important to minimize how often you ask the pt to ___ ___.
change positions
Inspect and palpate the ___ ___ ___ on the neck and note any masses or enlgment.
cervical lymph nodes
Pt should be in the ___ position while assessing the abdomen.
supine
When assessing the ___ ___ system includes palpating the femoral pulses, inguinal lymph nodes, inspecting for lower ext edema, and palpate for pitting edema. Also inspect for varicose veins.
peripheral vascular
When assessing the ___ system, note for any deformities or enlged joints and check for ROM. Also inspect the alignment and the spine and ext.
musculoskeletal
When assessing the ___ system, assess lower ext bulk, tone, and strength, assess sensation and reflexes and observe any abnorm mvmts. Also observe the pt’s gait and ability to walk heel-to-toe, walk on the toes, walk on the heels, hop in place, and do shallow knee bends.
nervous/neurological
If you can touch it and reproduce the pain, it’s most likely ___ in origin.
musculoskeletal
