Physical exam Flashcards
A statement in the patient’s own words that describes the reason for the visit is called:
chief complaint (CC)
When documenting a patient’s allergies in a paper record, they are typically written in ___ ink.
red ink
Which type of communication technique is utilized in order to encourage the patient to respond in more detail?
open-ended
Which instrument is used to examine and view the ears?
otoscope
What term defines a physician listening to the patient’s heart or digestive organs?
auscultation
to measure
mensuration
Which word is an electrical recording or graph of the heart?
electrocardiogram
Which position will the patient be placed in for symptoms of shock?
Trendelenburg
A patient comes in for an examination of external hemorrhoids. Which position should the patient be positioned in for this exam?
Sims
A tuning fork is used to check the patient’s auditory acuity and bone vibration, as well as:
diabetic peripheral neuropathy.
questions that provide a guide to the patient’s general health and help detect conditions
Systems review (SR) or review of systems (ROS)
Record of a patient’s demographic information, along with the history, physical examination, and initial lab findings
Database
Subjective findings
symptoms, they are what the patient feels and can be interpreted only by the patient.
Objective findings
signs, They are the indicators of health or disease that a provider detects when examining a patient.
closed questions
ask for specific information. This form of questioning limits the answer to one or two words—in many cases, yes or no.
asks for general information or states the topic to be discussed, but only in general terms.
open ended question
The patient completely rejects the information.
Denial
Rewording or rephrasing a statement to check the meaning and interpretation.
Restatement
Past history (PH) or past medical history (PMH)
A summary of the patient’s previous health.
clarification
actively listening and responding to the pt
Patient sits on the exam table with the head of the table elevated 90 degrees
Fowler position
Supine position
on your back. The patient lies flat with face upward and the lower legs supported by the table extension
The patient lies upward, with the weight distributed primarily to the surface of the back
Dorsal recumbent position
Prone Position
on your belly. The patient lies face down on the table on the ventral surface of the body
Patient is placed on the left side, with left arm and shoulder drawn back behind the body so that the body’s weight is predominantly on the chest
Sims Position
Place the patient on his or her back with the knees sharply flexed and the arms at the sides or folded over the chest. usually used for ladies vaginal exams
Lithotomy Position
This position can be achieved only if the examination table separates so that the legs can be elevated higher than the head
Trendelenburg Position
How to interact with children
-allow to touch stethoscope
-praise for good behavior
-game to distract
What to do for an anxious pt
be calm
How do you correct an error on a paper chart ?
line through the error and initial
How do you correct an error on a Electronic chart?
addendum
Percussion hammer
also called reflex hammer , used to strike the tendons of the knee and elbow to test the neurologic reflexes.
Main reason in the patient’s own words that describes the reason for the visit
Chief complaint
Involves tapping or striking the body
Percussion
Performed with one hand, both hands, or finger, fingertips, or palmar aspect of the hand
Palpation
