Pt assessment vocabulary Flashcards
1
Q
Chief Complaint
A
reason why the pt has sought medical attention in their words.
2
Q
medical history
A
history of present illness (HPI)- most important
Past Medical History (PMH)
3
Q
OPQRST
A
onset provocation quality region or radiation severity (pain scale 0-10) timing (duration of complaint)
4
Q
SAMPLE
A
S/S allergies medications/ compliance pertinent medical history last oral intake and out events leading up to event
5
Q
CAGE
A
Concerned- about ETOH intake
Annoyed- if asked
Guilt- because of drinking
Eye opener- need the drinks to start the day
6
Q
Asking about Current Health Status
A
medications they are on allergies tobacco use ETOH diet screening test sleep patterns exercise environmental hazards safety measures
7
Q
What is public distance?
A
> 12 ft
8
Q
what is social distance
A
6-12 ft
9
Q
personal distance?
A
1.5-4 ft
10
Q
intimate distance?
A
0-1.5ft
11
Q
what is an open ended question?
A
do not require a yes or a no
12
Q
what is a direct question?
A
can be answered yes or no
13
Q
leading question?
A
avoid these, they lead the pt into answering a certain way, or in a response that you are looking for.
14
Q
facilitated question?
A
using questions or phrases that allow the pt to continue to talk about a particular concern
15
Q
what is reflection?
A
its a way to give a feed back loop by repeating part of what they said to show understanding.
16
Q
what are somethings you should avoid doing in asking a pt a question?
A
avoid patronizing terms using slang or medical terms they may not understand using derogatory terms "drunk" giving false assurances stereotyping
17
Q
what is HPI
A
history of present illness
18
Q
what is PMH
A
past medical history
19
Q
eyes (anisocoria)
A
difference in pupil sizes
20
Q
what is photosensitivity?
A
sensitive to light
21
Q
what is nystagmus?
A
a twitch or abnormal eye movement when following an object
22
Q
parts of the ear are?
A
helix - top
tragus- the middle
lobe- bottom
23
Q
bruits sound? where can you listen for it?
A
its a build up of plaque, it can be heard on the carotids
24
Q
Rhonchi
A
effects the large airway, the bronchus (COPD, pneumonia)
fluid accumulation
25
wheeze
effect the bronchus, trapping air (its a narrowing of the bronchi)
26
total lung volume is?
6L
27
rub
sound results from the movement of inflamed and roughened pleural surfaces against one another during movement of the chest wall.
28
crackles
fluid in the lower lobes of the lung
29
Rales
these there lower airway (the alveoli having fluid in the,)
30
Hemianopsias
loss of vision in half of your visual field of one eye or both eyes
31
Scotomata
a partial loss of vision or blind spot in an otherwise normal visual field.
32
Pleurisy
is a condition in which the pleura — two large, thin layers of tissue that separate your lungs from your chest wall — becomes inflamed
33
Hemoptysis
Hemoptysis is the spitting of blood that originated in the lungs or bronchial tubes
34
tuberculosis
caused by a bacterium called Mycobacterium tuberculosis. The bacteria usually attack the lungs, but TB bacteria can attack any part of the body such as the kidney, spine, and brain. Not everyone infected with TB bacteria becomes sick.
35
Goiter
an abnormal enlargement of your thyroid gland.
36
Dysphagia
Dysphagia is the medical term for swallowing difficulties.
37
Regurgitation
the action of bringing swallowed food up again to the mouth.
38
Hematemesis
the vomiting of blood
39
Nocturia
Nocturia is a condition in which you wake up during the night because you have to urinate
40
gravidity
number of pregnancies a woman has had
41
Para
Para is the number of completed pregnancies beyond 20 weeks gestation
42
Paresthesia
Paresthesia refers to a burning or prickling sensation
43
Hemophilia
Hemophilia is usually an inherited bleeding disorder in which the blood does not clot properly
44
People who they call pink puffer are what type of respiratory problems?
emphysema
- These pts it takes a large amount of energy to expel air from their alveoli that have been broken down. they purse their lips to try and expel the air.
45
The Blue bloaters are what type of respiratory problems?
chronic bronchitis.
- swelling and inflammation of the bronchioles
- They retain more CO2 and have generally lower SpO2
46
Eupnea
normal breathing
47
Tachypnea
fast breathing (faster than 20 bpm)
48
Bradypnea
slow breathing (less than 12 bpm)
49
apnea
lack of breathing
50
Cheyenne-stokes Respirations
(dramatic brain injury) an abnormal pattern of breathing characterized by progressively deeper and sometimes faster breathing. this is followed by gradual decrease that results in a temporary stop in breathing (apnea)
51
Biots respirations
(stroke or brain trauma) an abnormal pattern of breathing characterized by groups of quick, shallow inspirations followed by regular or irregular periods of apnea.
52
Kussmaul respirations
(DKA - Metabolic) this is a deep and labored breathing pattern often associated with severe metabolic acidosis. DKA, but also renal failure.
This is a type of hyperventilation. This is to reduce the amount of CO2 in the body to try and compensate for the acidosis in the body.
53
Apneustic
disturbance of respiratory rhythm characterized by severely prolonged inspiratory effort.
54
what can noisy breath sounds tell us?
that there is some type of obstruction in the lungs
55
What does the systolic pressure tell us?
the amount of squeeze the heart is expelling. about 60-65% of the blood in a healthy heart is pushed out.
56
Diastolic Pressure will tell us?
The vascular tone. It is the amount of pressure that the blood it putting on the vessels.
57
If the bilateral BP is >20 points this is a...
Abnormal finding
| Can indicate Aortic aneurysm
58
What is the MAP equation?
Systolic + 2(diastolic) / 3
59
what does MAP tell us?
blood pressure in an individual in a single cardiac cycle.
| It tells us the over all perfusion of the body
60
What is the MAP level that we want to stay at?
Around 65 or above
61
What does it mean if the MAP is less than 50?
That it is leading to organ decreased perfusion
62
What does it mean for your eyes to accommodate?
they draw in together when object moves closer
63
Sclera
The white around the Iris
| Yellow / Brown color = liver failure.
64
Nystagmus
involuntary eye movement often seen in intoxicated patients
65
Helix of the ear
top of the ear
66
Targus of the ear
small pointed eminence of the external ear
67
Lobes of the ear
bottom of the ear
68
Where is the angle of Louis?
second rib is located here, location of the carina of the lungs
69
There are the 4 points that we listen to the heart?
Working from left to right
1) Aortic
2) pulmonic
3) Tricuspid valve
4) Mitral valve
70
Why do people feel pain in their organs?
Its a stretching
71
halitosis
unpleasant odor on exhaled breath
72
Ecchymosis
a bruise
73
Narrow pulse pressure?
a drop in the left ventricular stroke volume, suggest significant blood or fluid loss.
74
Wide pulse pressure with bradycardia
Cushing Triad (ICP)
75
Anuria
non passage of urine
76
What is ascites
cirrhosis of the liver (hepatitis or alcoholism)
| Fluid is building up in the liver.
77
Murphys Sign
Tenderness to the upper right quadrant, checks for cholecystitis
78
cervix sign
narrowing of the opening of the stomach
pyloric stenosis
projectile vomiting
79
What is a Hernia
Its part of an organ that is protruding though the abdominal cavity
80
McBurneys Point
Rebound tenderness after palpation.
| Sign of acute appendicitis
81
Kehrs Sign
acute pain in the tip of the shoulder due to the presence of blood in the peritoneal cavity
82
Referred Pain
pain that is perceived at a location other than the site of the painful stimulus
83
Pulmonary Neoplasm
Lung Tumor
84
Thymoma
Tumor of the thymus
85
Thyroid storm
hyperthyroidism: associated with Graves disease
Can cause A-Flutter
High fever of 100 to 106
86
Urticaria
hives or a rash
87
What are adventitious Breath Sounds?
abnormal or noisy breath sounds
88
What is Aphasia?
Speechlessness
| a disturbance of the comprehension and formulation of language
89
Expressive Aphasia?
Loss of the ability to produce language
90
Sensory Aphasia?
Pt are unable to understand language in its written or spoken form
91
Vermilion Boarder
The line between lip and skin around it.
92
Cullen sign
Bruising around the belly button to show pancreatitis of ectopic pregnancy
93
mydriasis
dilated pupils
94
Rhomberg test
balance with eyes closed.
