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Fundamentals > Pt assessment vocabulary > Flashcards

Pt assessment vocabulary Flashcards

1
Q

Chief Complaint

A

reason why the pt has sought medical attention in their words.

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2
Q

medical history

A

history of present illness (HPI)- most important

Past Medical History (PMH)

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3
Q

OPQRST

A 
onset
provocation
quality
region or radiation
severity (pain scale 0-10)
timing (duration of complaint)
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4
Q

SAMPLE

A 
S/S
allergies
medications/ compliance 
pertinent medical history
last oral intake and out
events leading up to event
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5
Q

CAGE

A

Concerned- about ETOH intake
Annoyed- if asked
Guilt- because of drinking
Eye opener- need the drinks to start the day

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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
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7
Q

What is public distance?

A

> 12 ft

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8
Q

what is social distance

A

6-12 ft

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9
Q

personal distance?

A

1.5-4 ft

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10
Q

intimate distance?

A

0-1.5ft

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11
Q

what is an open ended question?

A

do not require a yes or a no

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12
Q

what is a direct question?

A

can be answered yes or no

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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.

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14
Q

facilitated question?

A

using questions or phrases that allow the pt to continue to talk about a particular concern

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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.

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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
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17
Q

what is HPI

A

history of present illness

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18
Q

what is PMH

A

past medical history

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19
Q

eyes (anisocoria)

A

difference in pupil sizes

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20
Q

what is photosensitivity?

A

sensitive to light

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21
Q

what is nystagmus?

A

a twitch or abnormal eye movement when following an object

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22
Q

parts of the ear are?

A

helix - top
tragus- the middle
lobe- bottom

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23
Q

bruits sound? where can you listen for it?

A

its a build up of plaque, it can be heard on the carotids

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24
Q

Rhonchi

A

effects the large airway, the bronchus (COPD, pneumonia)

fluid accumulation

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25
Q

wheeze

A

effect the bronchus, trapping air (its a narrowing of the bronchi)

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26
Q

total lung volume is?

A

6L

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27
Q

rub

A

sound results from the movement of inflamed and roughened pleural surfaces against one another during movement of the chest wall.

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28
Q

crackles

A

fluid in the lower lobes of the lung

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29
Q

Rales

A

these there lower airway (the alveoli having fluid in the,)

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30
Q

Hemianopsias

A

loss of vision in half of your visual field of one eye or both eyes

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31
Q

Scotomata

A

a partial loss of vision or blind spot in an otherwise normal visual field.

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32
Q

Pleurisy

A

is a condition in which the pleura — two large, thin layers of tissue that separate your lungs from your chest wall — becomes inflamed

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33
Q

Hemoptysis

A

Hemoptysis is the spitting of blood that originated in the lungs or bronchial tubes

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34
Q

tuberculosis

A

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.

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35
Q

Goiter

A

an abnormal enlargement of your thyroid gland.

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36
Q

Dysphagia

A

Dysphagia is the medical term for swallowing difficulties.

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37
Q

Regurgitation

A

the action of bringing swallowed food up again to the mouth.

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38
Q

Hematemesis

A

the vomiting of blood

39
Q

Nocturia

A

Nocturia is a condition in which you wake up during the night because you have to urinate

40
Q

gravidity

A

number of pregnancies a woman has had

41
Q

Para

A

Para is the number of completed pregnancies beyond 20 weeks gestation

42
Q

Paresthesia

A

Paresthesia refers to a burning or prickling sensation

43
Q

Hemophilia

A

Hemophilia is usually an inherited bleeding disorder in which the blood does not clot properly

44
Q

People who they call pink puffer are what type of respiratory problems?

A

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
Q

The Blue bloaters are what type of respiratory problems?

A

chronic bronchitis.

  • swelling and inflammation of the bronchioles
  • They retain more CO2 and have generally lower SpO2
46
Q

Eupnea

A

normal breathing

47
Q

Tachypnea

A

fast breathing (faster than 20 bpm)

48
Q

Bradypnea

A

slow breathing (less than 12 bpm)

49
Q

apnea

A

lack of breathing

50
Q

Cheyenne-stokes Respirations

A

(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
Q

Biots respirations

A

(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
Q

Kussmaul respirations

A

(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
Q

Apneustic

A

disturbance of respiratory rhythm characterized by severely prolonged inspiratory effort.

54
Q

what can noisy breath sounds tell us?

A

that there is some type of obstruction in the lungs

55
Q

What does the systolic pressure tell us?

A

the amount of squeeze the heart is expelling. about 60-65% of the blood in a healthy heart is pushed out.

56
Q

Diastolic Pressure will tell us?

A

The vascular tone. It is the amount of pressure that the blood it putting on the vessels.

57
Q

If the bilateral BP is >20 points this is a…

A

Abnormal finding

Can indicate Aortic aneurysm

58
Q

What is the MAP equation?

A

Systolic + 2(diastolic) / 3

59
Q

what does MAP tell us?

A

blood pressure in an individual in a single cardiac cycle.

It tells us the over all perfusion of the body

60
Q

What is the MAP level that we want to stay at?

A

Around 65 or above

61
Q

What does it mean if the MAP is less than 50?

A

That it is leading to organ decreased perfusion

62
Q

What does it mean for your eyes to accommodate?

A

they draw in together when object moves closer

63
Q

Sclera

A

The white around the Iris

Yellow / Brown color = liver failure.

64
Q

Nystagmus

A

involuntary eye movement often seen in intoxicated patients

65
Q

Helix of the ear

A

top of the ear

66
Q

Targus of the ear

A

small pointed eminence of the external ear

67
Q

Lobes of the ear

A

bottom of the ear

68
Q

Where is the angle of Louis?

A

second rib is located here, location of the carina of the lungs

69
Q

There are the 4 points that we listen to the heart?

A

Working from left to right

1) Aortic
2) pulmonic
3) Tricuspid valve
4) Mitral valve

70
Q

Why do people feel pain in their organs?

A

Its a stretching

71
Q

halitosis

A

unpleasant odor on exhaled breath

72
Q

Ecchymosis

A

a bruise

73
Q

Narrow pulse pressure?

A

a drop in the left ventricular stroke volume, suggest significant blood or fluid loss.

74
Q

Wide pulse pressure with bradycardia

A

Cushing Triad (ICP)

75
Q

Anuria

A

non passage of urine

76
Q

What is ascites

A

cirrhosis of the liver (hepatitis or alcoholism)

Fluid is building up in the liver.

77
Q

Murphys Sign

A

Tenderness to the upper right quadrant, checks for cholecystitis

78
Q

cervix sign

A

narrowing of the opening of the stomach
pyloric stenosis
projectile vomiting

79
Q

What is a Hernia

A

Its part of an organ that is protruding though the abdominal cavity

80
Q

McBurneys Point

A

Rebound tenderness after palpation.

Sign of acute appendicitis

81
Q

Kehrs Sign

A

acute pain in the tip of the shoulder due to the presence of blood in the peritoneal cavity

82
Q

Referred Pain

A

pain that is perceived at a location other than the site of the painful stimulus

83
Q

Pulmonary Neoplasm

A

Lung Tumor

84
Q

Thymoma

A

Tumor of the thymus

85
Q

Thyroid storm

A

hyperthyroidism: associated with Graves disease
Can cause A-Flutter
High fever of 100 to 106

86
Q

Urticaria

A

hives or a rash

87
Q

What are adventitious Breath Sounds?

A

abnormal or noisy breath sounds

88
Q

What is Aphasia?

A

Speechlessness

a disturbance of the comprehension and formulation of language

89
Q

Expressive Aphasia?

A

Loss of the ability to produce language

90
Q

Sensory Aphasia?

A

Pt are unable to understand language in its written or spoken form

91
Q

Vermilion Boarder

A

The line between lip and skin around it.

92
Q

Cullen sign

A

Bruising around the belly button to show pancreatitis of ectopic pregnancy

93
Q

mydriasis

A

dilated pupils

94
Q

Rhomberg test


A

balance with eyes closed.

Fundamentals (8 decks)

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