Pt Encounter Script Flashcards
1
Q
What are the 6 elements of a general health survey?
A
1) Health
2) Awareness/ LOC
3) Distress
4) Grooming/ hygiene
5) Face
6) Posture/ motor
HAD GFP
2
Q
General health survey for an average/ well patient
A
1) Pt is a well-appearing man/ woman who is awake and oriented with no signs of distress.
2) Pt has appropriate grooming and hygiene for this visit and their mood and affect/ facial expression is flat/ cheerful
4) And their posture is upright with appropriate motor activity
3
Q
ROS: head
A
Hair loss, scalp pain, and jaw pain (with chewing)
4
Q
ROS: eyes
A
Redness, double vision, and blurry vision
5
Q
ROS: ears
A
Loss of hearing, ringing in ears, and ear pain.
6
Q
ROS: nose/ sinuses
A
Runny nose, stuffy nose, and bloody nose.
7
Q
ROS: throat
A
Sore throat, hoarseness, and trouble swallowing
8
Q
ROS: neck
A
Stiff neck, changes in ROM of neck, and lumps or bumps in neck.
9
Q
ROS: cardiovascular
A
Chest pain, feeling of heart skipping a beat, and heart racing
10
Q
ROS: respiratory
A
Shortness of breath, wheezing, and cough.
11
Q
ROS: GI
A
Nausea, vomiting, and constipation
12
Q
ROS: urinary
A
Difficulty urinating, pain during urination, and change in color or smell of urine.
13
Q
ROS: genital
A
Itching, swelling, and pain of genitals
14
Q
ROS: musculoskeletal
A
Acute back pain, joint pain, and changes in range of motion of joints.
15
Q
ROS skin
A
Rashes, dryness, and itchiness.
16
Q
ROS: endocrine
A
Cold or heat sensitivity, excessive thirst, and excessive hunger
17
Q
ROS: peripheral vascular
A
Numbness, coldness, and swelling in hands or feet.
18
Q
ROS: hematologic
A
Bruising or bleeding, history of anemia, or blood transfusions.
19
Q
ROS neurologic
A
Pt denies dizziness, headaches, and changes in memory
20
Q
ROS: psychiatric
A
Anxiety, depression, and suicidal thoughts.
21
Q
Psych exam
A
-Pt’s fluency and rate of speech are appropriate. She displays logical and organized thoughts.
-Her higher cognitive functioning is intact.
22
Q
2 depression questions
A
1) Over the past 2 weeks have you felt down, depressed, or hopeless?
2) Over the past 2 weeks, have you felt little pleasure in doing things?
23
Q
3 anxiety questions
A
1) Over the past 2 weeks, have you felt nervous, anxious, or on edge?
2) Over the past 2 weeks, have you been unable to stop or control worrying?
3) Over the past 4 weeks, have you had an anxiety attack; suddenly feeling fear or panic?
24
Q
What are the social Hx questions?
A
1) Tobacco
2) Illicit drugs + Rx misuse
3) Alcohol
4) Sexual history
○ Partners (marital status)
○ Protection
○ Preference
5) Home life / abuse
6) Occupation/ military history /travel
7) Exercise and diet + caffeine
25
What are the 7 attributes of a symptom?
Onset
Location
Duration
Characteristic
Alleviating and aggravating factors
Radiation
Timing
Severity
(OLD CARTS)
26
List the general order of the steps of a patient exam, before the actual physical exam part
CC
HPI
ROS
Medical Hx
Family Hx
Social Hx
Vital Signs
27
First 3 (out of 4) steps of a hair/ skin/ nails PE
1) Part hair of scalp and look for lesions, rashes, or infestations
a. **No evidence of lesions, rashes, erythema, hypo/hyperpigmentation.
b. And their hair distribution is even**
2) Visually assess a patient's face, ears, and trunk. Turn over arms and move legs to see all sides. Look at palms and soles of feet. Look at and touch their nails and toenails. Look at conjunctiva, lips, oral mucosa using a pen light.
a. **No erythema, rashes, lesions, or hypo/hyperpigmentation on the visible skin.
b. No signs of pallor, jaundice, or cyanosis of the oral mucosa, conjunctiva, or palms and soles of the feet.
c. Nail beds are an appropriate color and shape with no lesions or pitting**
3) Touch the patient's arm and leg, and pinch the patient's skin on their arm and leg
a. **Skin is warm and dry with an even texture and has appropriate turgor (mobility and elasticity)**
28
Last step of a hair/ skin/ nails PE
*Identify any nevi and counsel patient on ABCDE method to screen for melanoma*
a. No nevi identified. You want to look once a month for any suspicious moles or lesions, right when you get out of the shower is a good time to do this, use a hand mirror to look at all the nooks and crannies. When you're looking at a spot, you want to use the ABCs of melanoma:
i. A: Is it asymmetrical?
ii. B: Are the borders clear or blurry?
iii. C: Is it one color or multiple?
iv. D: Is it bigger than the size of a pencil eraser (about 6mm)?
vi. E: Is it evolving or changing over time?
That's the most important thing to look out for.
29
3 steps of a head exam
1) Look at skull and face
a. **Pt's skull is symmetrical + of an appropriate size**
b. **Face is without involuntary movements, asymmetry, or lesions**
2) Palpate skull, face, and mastoid process (posterior auricular) *ask if it hurts*
a. **Mastoid process is without redness or pain**
b. **Skull is without deformities, hematoma, or inappropriate depressions.**
c. **Face is without bony deformities, crepitus, or masses**
3) **Battle sign and raccoon sign are absent with no other signs of trauma**
30
Two steps of a CNV exam
1) Move hands over patient's forehead, cheeks, and chin.
-Ask if they can feel it and if it's the same on both sides.
2) Have pt clench jaw
**Muscles of mastication have appropriate strength, and sensation bilaterally is intact in the distribution of V1-3, and corneal reflex is deferred, so CNV is intact.**
31
Two steps of a CNVII exam
1) Look at face.
a. **No drooping of the cheeks, mouth, or nasolabial folds.**
2) Ask pt to raise eyebrows, smile, puff out cheeks.
a. **Muscles of facial expression are intact so facial nerve/ CN7 is intact**
32
List the medical history questions
Allergies
Surgeries
Hospitalizations
Immunizations
Tests/ screenings
Childhood
Adult
Meds
Psych/ pregnancy/ periods
33
First 4 steps of an eye exam
1) Look at lids and palpate lacrimal apparatus
**a. Lids have no discoloration, masses, edema, or ptosis.
b. No evidence of swelling or tearing of lacrimal apparatus**
2) Conjunctivae and sclerae- have them pull lower lid down, use pen light
a. **Conjunctivae and sclera are of appropriate color and no apparent swelling**
3) Visual field screening (wiggle hands around the patient in 3 spots)
a. **No evidence of peripheral vision loss**
4) Have pt follow pen with eyes making H pattern, pausing at the sides
a. **EOMs are intact and without nystagmus; downward medial gaze intact so CN4 is functioning, lateral gaze is appropriate so CN6 is intact, and all other EOM movements are intact so CN3 is intact.**
34
Steps 5-8 of an eye exam
5) Pen to test accommodation: Move pen in front of eye after asking to look in corner of room
a. **Displays accommodation**
6) Visual acuity: Use chart; ask them to cover one eye and read the lowest line they can read with each eye, then do both eyes. Do color vision too.
a. **Say whether 20/20, 20/30, etc for each one
b. Color vision is intact**
7) Cornea and lenses using light (look from the side and front)
a. **Pt's corneas reflect light appropriately and symmetrically, and the lens is clear**
8) Pupils using light
a. **Pupils are PERRLA; pupillary reflex is present both directly and consensually and are symmetrical**
**CNII is intact since visual acuity and visual fields were appropriate.
CNIII is intact since pupils were PERRLA as well as EOMs, and ptosis is absent.**
35
2 steps of an optic exam
Darken lights, ask pt to focus on object far away
1) Come in at 15 degrees with ophthalmoscope
a. **Red light reflex is present**
2) Move closer to pt and focus scope
a. **Retina and its veins are visualized and retina is without lesions or hemorrhages.
b. Optic disc not visualized but if it were it would be lateral of the line of sight and without papilledema and with a clear border.**
c. **Fovea and macula not visualized but if they were they would be without exudates or cysts**
36
4 steps of an ear exam
1) Look at auricles, palpate auricle and tragus
a. **Auricles are without deformity or masses**
a. **No pain with motion of auricle**
2) Use otoscope
a. Brace
b. **Ear canals are without foreign bodies or erythema**
c. **Tympanic membranes are pearly gray and cone of light is anterior, malleus not visualized**
3) Gross hearing test (fingers rubbing; rub both hands on each side, then just one and have them ask)
a. **No signs of hearing loss, so CN8 is intact**
4) Webber and Rinne
a. **Webber test shows no lateralization
b. Rinne shows that air conduction is greater than bone conduction**
37
4 steps of a nose exam
1) Look at external surface
a. **Nose is symmetrical with no lesions or deformity**
2) Palpate nose, frontal, and maxillary sinuses
a. **Nose is without tenderness or masses, frontal and maxillary sinuses are without tenderness**
3) CNI: Have pt occlude one nostril and smell, then again with other side
a. **Sense of smell is intact so CN1 is intact**
b. **Nares are patent**
4) Otoscope:
a. **Internal nares are without rhinorrhea or cracking**
b. **Mucosa is of appropriate color with no edema**
c. **Septum is without deviation or perforation**
38
5 steps of a mouth and pharynx exam
1) Look at lips and ask pt to protrude tongue and push tongue against both cheeks
a. **Lips are pink and moist**
b. **Dysarthria is absent and tongue movements are appropriate, and gag reflex is deferred, so CN12 is intact.**
2) Ask patient to say "aaa" and look with pen light, look at posterior pharynx too
a. **Soft palate and uvula rise bilaterally, and gag reflex is deferred, so cranial nerves 9 and 10 are intact
b. Posterior pharynx has no edema or lesions.**
3) Look at oral mucosa, tongue, gums, and floor of mouth with tongue depressor and pen light.
a. Ask patient to move tongue to the side, stick tongue out, and lift tongue
b. **Oral mucosa, tongue, gums, and floor of mouth are of appropriate color with no lesions or ulcers**
4) Look at and palpate teeth, gums, and floor of mouth
a. **Teeth are firmly implanted without caries
b. Gums are pink with no retraction or bleeding
c. Floor of mouth is pink and without masses**
39
5 steps of a neck and TMJ exam
1) Look at neck, and thyroid with oblique lighting
a. **Neck is symmetrical with no erythema**
2) Look at and palpate TMJ (anterior to ear), have pt open and close mouth.
a. **No edema or erythema of the TMJ and it has an appropriate smooth ROM**
3) Palpate lymph nodes (including beneath jaw)
a. In front of tragus, postauricular 1 in into hair, base of skull in hairline, along inferior jaw from TMJ to mid chin, along SCM and in front of and behind it, superior and inferior to clavicle along length
b. **Lymph nodes are without tenderness and are of appropriate size.
c. Inferior aspect of mandible is without swelling, tenderness, or induration.**
4) Palpate thyroid and trachea (move trachea), have pt swallow.
a. **Thyroid is symmetric, of appropriate size and consistency and is without tenderness or nodules.
b. Trachea is of appropriate size and without pain with movement**
5) Shrug shoulders, move head against resistance
a. **CN11 is intact**
40
First step of a respiratory exam
1) After asking to take gown off, look and listen to breathing:
**a. No audible breath sounds or gagging
b. Respirations are of an appropriate rate and rhythm
c. No suprasternal, supraclavicular, substernal, subcostal, or intercostal retractions
d. No sternocleidomastoid or scalene muscle use.**
41
Steps 2-5 of a respiratory exam
2) Press pt's upper chest and lower ribs, ask if it hurts
a. **No tenderness to palpation**
3) Feel pt's back as they breathe
**a. Chest expansion is symmetric
b. Diaphragmatic excursion is between 3 and 5cm.**
4) Have pt say "EE" and feel between scapulae
a. **Tactile fremitus is symmetric**
5) Look at pt from side and front
a. **AP diameter is about .75**
42
Steps 6-8 of a respiratory exam
6) Percuss (tapping): tap on 7 spots on the back bilaterally and 6 on the front of their chest
**a. No dullness over lung fields**
7) Stethoscope auscultation: listen to full breath in 7 places on the back bilaterally and 6 on the front (3 above breast and 3 below). One full breath in each spot.
a. **Lung sounds are clear with no rales, rhonchi, or wheezing**
8) Ask pt to say "EE", then say 99, then whisper 99, listening in 2 places bilaterally on back and one on right side.
a. **No voice sounds are transmitted.**
43
First 3 steps of a cardiac exam
1) Place fingertips on chest and look for any movement or sensation of chest. Place sides of hands on chest and feel for vibration.
a. **No lifts, heaves, or thrills felt**
2) PMI: ask pt to lift left breast, feel for 4th/5th intercostal on left side and feel for apical pulse.
a. **Apical pulse is about 2.5cm with no displacement**
3) Feel radial pulses bilaterally
a. **Radial pulses are 2+ bilateral**
44
Steps 4-6 of a cardiac exam
4) Listen to upper left (2nd IC space) for aortic valve, upper right for pulmonic, lower left border of sternum for tricuspid, then a couple inches further laterally than that for mitral. Do with both bell end (lightly) and diaphragm (press down)
**a. Listening with both the bell end and diaphragm for aortic valve
b. Same thing for the pulmonic
c. Then tricuspid
d. Then mitral
e. No murmurs, rubs, or gallops**
5) Lean the pt forward while exhaling while listening to left 2nd ICS.
a. **No aortic regurgitation**
6) Lay pt down, lay on left side, listen to lower left 5th IC space
a. **No mitral stenosis**
45
Last step of a cardiac exam; JVP
1) Move bed up to 30', have pt turn head to the left, then look for IJV on right side. Observe pulsation and directly above is meniscus, measure from sternal angle to meniscus (height); add 5 to your cms to get JVP
a. **JVP is Xcm, which is within the normal range of 6-8 centimeters.**
46
First 3 steps of abdominal PE
1) **Pt is showing no signs of distress.**
2) Make sure all of abdomen is visible:
○ **Abdomen is flat and not protuberant with no discoloration or cellulitis
○ No masses or pulsations of the aorta, no surgical scars**
3) Listen in all 4 quadrants with stethoscope
○ **Bowel sounds are present in all 4 quadrants and not hypo or hyperactive**
47
Steps 3-5 of an abdominal PE
3) Listen to bruits with the bell at:
○ the aorta beneath xiphoid process (midline).
○ just laterally and inferior to this for renal arteries (bilaterally).
○ just lateral and inferior to umbilicus for iliac arteries (bilaterally).
○ groin for femoral arteries
○ **No evidence of bruits**
4) Percuss all 4 quadrants
○ **Percussion is consistent with no excessive dullness**
5) Percuss organs; bladder, spleen (left), liver (right)
○ **No increased dullness**
48
Steps 6-8 of an abdominal PE
6) Have pt lay down supine and bend knees. Begin light palpation and ask if any tenderness.
○ **No masses, induration, rigidity, or tenderness or pain to palpation.**
7) Feel for spleen (left rib, ask pt to hold breath), liver (right rib), kidneys bilaterally (posterior pressure) bladder
○ **No palpation of the spleen.**
* Palpate down midline
○ **No large midline pulsatile mass**
8) Check CVA tenderness bilaterally; tap on each side of middle lower back
○ **No tenderness to palpation**
49
How do you perform McBurney's point for appendicitis? What do you verbalize?
Draw a line from the ASIS to umbilicus, find the midpoint, go two inches inferior to this, palpate McBurney Point for local tenderness. **Any pain?
No tenderness with palpation**
50
How do you perform Rovsing sign for appendicitis? What do you verbalize?
Palpate deeply and evenly in the LLQ and quickly let go
**Any pain here?** *point to right lower quadrant*
**No tenderness in RLQ or referred rebound pain, Rovsing sign is absent**
51
How do you perform Psoas sign for appendicitis? What do you verbalize?
Have patient flex Right hip against your resistance on the R thigh
**Psoas sign is absent**
52
How do you perform Obturator sign for appendicitis? What do you verbalize?
Flex patient’s right leg at hip and with knee bent, rotate leg internally
-Right hypogastric pain is + obturator sign secondary to inflamed muscle
§ **Ask if any right hypogastric pain (*point*)
§ Obturator sign for appendicitis is absent.**
53
How do you perform Murphy's sign for cholecystitis? What do you verbalize?
Palpate under R costal margin as the patient inspires, ask if any tenderness with inspiration
**No arrested breathing or increased tenderness with inspiration, Murphy's sign for cholecystitis is absent.**
54
MSK PE: What do you say after you've examined all the joints?
No swelling, crepitus, bony deformity, or asymmetry. Alignment is appropriate. No redness, warmth, swelling, or pain (inflammation). No skin changes, atrophy, or systemic illness. All joints have appropriate ROM and strength.
55
MSK shoulder: What are you palpating and what passive ROM are you testing?
* Palpate acromion, greater tubercle, coracoid.
* Palpate clavicle from SC joint to AC joint
* Passive ROM: flexion and abduction (forward and out)
56
MSK elbow: What do you palpate? What do you test for resisted ROM? What two things do you assess for?
* Palpate epicondyles and space bt epicondyles and olecranon.
* Resisted/ strength: flexion/ extension
**Strength is appropriate**
57
MSK wrist and hand: What do you palpate? What ROMs are tested for strength/ resistance?
* Palpate distal radius and ulna, carpals, phalanges, and anatomic snuff box
* Strength/ resistance:
○ Wrist: flexion/ extension
○ Finger: flexion
58
MSK spine:
1) What do you look at and palpate?
2) What do you say?
Look at spine and palpate the entire spine, ask if tender
○ **No tenderness of spinous processes or paravertebral muscles. No spasm of paravertebral muscles.
○ Curvature of cervical, thoracic, and lumbar spines are appropriate
○ Shoulders and iliac crests are appropriately aligned.**
59
MSK hip:
What is palpated?
What passive ROM is tested?
What strength ROM is tested?
What do you observe? What do you say?
-Palpate iliac crest, ASIS, greater trochanter, SI joint, posterior ilium, and sacrum
-Passive ROM: Flexion
-Strength/ resisted: Flexion
-Observe gait
> **Gait is appropriate**
60
MSK knee:
What do you palpate?
What passive ROM do you test?
What do you test for strength/ resistance?
* Palpate knee: quads, patella, patellar tendon/ infrapatellar spaces, anterior tibial joint line
* Passive ROM: flexion/ extension
* Strength/ resisted: flexion/ extension
61
MSK ankle and foot:
What do you palpate?
What active and passive ROM do you test?
What stability do you test?
* Palpate anterior joint lines, Achilles tendon, heel, malleoli (med and lat), tarsals, metatarsals, phalanges.
* Active and passive ROM: plantar/ dorsi flexion and eversion/ inversion.
* Stability: stabilize ankle and invert/ evert heel for tibiotalar, stabilize heel and invert/ evert foot for talonavicular joint.
**ROM and strength are appropriate**
62
First step of a nervous system PE
Observe and say:
**No asymmetric sagging or flaccidity, no tremors or involuntary movements, and no visible muscle atrophy. No obvious favoring of one side or unilateral weakness and no altered states.**
63
Second step of a nervous system exam
FAST counseling: **it’s always a good idea to know the symptoms of a stroke, so you can use the FAST mnemonic to remember it:
a. F stands for face drooping
b. A stands for arm weakness
c. S stands for speech difficulty
d. T stands for time to call 911 if you see any of those symptoms**
64
Third step of a nervous system PE
Sensation; stroke bilaterally and ask if same or different:
a. CV already done
b. C3: from lower neck over clavicles to shoulders
c. T4: side boob
d. T10: sides of stomach
e. C6: front of lower arm
f. C8: back of lower arm
g. L1: inguinal region
h. L4: outer thigh to inner thigh inferiorly
j. L5: outer calf to inner calf inferiorly
65
Steps 4-5 of a nervous system PE
4) Vibration: use big tuning fork, ask if pt can feel on hand and foot
5) Proprioception: show pt what moving their finger up, down, outside, inside feels like, then ask them what direction you're moving their finger and toe in.
a. **Sensation is intact**
66
Steps 6-8 of a nervous system exam
6) Strength: ask pt to grip two of your fingers in each hand as hard as they can
a. **Grip strength is appropriate**
7) Have pt close eyes, tell them this is what one point feels like and this is what two feels like. Then ask them if it's one or two on both hands and feet.
8) Ask pt to identify 2 numbers you draw on their palms
a. **Discriminative sensation is intact**
67
Step 9 of a nervous system PE
9) Reflexes
a. Biceps: C5, C6
b. Triceps: C6, C7 (hold pt's arm)
c. Brachioradialis: C5, C6
d. Quadriceps: L2-4
e. Achilles: S1
**Reflexes are intact**
68
Last step of a nervous system exam
10) Ask pt to touch their finger to their nose, then to your finger, with each hand. Then ask pt to touch their heels to their shins.
**Cerebellar function is intact**
69
List all 5 steps of a peripheral vascular exam
1) Look at pt and touch and poke calf and arm: **no edema or erythema, no varicose veins or DVT symptoms, no ulcers, and temperature is appropriate.**
2) Palpate fingernails and toenails bilaterally: **Capillary refill is less than 2 seconds**
3) Feel and auscultate carotid pulse: No bruits
4) PT pulse (posterior medial malleolus) and DP pulse (lateral to big toe tendon) bilaterally
a. **Pulses are 2+ bilaterally and femoral pulse is deferred**
5) Palpate axillary nodes
**Axillary nodes are of appropriate size and without tenderness to palpation, inguinal nodes are deferred**
70
What is the one special test for the peripheral vascular system? How is it done?
Allen test: Hold down radial and ulnar pulses, then let go of ulnar, then let go of radial. Look for color to return.
71
What does the Romberg test test for? How is it done?
Cerebellar ataxia; Ask pt to stand with feet together, then close their eyes, and see if they entirely lose balance
72
What is the Asterixis test for? How is it performed?
Metabolic encephalopathy; ask pt to hold hand up like "stop" for 1-2 mins.
73
