What is the appropriated assessment to perform when a patient is new to the practice or hospital?
Comprehensive
What is the appropriate assessment to perform on a routine follow up or urgent care visit?
Focused
This type of assessment provides fundamental & personalized knowledge about patient along with strengthening the clinicial-patient relationship?
Comprehensive
When a patient comes into the clinic complaining about pain to a specific body system, what is the appropriate assessment to perform?
Focused
Which assessment helps to identify or rule out physical causes related to patient concerns?
Comprehensive
T/F The comprehensive assessment addresses focused concerns or symptoms?
F-focused addresses focused concerns/symptoms
T/F The focused assessment provides a baseline for future assessments?
F-comprehensive provides baselines
Which assessment creates a platform for health promotion along with developing proficiency in essential skills of PE?
Comprehensive
T/F The physical findings during an exam is an example of subjective data
F-objective
T/F What the patient tells you in the exam is an example of subjective data
T
Is the chief complaint associated with subjective or objective data?
Subjective
List in the appropriate order the overview of components for the adult health history
Identifying data
Reliability
Chief complaint
Present Illness
Past hx
Family hx
Personal & social hx
Review of sys
What is recorded typically w/ identifying data?
Age
Gender
Marital status
occupation
Who can be the source of Hx or referral?
Patient
Family member
Friend
Officer
Consultant
Medical record
What is the most important info for the CC
Patient's own words
The present illness should include what?
Onset of problem
Setting occurred
Manifistations
Treatments
What should each principle sympton be well characterized with?
Location
Quality
Quantity or serverity
Timing-onset, duration, frequency
Setting
Factors that aggravated/relieve
Associated manifestations
What is important to also ask during the present illness questions?
Medications
Allergies
Tobacco
Alcohol/drug use
What should be noted when asking about meds
Name, dose, route, freq
What should be noted when asking about allergies
Specific reactions
What information is collected during the past hx?
Childhood illness
Adult illness
Health maintenance
What are the four areas of cover for adult illnesses in the past hx
Medical
Surgical
Ob/gyn
Psychiatric
What is important to note during the past hx for medical?
Diabetes, hyperstension, hepatitis, asthma, sexual partners & practices
What is important to note during the past hx for surgical
Date, indications, & type
What is important to note during the ob/gyn of the past hx
Ob hx
Menstrual hx
Contraception type
Sexual fx
What is important to note during the pscyiatric for past hx
Illness/time frame
Dx
Hospitilaztions
Tx
What is especially to note during the past hx for health maintenance?
Immunizations & screening tests
How should the family hx being noted during the comprehensive assessment?
Outline/diagram age, health, cause of death of immediate relative -parents, grandparents, siblings, children, & grandchildren
What following conditions should be reviewed during the family hx & note whether they are past, present or absent in family:
Hypertension
CAD
high cholesterol
Stroke
Diabetes
Thyroid/renal disease
Arthritis
TB
Asthma
Pulmonary disease
Headache
Seizure
Mental illness
Suicide
Substance abuse
Allergies
Patient's symp
Breast, ovarian, colon or prostate cancer
What does the personal & social hx capture?
Personality
Interests
Support sources
Coping style
Strenghts & fears
What is important to note during the personal & social hx?
Occupation
Last yr school
Home life
Spouse
Stressors
Life exp
Religious affiliation/spirtual beliefs
ADL's
List in order the Review of Systems for the comprehensive assessment
General survey
Skin
HEENT
Neck
Breasts
Respiratory
Cardio
GI
Peripheral vascular
Urinary
Genital
Musculoskeletal
Psychiatric
Neuro
Hematolgic
Endocrine
What are the things you should do for preparing for the physical exam?
Reflect on your approach to patient
Proper lightning/environment
Patient is comfortable
Equipment check
Sequence of exam
What are the cardinal techniques for the examination?
Inspection
Palpation
Percussion
Ausculation
What is close observation of details of patient's appearance, behavior & body movements?
Inspection
What is tactile pressure applied from the fingerpads to assess skin, lymph nodes, contours & size of organs & masses; & joint crepitus?
Palpation
What is it when I strike my plexor finger (3rd) to deliver a rapid blow/tap against distal pleximeter finger against the surface of the chest or abdomen to make a sound?
Percussion
What is it when I use the stethocsope to detect characteristics of heart, lung, bowel sounds?
Ausculation
These precautions are based on the principle that all blood, body fluids, secretions, excretions except sweat, nonintact skin & mucous membranes may contain transmissible infectious agents?
Standard & MRSA precautions
Why is it important to wash your hands b4 & after examining patients?
It will show your concern for patients welfare & displays your awareness for patient safety
Why is it important to change your white coat frequently?
Cuffs can become damp/smudged
These precautions are a set of guidelines designed to prevent transmission of HIV, HBV & other blood-bourne pathogens when providing 1staid/healthcare?
Universal precautions
What are the following fluids that are considered potentially infectious under universal precautions?
Blood
Body fluids
What are the body fluids that are considered potentially infectious under universal precautions
Visible blood
Semen
Vaginal secretions
Cerebrospinal
Synovial
Pleural
Peritoneal
Pericardial
Amniotic fluids
What are the protective barriers against body fluids?
Gloves
Gowns
Aprons
Masks
Protective eyewear
It is important for all health care workers to observe the important precautions for what?
Safe injections
Prevention of injury-scalpels, other sharp instruments & devices
What is possibly the most important goal during the exam as far as positioning is concerned for the patient?
minimize how often you ask patient to change pos
Where is the recommended position for the clinician to be & why is it considered to be advantageous?
Right side b/c it is more reliable to estimate things such: JVP, palpating hand rests more comfortably on apical impulse, right kidney is more palpable & tables-accommodate right hand approach
Does the general survey continue throughout the hx & exam?
Yes
How should you obtain vital signs?
Patient sitting on edge of table
Why is it important to darkened room for the opthalmoscopic exam?
Promotes pupillary dilation & fundi visibility
Where should you be for palpation of the thyroid gland?
Posterior to the patient
Why is it important to adjust the head to 30 degrees for the cardio exam?
It allows for you to see jugular venous pulsations
How should the patient be positioned to listen for S3 or mitral stenosis?
Roll partly onto left side
Where do you listen for possible mitral stenosis & S3 sounds?
Apex
How should the patient be positioned to listen for the murmur of aortic regurgitation?
