Reading...
Play button
Play button
Use LEFT and RIGHT arrow keys to navigate between flashcards;
Use UP and DOWN arrow keys to flip the card;
H to show hint;
A reads text to speech;
25 Cards in this Set
- Front
- Back
|
Chief Complaint(s)
|
quote the patients own words
if non specific complaint - note goal |
|
|
Present Illness
|
Location, Quality, Quantity or severity, Timing (onset, duration, and frequency), The setting in which it occurs, Factors that have aggravated or relieved symptom, Associated manifestations
Include pertinent positives. Medications Allergies Tobacco, alcohol, and drug use |
|
|
Past History
|
Childhood illnesses
Adult illnesses (medical, surgical, ob/gyn, psychiatric) Health maintenance |
|
|
Family History
|
Age and health or age and cause of death of each immediate relative
|
|
|
Personal and Social History
|
Capture's personality and interest, source of support, coping style, strengths, and fear.
Include: occupation, school completed, home situation, sources of stress, important life experiences, leisure activities, religion, activities of daily life Exercise and Diet Safety Measures |
|
|
General
|
Usual weight, recent weight change, weakness, fatigue, fever
|
|
|
Skin
|
Rashes, lumps, sores, itching, dryness, change in color, changes in hair or nails, changes in size or color of moles
|
|
|
HEENT
Head |
Headache, head injury, dizziness, lightheadedness,
|
|
|
HEENT
Eyes |
Vision, glasses or contacts, last exam, pain, redness, excessive tearing, double or blurred vision, spots, spects, flashing lights, cataracts, glaucoma
|
|
|
HEENT
Ears |
Hearing, tinnitus, vertigo, earaches, infection, discharge, use or nonuse of hearing aids
|
|
|
HEENT
Nose and sinuses |
frequent colds; nasal stuffiness, discharge or itching; hay fever; nose bleeds; sinus trouble
|
|
|
HEENT
Throat |
condition of teeth and gums; bleeding gums; dentures (fit); last dental exam; sore tongue; dry mouth; frequent sore throat; hoarseness
|
|
|
Cardinal techniques of exam
|
Inspection, Palpation, Percussion, Auscultation
|
|
|
Inspection
|
observe appearance, behavior, and movement (facial expressions, mood, body habitus, and conditioning), skin condition, eye movement, pharyngeal color, symmetry of thorax, height of jugular venous pulsations, abdominal contour, lower extremity edema, and gait
|
|
|
Palpation
|
Assess areas of skin elevation, depression, warmth, tendernessl lymph nodes; pulses; contour and size of organ masses; and crepitus in the joints
|
|
|
Percussion
|
to evoke a sound wave such as resonance or dullness from the underlying tissue or organs
|
|
|
Auscultation
|
detect characteristics of the heart, lung, and bowel sounds
|
|
|
General survey
|
-general state of health, height, build, and sexual development
-obtain weight -note posture, motor activity, gait, dress, grooming, and personal hygiene, odors of body or breath, facial expressions, manner of speaking, state of awareness or consciousness |
|
|
Vital Signs
|
Blood pressure
Pulse Respiratory Rate Body Temperature (optional) |
|
|
Skin
|
-observe skin of face and characteristics
-identify lesions (note location, distribution, arrangement, type, and color) -inspect and palpate the hair and nails |
|
|
HEENT
Head |
-Examine the hair, scalp, skull, and face
|
|
|
HEENT
Eyes |
-check visual acuity and screen visual fields
-observe eye lids, inspect sclera and conjunctiva of each eye -inspect cornea, iris, and lens -compare pupils, test reactions to light -access extraocular movements -inspect the ocular fundi |
|
|
HEENT
Ears |
-inspect auricles, canals, and drums
-check auditory acuity (check lateralization and compare air and bone conduction) |
|
|
HEENT
Nose and Sinuses |
-examine the external nose
-examine nasal mucosa, septum, and turbinates -palpate for tenderness of the frontal and maxillary sinuses |
|
|
HEENT
Throat |
-inspect the lips, oral mucosa, gums, teeth, tongue, palate, tonsils, and pharynx
|
