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8 Cards in this Set
- Front
- Back
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General Guidelines
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Approach is flexible/disciplined
History and physical exam are interrelated Respect patient privacy Calm/balanced demeanor Revisit problem areas |
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Reliability
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Patient factors affecting accuracy
Sensory deprivation Emotional constraints Language barriers Cultural barriers Unresponsive/comatose patient |
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Exam Sequence
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General inspection
Laying on of the Hands Measurements Seated in gown Head and face Eyes Ears Nose Mouth and pharynx Neck Upper extremities Seated/back exposed Back/posterior chest Lungs Seated/chest exposed Anterior chest/lungs/heart Breasts Heart/abdomen Sitting/legs exposed Musculoskeletal Reclining 45 degrees Jugular veins Supine/chest exposed Female breasts Heart Supine/abdomen exposed Abdomen Inguinal area Male external genitalia Supine/legs exposed Feet/legs Hips Lithotomy position Internal/external genitalia Usually save for last Standing Spine Neurologic Abdominal/genital Bending forward Male rectal |
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Exam Sequence: Infant
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General inspection
Behavior Chest/heart/lungs Abdomen Extremities Genitals/rectum Neurologic Back Head/neck |
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Exam Sequence: Children
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At play
Motor skill Muscle strength Parent’s lap Extremities Head/neck Chest/heart/lungs Abdomen Standing Spine Lap Eyes Ears Nose/mouth |
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Exam Sequence: Pregnant Women
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Same as adult
Focus on abdominal/pelvic exam |
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Exam Sequence:Older Adult
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Same as adult
Functional assessment |
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Alliance and Compliance
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Discuss Findings
Explain Options Risks and Benefits Enlist the patients opinions and values to come with a treatment plan specific for the patient Consider Compliance Dosing Frequency Follow up Safety Issues |
