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What is the appropriated assessment to perform when a patient is new to the practice or hospital?
What is the appropriate assessment to perform on a routine follow up or urgent care visit?
This type of assessment provides fundamental & personalized knowledge about patient along with strengthening the clinicial-patient relationship?
When a patient comes into the clinic complaining about pain to a specific body system, what is the appropriate assessment to perform?
Which assessment helps to identify or rule out physical causes related to patient concerns?
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?
T/F The physical findings during an exam is an example of subjective data
T/F What the patient tells you in the exam is an example of subjective data
Is the chief complaint associated with subjective or objective data?
List in the appropriate order the overview of components for the adult health history
- Identifying data
- Chief complaint
- Present Illness
- Past hx
- Family hx
- Personal & social hx
- Review of sys
What is recorded typically w/ identifying data?
- Marital status
Who can be the source of Hx or referral?
- Family member
- 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
What should each principle sympton be well characterized with?
- Quantity or serverity
- Timing-onset, duration, frequency
- Factors that aggravated/relieve
- Associated manifestations
What is important to also ask during the present illness questions?
- Alcohol/drug use
What should be noted when asking about meds
Name, dose, route, freq
What should be noted when asking about allergies
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
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
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:
- high cholesterol
- Thyroid/renal disease
- Pulmonary disease
- Mental illness
- Substance abuse
- Patient's symp
- Breast, ovarian, colon or prostate cancer
What does the personal & social hx capture?
- Support sources
- Coping style
- Strenghts & fears
What is important to note during the personal & social hx?
- Last yr school
- Home life
- Life exp
- Religious affiliation/spirtual beliefs
List in order the Review of Systems for the comprehensive assessment
- General survey
- Peripheral vascular
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?
What is close observation of details of patient's appearance, behavior & body movements?
What is tactile pressure applied from the fingerpads to assess skin, lymph nodes, contours & size of organs & masses; & joint crepitus?
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?
What is it when I use the stethocsope to detect characteristics of heart, lung, bowel sounds?
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?
What are the following fluids that are considered potentially infectious under universal precautions?
What are the body fluids that are considered potentially infectious under universal precautions
- Visible blood
- Vaginal secretions
- Amniotic fluids
What are the protective barriers against body fluids?
- 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?
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?
How should the patient be positioned to listen for the murmur of aortic regurgitation?
Sit-lean forward & exhale