Term
| general written exam format |
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Definition
history
physical
assessment
plan |
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Term
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Definition
-chief complaint (CC)
-history of present illness (HPI)
-past medical history (PMH) including meds and allergies
-family history
-social history
-review of systems (ROS) |
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Term
| concrete physical characteristics |
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Definition
-age, gender, race
-hair and/or eye color
-things you can see, touch, feel, smell, etc. |
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Term
| culture and reflection of human behavior of a group |
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Definition
-ideas and attitudes
-relationships
-language and manner or speaking
-beliefs, etiquette, law, morals, entertainment, education, "what is held dear" |
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Term
| additional considerations for each examination |
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Definition
-standard precautions
-latex allergies
-patient draping
-patient positioning |
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Term
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Definition
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Term
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Definition
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Term
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Definition
| face up with upper body at 30 degree angle |
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Term
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Definition
| laying on left side with left leg extended and right leg flexed |
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Term
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Definition
| laying on back with knees bent up and feet flat on table |
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Term
| right lateral position (right lateral recumbent) |
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Definition
| laying on right side with right leg extended and left leg flexed |
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Term
| (dorsal) lithotomy position |
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Definition
| used for female pelvic exam; laying on back with feet in stirrups |
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Term
| basic physical exam skills |
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Definition
-inspection
-palpation
-percussion
-auscultation |
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Term
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Definition
-observation throughout the exam
-sight and smell
-verbal and nonverbal cues |
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Term
| What are the 2 types of lighting and what do they allow you to check for? |
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Definition
1. direct: color, texture
2. tangential: contour, variations in surface |
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Term
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Definition
| grinding/crackling of joint when moved |
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Term
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Definition
-precedes deeper palpation
-depth u p to 1 cm |
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Term
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Definition
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Term
| What side of the patient should you generally stand on? |
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Definition
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Term
| Never underestimate the power of the "________ ___ ___ __________" Avoid ______ _______ and ______ ___________. |
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Definition
"laying on of hands"
cold hands; long fingernails |
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Term
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Definition
| striking one object against another; produces vibration and sound |
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Term
| __________ of medium determines tone heard |
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Definition
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Term
| more dense the object, more ___________ the tone |
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Definition
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Term
| Explain the most common percussion technique. |
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Definition
-fingers of non-dominant hand spread over area
-middle finger firmly over area to percuss
-strike DIP joint area of middle finger |
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Term
| Explain the less common percussion technique and what it is used for. |
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Definition
-ulnar aspect of fist
-used to elicit tenderness over liver, kidneys, and gallbladder |
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Term
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Definition
loudest, high pitch, moderate duration, drumlike
(ex: gastric bubble) |
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Term
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Definition
very loud but low pitch, long duration, boomlike
(ex: "holey" lungs, emphysema) |
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Term
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Definition
loud, low pitch, hollow sound
(ex: normal lungs) |
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Term
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Definition
soft to moderate, moderate to high pitch, thudlike
(ex: liver) |
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Term
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Definition
softest, short duration, very dull
(ex: muscle) |
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Term
| What do you use to auscultate? |
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Definition
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Term
| Sound of auscultation is produced by _____. Listenn to _______, _______, ______, and ______. |
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Definition
body
intensity, pitch, duration, quality |
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Term
| Auscultation is usually the _____ portion of the exam, but it is the second portion after __________ for the _________ exam. |
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Definition
| last; inspection; abdominal |
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Term
| What are the main vital signs? |
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Definition
blood pressure
heart rate
respiratory rate
temperature |
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Term
| What are other vital signs that give a baseline of a person's health status? |
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Definition
height
weight
BMI & waist circumference
oxygen saturation
pain assessment
fetal heart tones if pregnant |
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Term
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Definition
| peripheral measure of cardiovascular function |
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Term
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Definition
| first beat auscultated; corresponds to greatest pressure exerted on arterial wall |
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Term
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Definition
| last beat auscultate; corresponds to least amount of pressure exerted on arterial wall |
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Term
| equipment needed to take blood pressure |
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Definition
| stethoscope and sphymomanometer |
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Term
| Bladder length of sphygmomanometer must be ____% or more of the arm circumference. |
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Definition
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Term
| What artery are you listening to when you take a blood pressure? |
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Definition
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Term
| Do you place the diaphragm or the bell on the artery when taking a blood pressure? |
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Definition
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Term
| What position should the patient's arm be in to take a blood pressure? |
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Definition
| at the level of the heart |
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Term
| Inflate the cuff at least ___-___ mm Hg above the expected systolic B/P reading. |
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Definition
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Term
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Definition
| sound heard while taking blood pressure |
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Term
| If you need to repeat the reading, wait at least ____ seconds between reading with the cuff ___________. |
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Definition
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Term
| Where is the pulse most commonly measured? |
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Definition
| over radial artery at wrist |
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Term
| Do not use your ______ to measure pulse! |
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Definition
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Term
| How does respiratory rate need to be documented? |
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Definition
| rate and labored/unlabored |
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Term
| Respiratory rate is counted as __________/__________ cycles per minute |
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Definition
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Term
| What are the 3 methods of checking temperature and what are their expected values? |
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Definition
rectal: 99.6
oral: 98.6
axillary: 97.6 |
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Term
| What are the 3 methods of checking temperature and what are their expected values? |
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Definition
rectal: 99.6
oral: 98.6
axillary: 97.6 |
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Term
| What is an underweight BMI? |
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Definition
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Term
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Definition
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Term
| What is an overweight BMI? |
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Definition
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Term
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Definition
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Term
| What is a morbidly obese BMI? |
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Definition
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Term
| Waist circumference in women should be? In men? |
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Definition
| 35 inches in women; 40 inches in men |
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Term
| How is oxygen saturation most commonly measured? |
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Definition
| externally, non-invasively via pulse oximetry |
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Term
| What are the 3 different pain assessment scales? |
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Definition
numeric pain intensity scale
Wong/Baker faces rating scale
Oucher scale |
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Term
| numeric pain intensity scale |
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Definition
| 1-10; 1 being no pain, 5 being moderate pain, 10 being worst pain |
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Term
| Wong-Baker faces pain rating scale |
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Definition
| 0-5; based on pictures of facial expressions; often used in pediatrics |
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Term
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Definition
| 0-10; based on facial expression of infant or child |
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