Bates Chapter 1 Flashcards | Quizlet

Bates Chapter 1

9/27/16, 10:06 PM

43 terms by room220PA

Components of Adult Health History

1. Identifying data and source of history

2. Chief Complaint
3. History of Present Illness
4. Past Medical History
5. Family History
6. Social History
7. Review of Systems
ICHPFSR- I can't help people find shitty
rashes

Comprehensive vs. Focused Exam

Comprehensive: New patients, full exam,

fundamental and personal knowledge
about patient, identifies physical causes
related to patient concerns, creates
platform for health promotion through
patient education
Focused: Routine, urgent care visits,
symptoms related to a specific body
system, addresses focused concerns or
symptoms, applies exam methods relevant
to assessing the concerns or problem

Seven attributes of a symptoms

Location, quality, quantity or severity,

timing (onset, duration, frequency),
setting, factors that aggravate or relieve
the symptom, associated manifestation

ROS

Skin, HEENT, neck, respiratory,

cardiovascular, gastrointestinal, urinary,
musculoskeletal, neurological, psychiatry,
endocrine, hematology

ROS skin

Rashes, lumps, itching, dryness, color or

size change of moles or lesions, hair and
nail changes

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ROS eyes

Vision, glasses or contacts, pain, redness,

blurry or double vision, flashing lights,
specks

ROS head and ears

Headaches, head injury, decreased

hearing, tinnitus, earache

ROS nose

Nosebleeds, discharge, stuness

ROS throat

Hoarseness, thrush, sore tongue

ROS neck and breast

Lumps, swollen glands, pain

ROS respiratory

Cough, sputum, dyspnea (shortness of

breath), hemoptysis (coughing up blood)

ROS cardio

Chest pain, tightness, swelling

ROS GI

Heartburn, constipation, rectal bleeding

What does the Physical exam include?

1) General survey
2) Vital signs
3) Skin
4) Mental status

What are the parts of the SOAP note?

Subjective
Objective
Assessment
Plan
- education
- F/u(return)

What is included in the subjective?

Pt history (CC, HPI, Allergies,

immunizations, meds, PMHx, surgical Hx,
Family Hx, Social History, ROS
(CHA IM Pissed She Fed Social Rats)

Objective

Physical exam findings, results of

diagnostic tests
Vitals, General appearance, Exam

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Assessment

Identify all absolute and working

diagnosis (acute and chronic)
Include past diagnosis if important to
primary diagnosis

Plan

1) Management/intervention for ID Dx
2) Lab and diagnostic tests
3) Pharmacological and non-pharm
treatment
4) Referrals
5) Pt education
6) F/u
(My Lovely Pig Reads Enlightening Films)

What are the steps for preparing a

physical exam?

1) Approach pt
2) Adjust lighting and environment
3) Check equipment
4) Ensure pt comfort
5) choose the sequence of examination
(AAECS)

Cardinal techniques of exam?

1) Inspection
2) Palpation
3) Percussion
4) Auscultation
(I Pound Plenty Ass)
Abd exam
1) Inspect
2) Auscultate
3) palpation
4) percussion

Inspect

1) Inspection - close observation, details

of general appearance, behavior, and
movement
(BAM)

Palpation

tactile pressure from palmar fingers/pads.

Assess for skin changes, warmth,
tenderness, masses, pulses, crepitus (So
Would The Mom Please Creep)

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Percussion

Use of striking or plexor finger to deliver

rapid tap against distal pleximeter finger
to evoke a sound wave. Assess for
Dullness, Resonance, Tactile vibration
(Dull Red Tacts)

Auscultation

Use of diaphragm or bell of stethoscope

on direct skin to detect heart, lung, and
bowel sounds (He Loves Bowls)

ROS Urinary

Frequency, burning or pain, blood in urine

ROS Musculoskeletal and Extremity

Extremity - calf pain with walking,

cyanosis, edema
Musculoskeletal - stiness, back pain,
muscle or joint pain

ROS Neurologic

Dizziness, weakness, tingling, numbness

ROS Hematologic and Endocrine

Hematologic - easy bruising, easy

bleeding
Endocrine - heat or cold intolerance,
sweating, frequent urination

ROS Psychiatric

Nervousness, depression, memory loss,

stress

Subjective vs. Objective

Subjective: What the patient tells you,

from chief complaint through ROS
Objective: All physical exam findings

Identifying Data

Age, gender, occupation, mental status

Chief Complaint

- Exact reason the pt has sought care.

Nature and duration should be included.
- Use quotations
- Include demographics (race and age)

History of Present Illness

- Describes how each symptom

developed
- include 7-8 attributes of the pain or
symptom

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OPQRST (7-8 attributes of the pain or

symptom)

Location, Quality, Quantity or severity,

timing (onset, duration and frequency),
setting, factors that have aggravated or
relieved, associated manifestations
O - onset
P - provoking
Q - quality
R - radiation
S - severity
T- timing

Pertinent Positives and Negatives

-Information obtained from your review of

systems which pertains to the chief
complaint
- Aids in formulating a dierential
diagnosis
- Aids in ruling in or out diagnosis
- Ex. "Earache," do you have any ringing?

OLD CARTS

Onset
Location
Duration
Character
Aggravating and Alleviating
Radiation
Timing
Severity

SOCRATES

Site
Onset
Character
Radiation
Associations
Time Course
Exacerbating/relieving factors
Severity

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Past Medical history

Childhood illnesses
Adult illnesses: medical, surgical,
OB/GYN, psychiatric
Medications (dose, frequency)
Allergies: Medications, environmental,
latex, food
Health Maintenance: Immunizations,
screening, LNMP (last known menstrual
period), last PE (last physical exam)

Past Surgical History

-Surgeries (date and indication)

- Procedures
- Hospitalizations

Family History

- Outlines or diagrams of age and health

or age and cause of death of :
grandparents, parents, siblings
- Also document presence or absence of
specific illnesses in family. This can include
outside immediate

Basic Genogram Symbols

Male - square
Female - circle
Triangle - child in utero
Double slash - Divorced
Box with X - deceased
Triangle with X - abortion

Psychosocial/Social History

- Living situation
- Education level
- Occupation
- Nutrition/Diet
- Smoke/drink/illicit drug use
-sexual history/domestic violence
- alternative health practices

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