HST History, Vital Signs and Physical Exam

Blood pressure is measured with a

sphygmomanometer

_____ hypertension occurs as a result of other conditions such as kidney or heart disease

secondary

Primary or _____ hypertension is hypertension without identifiable cause

essential

The standard unit for measuring blood pressure is mm of ____

mercury

When evaluating for orthostatic hypotension, if the pulse rate increases more than 10 bpm or if the blood pressure drops more than points this is documented as a positive ____

Tilt test

You should insert a rectal thermometer _____ for children

½-1 inches

You should insert a rectal thermometer _____ for adults

1 ½ inches

To take the tympanic temperature in an adult pull the pinna

Up and back

To take the tympanic temperature in a child pull the pinna

Down and back

Height should be recorded to the nearest

¼ inch

Auscultatory Gap

Period of diminished or absent sounds during Phase 2
(Often a sign of hypertension & can lead to falsely low systolic BP or falsely high diastolic BP)

What is the interview technique?

P: Provoke or Palliative
Q: Quantity or Quality
R: Region or Radiation
S: Severity Scale
T: Timing

Cheif Complaint

Subjective statement made by the patient describing the most significant signs or symptoms

Anthropometric measurement

Noninvasive quantitive measurements of the body. etc: height, weight, head circumference, BMI, and skinfold thickness

Differential diagnosis

Determining the correct diagnosis when two or more diagnosis are possible

What position is this?

Supine

What position is this?

Sims’

The process of listening to body sounds

Auscultation

A forecast of the probably outcome and course of a disease

Prognosis

Tapping or striking the body to determine location, size and denstiny of a body structure or organ

Percussion

The visual examination of the patient’s entire body and overall appearance

Inspection

Repeating back what the patient says in your own words

Restatement

Objective information that can be detected by a person other than the affected person

Sign

Abbreviation for history is:

H/O

The SOAP method of documentation is short for:

S-Subjective, O-Objective, A-Assessment, P-Plan

WNL is short for:

Within normal limits

NKA is short for:

No known allergies

A body temperature above normal

Febrile

CC is short for:

Chief complaint

Type of drape often utilized for proctologic exams/a sterile body sheet with a hole or "window" that exposes the incision site

Fenestrated drape

Instruments to better examine the nasal cavity

Penlight and Nasal speculum

Pressure at phase 1 of Korotkoff sounds

Systolic

Exam position to evaluate the back and feet

Prone

Temperature at the armpit

Axillary

Pressure at phase 5 of Korotkoff sounds

Diastolic

Absence of respirations

Apnea

Rapid breathing

Tachypnea

Heart points to the right side of the chest

Dextrocardia

Machine that measures both pulse and Oxygen saturation

Pulse Oximeter

Process of measuring

Mensuration

physical exam by touching

Palpation

What materials are required for evaluation of the ears and hearing

Otoscope and audiometer

Systematic moving of a patient’s body parts for exam purposes

Manipulation

Slow heart rate

Bradycardia

What instrument is needed for an exam of the female genitalia

Vaginal speculum

The blood pressure cuff should be what distance above the elbow

1 Inch

The sounds heard while checking blood pressure

Korotkoff sounds

Subjective information provided by the patient, not observable or measurable

Symptom

Primary condition for when a patient is receiving care. Abbreviated DX:

Diagnosis

Your patient needs to have the front of the body examined but is short of breath and can’t sit unsupported, what is a good alternative position?

Fowler’s

If a female patient is unable to get in the lithotomy position because of severe arthritis, what is an alternative position?

Dorsal Recumbent

How long after eating and drinking should you wait to check an oral temperature

15 minutes

An exceptionally high fever

Hyperpyrexia

Pulse that feels like it leaps out then quickly disappears

Bounding pulse

A fast pulse

Tachycardia

Crackling sounds that indicate fluid in the lungs

Rales

The instrument that amplifies body sounds

Stethoscope

Low blood pressure that results from moving from a lying to sitting or standing position

Orthostatic or postural hypotension

Deep snoring or rattling breathing sounds associated with parietal obstruction of airways

Rhonchi

To take the tympanic temperature in a child, pull the pinna:

Down and back

What are the three body meadurements for infants

Length, width, and head circumference

Height should be recorded to the nearest

¼ Inch

What position is this?

Semi-Fowler’s

What position is this?

High-Fowler’’s

What position is this?

Prone

What position is this?

Trendelenberg

What position is this?

Knee Chest

What position is this?

Dorsal Recumbent

What position is this?

Lateral Recumbent

What position is this?

Lithotomy

What position is this?

Sitting

What position is this?

Proctologic

Proctologic position is also known as

Jackknife

Instrument(s) used to examine the eyes/vision

Opthalmascope

Instrument(s) used to examine the ears/hearing

Otoscope

Instrument(s) used to examine the nose & sinus

Penlight/Nasal speculum

Instrument(s) used to examine the chest & lungs

Stethoscope

Instrument(s) used to examine the Heart

Stethocope/Percussion

Instrument(s) used to examine the mouth & throat

Tongue depressor

What position is this?

Dorsal Recumbent

What position is this?

Lateral Recumbent

Instrument(s) used to examine the male genitalia

gloves

Instrument(s) used to examine the rectum

gloves, lubricant

Instrument(s) used to examine the neurologic system

Penlight, relfex hammer, or verbal questions

Normal rectal temperature

98.9°-109.1°

Normal oral temperature

97.8°-99.1°

Normal axillary temperature

96.6°-98°

Formula to convert °C to °F

°F=(°Cx9/5)+32

Normal adult pulse rate

60-100 BPM

Normal child pulse rate

80-130 BPM

Normal adult respiratory rate

12-18 RR

Normal adult systolic blood pressure

Less than 120

Normal adult diastolic blood pressure

Less than 80

What is this pulse site

Carotid

What is this pulse site

Brachial

What is this pulse site

Femoral

What is this pulse site

Popliteal

What is this pulse site

Posterior tibial artery

What is this pulse site

Dorsalis pedis artery

What is this pulse site

Radial