with correct answers
Chief Concern Correct Answer-CC
Reason for seeking care
Pt's words, use quotes
History of Present Illness Correct Answer-HPI
Chronological account of cc and history
OLDCARTS
What is OLDCARTS? Correct Answer-O onset
L location
D duration
C character (describe)
A aggravating factors (what makes it worse)
R relief measures (what have they tried even if did not work)
T temporal factors (time of day, seasons, etc)
S severity (scale 1-10, describe if stabbing aching etc)
Past Medical History Correct Answer-PMH
Childhood illnesses
Immunizations
,Adult Illnesses
Surgeries/injuries
Communicable diseases
Medications
Allergies
Disabilities
Family History Correct Answer-FH
includes health status and age of immediate family members
2 generations
hereditary disorders
Current Health Status Correct Answer-CHS
personal status
occupation
habits
characteristics of daily living
sexual practices
hobbies/interests
recent travel
health habits and check-ups
Review of Systems Correct Answer-ROS
,relationship of CC to other body systems, general overall health
complaints in each system and the related symptoms
Physical examination order Correct Answer-Inspection
Palpation
Percussion
Auscultation
ABDOMINAL / GI :
inspection
auscultation
percussion
palpation
Aspects of inspection Correct Answer-use all senses to observe
throughout exam
provide privacy and dignity when able to
Aspects of palpation Correct Answer-touch, keep fingers together
light = up to 1 cm
deep = 1-4 cm
examine areas of pain last
palmar and finger pads= determine position, texture, size, consistency,
fluid, crepitus, forms of masses or structures
, ulnar surface = evaluate vibrations
dorsal surface = assess temperature
Aspects of percussion Correct Answer-striking one object against
another that produces vibrations and then sound waves
helps determine density in torso and trunk
Direct vs indirect percussion Correct Answer-Direct= striking hand or
finger directly on surface
Indirect= finger of one hand acts as the hammer and the finger of the
other hand acts as the striking surface
Tympanic Correct Answer-drumlike (gastric bubble)
Hyperresonance Correct Answer-booming sound (lungs of someone
with emphysema)
Resonance Correct Answer-hollow, normal healthy lungs
Dull Correct Answer-thud (over liver and dense areas)
Flat Correct Answer-soft dull (over muscles)