Test Bank For Advanced Assessment 4th Edition Interpreting
Findings and Formulating Differential Diagnoses by Mary Jo
Goolsby; Laurie Grubbs
a comprehensive health history/exam - ANSWER: appropriate for new patients in the
office or hospital; provides fundamental and personalized knowledge about the
patient; provides a baseline for future assessments; creates a platform for health
promotion through education and counseling
a focused health history/exam - ANSWER: appropriate for established patients
during routine/urgent visits; addresses focused concerns of symptoms; assesses
symptoms restricted to a specific body system; applies examination methods
relevant to assessing the concern or problem
identify examples of when you would obtain a comprehensive health history/exam -
ANSWER: patient new to practice; patient needs comprehensive exam for
school/work
a focused health history exam is appropriate - ANSWER: routine follow up visits;
urgent care visits
subjective data - ANSWER: symptoms - description of the problem from the patient's
perspective
objective data - ANSWER: what the health professional observes by inspecting,
palpating, percussing, and auscultating during the physical examination
OLDCARTS - ANSWER: Onset
Location
Duration
Characteristics
Aggravating and Alleviating Factors
Related Symptoms
Treatment
Severity
OPQRST - ANSWER: onset, provocation, quality, radiation, severity, time
BMI normal range - ANSWER: 18.5-24.9
BMI underweight - ANSWER: <18.5
BMI overweight - ANSWER: 25-29.9
BMI obese class 1 - ANSWER: 30-34.9
, BMI obese class II - ANSWER: 35-39.9
BMI extreme obesity - ANSWER: greater than or equal to 40
chief complaint - ANSWER: the main reason for the patient's visit/keep max to three
words
History of Present Illness (HPI) - ANSWER: information gathered regarding the
symptoms and nature of the patient's current concern; use OLDCARTS; allergies,
medications, supplements
Review of Systems (ROS) - ANSWER: A systematic approach for collecting the
patient's self-reported data on all body systems.
Hyperresonance - ANSWER: an abnormal booming sound produced during
percussion of the lungs; common over hyper-inflated lungs of COPD or asthma;
unilateral -> a large PTX or air-filled bulla
resonance - ANSWER: loud, low pitch, long duration; healthy lung
dullness - ANSWER: A flat percussion tone that is medium intensity, medium pitch,
medium duration, replaces resonance when fluid or solid tissue replaces air-
containing lung or occupies the pleural space (lobar PNA, hemothorax, pleural
effusion, empyema, fibrous tissue, or tumor)
vesicular - ANSWER: the soft, low-pitched, normal breath sounds heard throughout
inspiration, continue without pause through expiration, and then fade away about
one third of the way through expiration; heard over most of peripheral lung fields
Broncho-vesicular breath sounds - ANSWER: inspiratory=expiratory sounds (almost
equal in duration); normally heard in the 1st and 2nd interspaces anteriorly and
between the scapulae; if heard in locations distant, suspect replacement of air-filled
lung by fluid-filled or consolidated lung tissue
bronchial - ANSWER: louder, harsher, and higher in pitch; expiratory>inspiratory in
duration; a silent gap between the inspiratory and expiratory sounds present
tracheal - ANSWER: loud harsh sounds heard over the trachea in the neck;
inspiratory=expiratory
crackles - ANSWER: intermittent, nonmusical, brief; fine -> high pitched, very brief;
coarse-> louder, lower in pitch
wheezes - ANSWER: audible whistling during inspiration (stridor-sign of upper airway
obstruction in the larynx or trachea) or expiration (COPD), or continuous (asthma,
CHF)
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