Patient History and Assessment Flashcards
6 cards from real RMA practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 6 Patient History and Assessment flashcards as text
When obtaining a patient's past medical history (PMH), which category of information is included?
Answer: Previous illnesses, hospitalizations, surgeries, and significant medical diagnoses
Past medical history includes previous illnesses, chronic conditions, hospitalizations, surgeries, and significant diagnoses that are no longer active — providing context for the patient's overall health background.
The OLDCARTS mnemonic is used to characterize a patient's chief complaint during the history of present illness (HPI). What does the 'C' in OLDCARTS stand for?
Answer: Character
In OLDCARTS, C stands for Character — describing the quality of the symptom (e.g., sharp, dull, burning, pressure-like, throbbing), which helps differentiate diagnoses.
A patient's record shows a blood pressure of 90/60 mmHg, heart rate of 118 beats/min, respiratory rate of 22 breaths/min, and temperature of 38.9°C. Which clinical picture do these vital signs MOST suggest?
Answer: Systemic inflammatory response (possibly sepsis)
Low blood pressure, tachycardia, tachypnea, and fever together meet criteria for Systemic Inflammatory Response Syndrome (SIRS), raising concern for sepsis — a medical emergency requiring immediate evaluation.
When recording patient height and weight, what action should be taken to ensure accuracy?
Answer: Have the patient remove shoes, stand straight, and measure in a standardized position with the stadiometer
Height must be measured with a calibrated stadiometer with the patient shoeless, standing upright with heels together and eyes looking forward (Frankfort plane), to ensure reproducible, clinically valid measurements.
During a patient intake, the medical assistant asks about the patient's immunization history. Which ADULT vaccine is recommended ANNUALLY?
Answer: Influenza vaccine (flu shot)
The CDC recommends that all persons 6 months and older receive an influenza vaccine every year, as influenza strains change annually and vaccine immunity wanes within months.
A patient states they have had lower back pain for the past three weeks. Using the PQRST pain assessment tool, what does the 'Q' represent?
Answer: Quality — what the pain feels like descriptively
In the PQRST pain assessment mnemonic, Q stands for Quality — asking the patient to describe the character of the pain in their own words (e.g., sharp, dull, aching, burning, stabbing, throbbing).