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34 Cards in this Set
- Front
- Back
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List the parts of the patient history.
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CC, HPI, PMH, PSH, MEDS, ALL, FH, SH, ROS
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What is a good opening sentence for the HPI? Especially for rotations?
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"Name is an age ethnicity gender with/without significant medical history who has been having [Problem] for [time]."
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What are the parts of the mnemonic OLDCARTS?
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Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Treatments, associated Symptoms
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What should be included when documenting medications?
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Prescription, OTC, and supplements must all be mentioned. Useful to number.
Include: generic name, dosage, how many taken, what form, RoA, how often taken, indication. |
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Does one use bullet points in the HPI?
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No, the HPI should be written as a narrative - however, bullets can be used for other sections of the history.
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How often do you ask about allergies? What do you document?
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Ask about allergies at every visit - new allergies can develop over time. Common ones to ask about are latex, milk, nuts, eggs, and shellfish.
Be sure to document the type of reaction, whether it is a true allergy or an intolerance. If no allergies, use NKDA, NKFA. |
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What are the CAGE questions?
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They are questions to determine alcohol abuse - C: ever feel the need to cut back? A: ever feel annoyed when people talk about your drinking? G: ever feel guilty for drinking? E: "eye opener" Do you feel the need for a morning shot or beer?
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What are important parts of asking about recreational drugs?
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Have eye contact with the patient, ask about specific drugs, and always ask if they have ever used needle drugs.
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What is included in a CBC?
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WBC, Hb, Hct, Plt, MCV, RDW
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what is included in a chemistry panel?
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Na+, K+, Cl-, HCO3-, BUN, Creatinine, Glucose
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How do you calculate pack years? Example - a patient admits smoking 3 packs a day for 5 years then cutting down to 10 cigarettes per day for the last 10.
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Pack years = (# packs/day x #years)
3 packs x 5 years = 15 pack years 10 cigarettes / 20 cigarettes (per pack) = 1/2 x 10 years = 5 pack years Total: 20 pack years |
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What are the components of a SOAP note?
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Subjective, Objective, Assessment, Plan
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What are the parts of the mnemonic VINDICATES?
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Vascular, Infection/inflammatory/autoimmune, Neoplasm, Drugs, Iatrogenic, Congenital/Developmental/Inherited, Anatomic, Trauma, Environmental/Endocrine/Metabolic, Supratentorial
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How many etiologies are necessary for a DDx?
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Three
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What are some examples of statuses that one would write with a Dx?
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Stable, chronic, acute, labile, newly diagnosed, new onset
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What are the components of the plan?
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Medications - Laboratory Studies - X-ray Studies - Patient Education - OMT - Follow-up.
It is OK to combine the plan and assessment. |
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How do you correct an error you have written in a file?
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Draw a single line horizontally through the error, initial and circle initials above the error, date and time the error.
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What must be present on every page of medical documents?
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Patient's name, Patient MR# and/or DOB, date of encounter, signature and title (cursive), name printed beneath signature, current page #/total page #
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What 4 areas do you auscultate on the chest for heart beats, and what are you listening for?
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left and right 2nd intercostal space (aortic and pulmonic), left 4th intercostal space (tricuspid), left 5th intercostal space (bicuspid)
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What are some things to describe when listening to heart sounds?
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Timing, duration, pitch, intensity, pattern, quality, location, radiation, and variation with respiration
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What are the grades I-VI for heart auscultation?
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I: Barely audible in a quiet room
II: Clearly audible III: Moderately loud IV: Associated Thrill V: very loud with easily palpable thrill VI: Audible with stethoscope off chest, thrill visible |
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What are the palpable pulses? Four major ones (three extra)
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Radial, femoral, dorsalis pedis, posterior tibialis (popliteal, carotid, brachial).
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What are the grades for peripheral edema?
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1+ = slight pitting, disappears rapidly
2+ = shallow pit that disappears after 10-15 seconds 3+ = deep pit that may last more than a minute 4+ = very deep pit that lasts 2-5 minutes |
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What is Jugular Venous Pressure? How is it measured?
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Jugular venous pressure is an indirect measurement of right arterial pressure.
Technique: elevate patient's head 45 degrees, identify maximum point of oscillation in the internal or external jugular, measure this height above the sternal angle using a metric ruler and horizontal aid. Add 5 cm to result - 7-8cm is normal. |
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What do right sided S-ANS fibers innervate in the heart? Left sided S-ANS fibers?
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Right side fibers innervate right heart and SA node.
Left side fibers innervate left heart and AV node. |
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Viscerosomatic signals from the vagus nerve have what effect?
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Can cause indigestion, wheezing, N/V, SOB
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Sympathetic viscerosomatic signals from T1-T6 have what effects?
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Pain radiates to left arm, shoulder, and jaw as an aching sensation, or to the chest as a squeezing pain.
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What TART findings are associated with viserosomatic dysfunctions of the heart?
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Positive red reflex (on left especially), ropiness in musculature, segmental changes, positive Chapman's points, presence of pectoral trigger point.
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What would be some treatments for viscerosomatic dysfunctions from the heart?
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Calm S-ANS activity in T1-T6 to prevent facilitated segments, open thoracic inlet, perform pectoral traction for lymphatic drainage, treat rib sternum and hyoid dysfunction since all have fascial continuity with mediastinum, pay attention to cranial base and C2 for P-ANS.
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What is the normal order for impulse conduction in the heart?
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Sinoatrial node --> AV node --> bundle of His --> bundle branches --> purkinje fibers
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What is happening during the following: P wave, QRS wave, T wave?
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P wave: atrial depolarization
QRS wave: ventricular depolarization T wave: ventricular repolarization |
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What is the PR interval?
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Atrial depolarization and delay in AV junction - allows time for atria to contract before the ventricles contract.
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What are the three pacemakers in the heart and what are their normal rhythms?
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SA node - dominant pacemaker - intrinsic beat 60-100 bpm
AV node - back up pacemaker, intrinsic rate 40-60 bpm Ventricular cells - back up pacemaker, 20-45 bpm |
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What steps do you take in analyzing an EKG rhythm strip?
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1) calculate rate 2) determine regularity 3) assess P waves 4) determine PR interval 5) determine QRS duration;
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