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4 Cards in this Set
- Front
- Back
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Physical Exam portion of H&P
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Vitals: T, BP, P, RR, O2Sat
Gen: NAD HEENT: NCAT, PERRL, EOMI, MMM Neck: no LAD, no JVD, no carotid bruits CV: RRR, no m/r/g, no heaves/thrills, PMI midaxillary 5th intercostal space, cap refill under 2 sec, radial/DP pulses 2+ bl Pulm: CTAB, no wheezing/rhonci/rales Abd: NABS, NT/ND, soft, no HSM, no masses Ext: No c/c/e Skin: No rashes/lesions Neuro: A&O x 3, CNII-XII grossly intact |
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A/P portion of H&P
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A: assessment
P: Problem-based; diagnostic vs therapeutic PPX (prophylaxis) Code Status: Dispo: HLOC |
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Admission orders
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ADC VANDML
Admit to (attending) Diagnosis (or primary symptom) Condition (stable) Vitals (per unit routine or 8h) Allergies Nursing: anything other than vitals, ex: BG checks Diet: NPO, specific diet, etc. Meds Labs/testing: specify time (STAT, AM/PM, etc) |
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CXR Interpretation
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RIPABCDEF
Rotation (spinous processes between clavicles) Inspiration (9-11 ribs)--note if appropriate Airway (trachea midline vs deviated) Bones (fractured?) Cardiac silhouette (cardiomegaly? aortic arch?) Diaphragm Everything else (soft tissues, wires/tubes) Fields (infiltrate, effusion, LNs, masses/lzns) Overall impression (normal vs not) |
