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A reads text to speech;
52 Cards in this Set
- Front
- Back
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Enter room |
Greet patient by name Introduce self Smile Sit down Shake hands |
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CC |
What brings you in today? Can you tell me more about that? Is there anything else you want to discuss today? |
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HPI |
OLDCAARTS |
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PMH |
MIIMASH |
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Family History |
Parents, siblings, alive?, disease?, cause of death |
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Social |
SHORES |
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ROS |
** |
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Constitutional |
Weight change, fever, chills |
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Eyes |
Glasses, Bluriness, Tearing |
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HEENT |
head trauma, headache, hearing loss |
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Breasts |
breast pain, breast discharge, breast lumps |
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CV |
High blood pressure, chest pain, palpitations |
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Respiratory |
Short of breath, wheezing, cough |
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GI |
Appetite changes, nausea, indigestion |
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GU |
Urinary frequency, painful urination, blood in urine |
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Integument |
Skin changes, skin sores, new moles |
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Neuro` |
Numbness, tingiling, seizures |
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MSK |
Muscle pain, joint stiffness, joint swelling |
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Endocrine |
Heat intolerance, cold intolerance, diabetes |
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Psych |
Mood change, anxiety, depression |
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Heme-lymph |
easy bruising, anemia, prolonged bleeding |
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Allergic-immunologic |
allergies, hives, lymph node swelling |
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Physical exam |
** |
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Vitals |
BP Pulse Respiration rate |
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Head |
Scalp and hair Cranial bone palpation Palpate sinuses |
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Eyes |
** |
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Inspection |
External eye - brows, lids, palpebral fissures, lacramial gland Eye - sclera, cornea, iris, conjunctiva, blood vessels, icterus, arcus senilis, conjunctivitis |
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Pupils |
Corneal light reflection direct and indirect response to light Accomodation (near far) |
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Fundoscopic |
Right eye to right eye Ocular fundus: red reflex, vessels, cup, disc, fovea, retinal background, AV nicking, copper wiring, hemorrhaging |
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Ears |
** |
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External |
Skin, position and alignment, auditory meatus, tophi, mastoid Move auricle and pull tragus for tenderness |
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Otoscope |
Canal, tymphanic membrane, cone of light, umbo, malleus |
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Nose |
External: symmetry and lesions Internal: septum, discharge, polyps, mucosa, color, turbinates |
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Oral mucosa |
Teeth, gums, tonsils, uvula, floor of mouth, palate, pharynx |
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Cranial nerves |
2 - vision card 3, 4, 6 - H with finger 5 - light touch (forehead, cheeks, jaw); clench teeth while palpates temporalis m 7 - smile, frown, raise eyebrows 8- whisper test (fingers) 9, 10 - say ahh 11 - head turn and shoulder shrug against resistance 12 - stick out tongue
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Neck |
Inspect - symmetry, masses, etc lymph nodes - occipital, anterior cervical, pre-auricular, submental, supraclavicular, posterior auricular, posterior cervical chain, submandibular, sublingual |
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Neck |
Trachea positon |
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Neck |
Thyroid gland |
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Neck |
Carotid pulse palpitation |
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Neck |
Ausculate for carotid bruits |
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Lungs |
Signs of respiratory distress Inspect thoracic cage (ask patient to remove shirt) Inspect skin Ausculate (4 anterior, 4 posterior, axilla (R+L) ) Ask patient to breathe through mouth |
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Heart |
Heaves and lifts on precordium A PET Mary points |
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Abdomen |
Inspect (contor, skin) Ausculation (bowel, aortic, renal bruits) |
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Percussion |
4 quadrants, liver lower edge |
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Palpate |
4 quadrants (light than deep) liver aorta |
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Neuro |
** |
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Neuro |
Sensory (arms, hands, legs, feet) (L and R symmetrical?)
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Reflexes |
Biceps, tricepts, brachioradialis, patellar, achilles |
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Cerebellar |
Rapid alternating movements Heel to shin Romberg |
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MSK |
Gait (normal walk, heels, toes, tandem gait) |
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Muscle strength |
Shoulder (add, ab, flexion, extension) Fingers (ab, add) Hips (Flexion) Knees (extension, flexion) Feet (dorsiflexion, plantar flexion) |
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Lower extermity |
Posterior tibial pulse Dorsalis pedis |
