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60 Cards in this Set

  • Front
  • Back
CPE
Complete Physical Exam

1) Personal Data=DOB, age, SSN#, name, address

2) CC (Chief Complaint)=reason for visit. ex: "pt feels like "golf ball in throat"

3) PI (Present Illness)=elaboration or details on the CC
- duration (how long have had it)
- frequency (how often does it happen
-influencing factors (what makes it feel good or bad)

4) Past History- hospitalazation,allergies,surgeries, major illnesses, is there any serious illness ex. diabetes, high blood pressure, immunization, Hep B, medications, BCP (Birth Control Pills)

5) Family History (Immediate Family)
-parents, grandparents, siblings, childrens, spouses, aunts and uncles

6) Personal History
-habits, diet, excercise, family, occupation
Charting
-when making a mistake cross out w/a line and put initial @ the end

-use black pen only
-document facts only ex. patient appeared upset
Temperature
Oral= 3 minutes
= normal range 97-99
= average 98.6 degree

Rectal= 5 minutes
= normal range 98-100
= average 99.6

Axillary = 10 minutes
= normal range 96-98
= average 97.6

Tymphanic = 3 seconds
= normal range 97-99
= average 98.6
Pulse
-1 minute
-normal pulse 60-100 BPM
-regular or irregular
-record as 72BPM irregularweak
72BPM regularnormal

->radial @ wrist
->carotid @ neck
->brachial @ under armpit (use for infants
->temporal @ temple
->femoral @ groin
->popliteal @ back of knee
->apical @ heart
Respiration
-include 1 inhale/ 1 exhale=1rpm

- taken for 1 minute

- normal range 16-20 RPM
Blood Pressure
Systolic
-top #,1st beat,heartcontracting
-cutting off circulation to see how blood flow
-normal range 110-140

Diastolic
-last beat
-bottom #, heart at rest
-normal range 60-90
Pulse Pressure
Systolic minus diastolic equal pulse pressure

Should be @ a normal 30-90

30 below = low BP
90 above = high BP
Blood Culture
looks for micro organism in the blood
Plain Red Top
-looks or test for glucose, protein, iron, calcium, cholesterol, billirubin,liver, kidney function, ketons except cells

-must set for 30-45 min before putting @ centrofuge
Light Blue Tube
- every person who goes under surgery must go under this test

-tests for coagulation testes
SST/Tiger Top
serum, gel, cells-fibrogen
Lavender
-WBC, RBC, platelets, HCT % cells, % plasma, fibrogen, HBg (hemoglobin)

-buffy coat (WBC platelets)

-cells
Billiruben
-wrap tube with foil
Medications
1) Theraputic=treats symptoms or disease ex. tylenol,advid,analgesic, antibiotics

2) Preventive Medication
ex. vitamins, immunization

3) Diagnostic = ex. MRI flouriscopy
Sources of Medications
1) Plants
2) Synthetic(drugs made in labs)
3) Animals
- ex. pig (tricuspid) used
for people w/heart
problems, losses blood
similar to people
4) Minerals
ex. potassium, iron,
lithium (mood stimula-
tor), B12 (boast immu-
nity)
Chemical Name
precise chemical composition ex: NaCl
Generic Name
shorter version of chemical name
ex: acethaminophen
Brand or Trade Name
shows legal ownership, copy mortons right

ex: tylenol, advil, motrin
Dr. order
- Dr. order presciption look out for this / DNS=Do not substitute

- if DNS is not checked off pharmacist will automatically give you generic brand
PDR (Physician's Desk Reference)
-use this as a tool

-info about medications

-what is it, who can use it
1. White Index=manufacturers index A-Z Listing
2. Pink Index= product name
3. Blue Index=product category
4. Yellow Index=generic & chemical name
.
--
I
1
..
--
II
2
...
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III
3
4
4
SS
1/2
po
by mouth
q
every
qd
everyday
Bid
2x a day
Tid
3x a day
Tid
3x a day
qid
4x a day
q.o.d
every other day
ex. common medicine for elderly
h
hour
hs
at bed time
prn
as needed
u.d. (ut dict)
as directed
STAT
immediately
d.c.
discontinue
-
C
with
-
S
w/out
mg
milligram (1,000 mg= 1 gram)
(1,000 gram = 1 kilo)
g
gram
ml
milliliter
L
liter
cc
cubic centimeter
TaB
tablet
cap
capsulet (taken on empty stomach)
gtts

gtt
drops

drop
Tbs
tablespoon
tsp
teaspoon
npo
nothing by mouth
pc
after meal
AC
before meal
Biceps Brachii
upper anterior arm
Triceps
upper posterior arm
Pectoralis Major
chest muscle
Deltoid

Gluteus Medius

Gluteus Maximus
shoulder cap
Trapizius
located upper back and neck (looks like triangle)
Latissimus Dorsi


Quadraceps Femosis
located middle back that wraps under each arm

large muscle on anterior thigh