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77 Cards in this Set
- Front
- Back
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What are the 4 major objectives of Clinical Problem solving?
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1. Identify the various components of the patient case
2.Differentiate between subjective and objective info 3.Develop patient specific questions used to obtain a complete patient history 4.Develop a problem list, assessment and plan for patient |
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What are the 5 components of the patient note?
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1. Tell a clear, concise story of the patient
2. Date & Time 3. Title 4.Patient Name and medical number 5.Signature and contact # |
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What are the components of the patient database?
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CC, HPI, PMH, MH, Allergy History, FH, SH, ROS, Results of PE, Lab findings, Problem list, SOAP note
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What is CC?
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Chief Complaint- why patient is seeking medical attention, why they are admitted to hospital
i.e. SOB, leg pain, etc |
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What is HPI?
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History of Present Illness- ask the patient to explain things about the illness
i.e. when it started, when/how it is exacerbated, when it is improved |
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What is PMH?
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Past Medical History- Lists the patients past and current diagnoses
i.e. hypertension 5 yrs, hyperlipidemia 2 yrs, asthma |
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What is MH?
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Medication History- Should include all current medications (prescription, OTC, alternative), include: name, dose, form, route of administration, schedule, duration of therapy
i.e. Lisinopril 10mg PO daily X's 3 yrs |
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What is Allergy History?
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Patient's allergies (drug and non-drug) should be listed, include: name, class, specific reaction type, report TRUE allergies
i.e. Rash to PCN's (allergy) NOT- Constipation on Oxycodone (side effect) |
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What is FH?
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Family History- Includes age and health of patients: parents, siblings, children. If relative deceased cause of death should be provided
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What is SH?
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Social History- Include info on the patients social habits, include: tobacco, alcohol, rec. drug use. Also include: marital status, occupation, living exposures, diet, insurance status
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What is ROS?
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Review of Systems- Last component of the patient history, relies on patient responses, question are asked regarding each SYSTEM of the body
Information is SUBJECTIVE |
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What is PE?
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Physical Exam- Reports what the clinician could see, feel, or hear during a patient exam. Usually starts with a GEN (general statement) of how the patient looks
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Physical Exam - VS
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Vital Signs (BP, pulse, Temp., Respiratory Rate, Height & Weight)
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Physical Exam - HEENT
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Head Ears Eyes Nose and Throat
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Physical Exam - COR
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Coronary
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Physical Exam - CHEST
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CHEST
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Physical Exam - ABD
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Abdomen
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Physical Exam - GU
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Genitourinary
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Physical Exam - RECT
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Rectal
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Physical Exam - EXT
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External
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Physical Exam - NEURO
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Neurological
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What are they SOAP Note components?
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Subjective info
Objective info Assessment Plan |
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What is an Assessment?
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An overall summary statement reflecting the patients overall health related to the problem at hand
i.e. what is happening to the patient, cause, acute vs chronic, current therapy |
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What is a Plan?
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After assessment the plan is developed. What is the goal of therapy? Cure or control? Acute vs chronic. Prevent long term complications or mortality? Improve compliance or cost?
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Name things to consider when creating a plan
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Contraindications of medications
Precautions on medications Allergies Drug-Drug interactions Compliance Issues Cost Lifestyle modifications Patient Education |
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What is Sensitivity in a lab test?
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The ability of a test result to test positive in patients that do have the disease
i.e. Test for WBC count allows you to know that there is an infection |
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What is Specificity in a lab test?
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The ability of a test result to be negative in patients without the disease
i.e. Test patient with elevated WBC for pneumonia- negative |
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Name 8 types of specimen samples
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Blood
Urine Fecal Sputum Tissue CSF Sweat Gastric Secretions |
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Name 4 types of vascular access
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Venipuncture
Finger Sticks Heel Sticks (infants) Arterial Line |
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Create the Electrolyte Panel
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Na Cl B-U-N
Glucose K CO2 Scr Ca Mg PO4 |
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Normal Range of Sodium
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Na 135-145 mmol/L
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Normal Range of Potassium
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K 3.4-4.8 mmol/L
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Normal Range of Chloride
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Cl 100-108 mmol/L
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Normal Range of Carbon Dioxide
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CO2 24-30 mmol/L
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Normal Range of Blood Urea Nitrogen
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B-U-N 8-25mg/dL
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Normal Range of Serum Creatinine
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Scr 0.7-1.5mg/dL
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Normal Range of Glucose
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Glucose 70-110mg/dL
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Normal Range of Calcium
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Ca 8.5-10mg/dL
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Normal Range of Magnesium
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Mg 1.4-2 mEq/L
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Normal Range of Phosphorus
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PO4 2.6-4.5mg/dL
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Primary extracellular cation
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Na+
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Functions of Sodium
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Regulates osmolality
Maintains transmembrane electric potential for neuromuscular function Excreted by Kidneys (skin and GI) |
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Cause and Signs of Hypernatremia
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Na level greater than 145mmol/L
Causes:fever, burns, diabetes insipidus Signs/Symptoms:thirst, confusion, weakness, increased urine output sodium |
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Cause and Signs of Hyponatremia
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Na level less than 135mmol/L
Cause:hyperglycemia (Na from ICF to ECF) Extracellular Vol. depletion from diarrhea, vomiting, kidney damage, burns Accumulation of water caused by heart failure, cirrhosis Signs:confusion, seizures, edema |
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Primary intracellular cation
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K+
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Functions of Potassium
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Regulates muscle/nerve excitability
Maintains acid/base balance Regulated by insulin, glucose, acid/base balance, renal function, GI and skin losses |
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What is Hyperkalemia?
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K level above 4.8
Causes: renal disease, diabetes, Addison's disease, Medications - ACE Inhibitors and Potassium Sparing Diuretics Symptoms: Diarrhea, muscle weakness, **Arrhythmia/EKG changes |
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What is Hypokalemia?
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K level less than 3.5
Causes: vomiting, GI losses, prolonged diarrhea, Cushing's disease, Medications- dextrose, HCTZ, furosemide, Steroids, albuterol Signs/Symptoms: Constipation, muscle weakness, confusion, EKG changes |
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Primary extracellular anion
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Cl-
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Functions of Chloride
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Maintains resting membrane potential
maintains acid/base balance regulated by the kidneys |
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What is Hyperchloremia?
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Cl above 108mmol/L
Cause Metabolic acidosis, respiratory alkalosis, hypernatremia, dehydration |
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What is Hypochloremia?
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Cl less than 100mmol/L
Causes:hyponatremia, GI loss (diarrhea) nasogastric suction, vomiting |
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CO2 excreted by the lungs and acts as an ______ in the respiratory acid/base system
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acid
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CO2 elevation = respiratory __________
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acidosis
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CO2 decrease = respiratory _________
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alkalosis
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What is the B-U-N?
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The Blood-Urea-Nitrogen reading is an indication of the concentration of urea nitrogen-an end product of protein metabolism
Produced by the liver Filtered by the kidneys Elevation could mean: renal failure, dehydration, GI bleeds, high protein diet Decreases: Liver disease |
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What is Scr?
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Serum Creatinine is the product of muscle breakdown
It is filtered and secreted but not reabsorbed Elevations:medications, renal disease Decreases: low muscle mass-elderly |
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What is the function of Glucose?
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Fuel for cellular function, skeletal muscle function
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How is Glucose obtained?
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carbohydrates
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How is Glucose stored?
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Stored in the liver as glycogen, adipose tissue as fats and triglycerides
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What is Hyperglycemia?
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Blood Glucose is above 126mg/dL
Causes: Food, diabetes, post-MI, infection, Steroids, Diuretics Signs/Symptoms:polyuria, polydipsia, polyphagia |
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What is Hypoglycemia?
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Blood Glucose less than 55mg/dL
Causes:exercise, poisoning (ETOH, salicylates, insulin) Signs/symptoms: palpitations, weakness, sweating, irritability, headache |
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What is the function of Calcium?
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Bone and tooth structural integrity
Nerve impulse muscle contraction |
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Most abundant mineral in the body
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Calcium
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Calcium is regulated by Vitamin ___ through _______
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D
absorption |
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Calcium is regulated by __________ hormone and ________ through _______
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parathyroid hormone
calcitonin renal excretion |
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50% calcium is _______ bound
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protein
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What are the causes and symptoms of hypercalcemia?
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Causes: Bone neoplasms, antacids, chronic diuretic
symptoms: muscle weakness, anorexia, GI disturbances, EKG |
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What are the causes and symptoms of hypocalcemia?
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Causes: hypoparathyroid, vitamin D deficiency, alcoholism, drugs
symptoms: numbness or tingling- fingers, around mouth, fatigue, tetany, coma |
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What is the function of Magnesium?
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Neuromuscular function
co factor for the movement of Na, K, and Ca in and out of cells Excreted by the kidneys |
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What are the causes and symptoms of hypermagnesemia?
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Causes: Renal failure, hyperparathyroidism, magnesium antacids
Symptoms:muscle weakness, confusion, respiratory depression, arrhythmia |
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What are they causes and symptoms of hypomagnesemia?
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Causes:diarrhea, diuretics, alcohol, hypokalemia, hypophosphatemia
symptoms:muscle tremors, ocular nystagumus, altered mental status, arrhythmia, seizures |
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Second most abundant intracellular cation
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Mg
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What is the function of Phosphorus?
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Energy metabolism, bone integrity, release of oxygen from hemoglobin
Regulated by equilibrium of Calcium |
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Primary intracellular anion, found in bone
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Phosphorus
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What are the causes and symptoms of hyperphosphatemia?
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cause:renal failure, bone disease, DKA, androgens, lasix, HCTZ
symptoms: Calcium deposits in soft tissue, bone pain |
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What are the causes and symptoms of hypophosphatemia?
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Cause: acute ETOH intoxication, malabsorption, starvation, aluminum antacids, steroids, diuretics, anticonvulsants
symptoms: muscle weakness, bone pain, rhabdomyolysis, seizures, coma |
