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60 Cards in this Set
- Front
- Back
CPE
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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 |
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Charting
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-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 |
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Temperature
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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 |
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Pulse
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-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 |
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Respiration
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-include 1 inhale/ 1 exhale=1rpm
- taken for 1 minute - normal range 16-20 RPM |
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Blood Pressure
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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 |
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Pulse Pressure
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Systolic minus diastolic equal pulse pressure
Should be @ a normal 30-90 30 below = low BP 90 above = high BP |
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Blood Culture
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looks for micro organism in the blood
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Plain Red Top
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-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 |
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Light Blue Tube
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- every person who goes under surgery must go under this test
-tests for coagulation testes |
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SST/Tiger Top
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serum, gel, cells-fibrogen
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Lavender
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-WBC, RBC, platelets, HCT % cells, % plasma, fibrogen, HBg (hemoglobin)
-buffy coat (WBC platelets) -cells |
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Billiruben
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-wrap tube with foil
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Medications
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1) Theraputic=treats symptoms or disease ex. tylenol,advid,analgesic, antibiotics
2) Preventive Medication ex. vitamins, immunization 3) Diagnostic = ex. MRI flouriscopy |
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Sources of Medications
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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) |
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Chemical Name
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precise chemical composition ex: NaCl
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Generic Name
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shorter version of chemical name
ex: acethaminophen |
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Brand or Trade Name
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shows legal ownership, copy mortons right
ex: tylenol, advil, motrin |
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Dr. order
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- Dr. order presciption look out for this / DNS=Do not substitute
- if DNS is not checked off pharmacist will automatically give you generic brand |
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PDR (Physician's Desk Reference)
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-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 |
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1
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2
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--- III |
3
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4
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4
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SS
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1/2
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po
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by mouth
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q
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every
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qd
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everyday
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Bid
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2x a day
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Tid
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3x a day
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Tid
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3x a day
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qid
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4x a day
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q.o.d
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every other day
ex. common medicine for elderly |
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h
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hour
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hs
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at bed time
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prn
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as needed
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u.d. (ut dict)
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as directed
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STAT
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immediately
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d.c.
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discontinue
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C |
with
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S |
w/out
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mg
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milligram (1,000 mg= 1 gram)
(1,000 gram = 1 kilo) |
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g
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gram
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ml
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milliliter
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L
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liter
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cc
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cubic centimeter
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TaB
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tablet
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cap
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capsulet (taken on empty stomach)
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gtts
gtt |
drops
drop |
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Tbs
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tablespoon
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tsp
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teaspoon
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npo
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nothing by mouth
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pc
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after meal
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AC
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before meal
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Biceps Brachii
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upper anterior arm
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Triceps
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upper posterior arm
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Pectoralis Major
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chest muscle
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Deltoid
Gluteus Medius Gluteus Maximus |
shoulder cap
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Trapizius
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located upper back and neck (looks like triangle)
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Latissimus Dorsi
Quadraceps Femosis |
located middle back that wraps under each arm
large muscle on anterior thigh |