clinical 2
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| What is subjective information? | Information supplied by the pt.
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| What is objective information? | Information obtained by the doctor or M.A. by examination
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| What does POMR mean? | Problem Oriented Medical Record
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| What goes on the right side of the chart? | Progress sheet, cc, vitals, history
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| What does SOAP Mean? | Subjective Objective Assessment Plan
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| What is Cheif Complaint? How is it written? | The reason why the pt. is at the doctor. It is written in the pt.'s own words.
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| What are the steps for filing? | Inspection, Indexing, coding, sorting, storing
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| Inspection of filing? | Divide reports information
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| Indexing? | organizing by name, subject, or other identiffication which to file under
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| Coding? | Marking the index identiffier
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| Sorting? | sort the material, i.e. alphabetically
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| Storing? | locate file in appropriate location. i.e. draw or shelf.
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| What is purging? | Means clean out. Thining our charts.
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| How long are the charts kept? | 6 years
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| What is chronological filing? | filling according to date
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| What is alphabetic filing? | Names are organized like a telephone book.
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| What filling offers the most privacy? | Numerical
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| What does CHEDDAR mean? | Cheif complaint History Exam Details Drugs Assessment Return
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| How does a chart provide legal protection? | It is a legal document for both pt. and provider
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| How is an error corrected in the chart? | put one single line through the error and make correction on top or to the side of error.
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| Vital signs are an indication of? | the measurement of body functions that are essential to life
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| What does febrile mean? | above normal body temperature
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| What does Afebrile mean? | normal body temperature
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| What are the sites for body temperature? | oral, axillary(armpit), rectal, temporal(forehead), aural/tympanic(ear)
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| What are the pulse sites, what is each used for? | RADIAL:measure heart rate per minute. BRACHIAL:used to measure blood pressure APICAL:measuring infants heart rate CAROTID:used for CPR FEMORAL:measure heart rate POPIRAL:evaluate lower extremity circulation DORSALIS:evaluate lower circulation
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| What is the heat regualtion center of the body? | Hypothalamus
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| What are the types of fever and ranges? | SLIGHT:99.6-101 MODERATE:101-102 SEVERE:102-104 DANGEROUS:104-105 FATAL:106(+)
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| What is Rales? | noisy breathing
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| What is Dyspena? | difficulty or labored breathing
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| What factors can affect pulse rate? | anxiety, fear, anger
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| Pulse is measured by what? | beats per minute
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| What is the irregularity of pt.'s heart rhythem called? | arrhythemia
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| What is the normal adult range of pulse? | 60 to 100 beats per minute
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| What things should the M.A. ensure of before taking an oral temp? | has pt. have anything in their mouth, or had anything to drink or ear in past 15min
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| What is tachycardia? | rapid heart beat
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| What is bradycardia? | slow heart beat
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| What is the noraml respiratory rate for adults? | 16-20rpm
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| One respiration consists of? | 1 total inspriation(inhale) 1 total expiration(exhale)
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| Orothopnea? | difficulty breathing when lying straight
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| Hyperpnea? | excessive breathing
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| Bradypnea? | slow breathing
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| Tachypnea? | rapid breating
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| Apnea? | absence of breathing
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| What is the O2 saturation range of a healthy individual? | 95 and up
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| Describe systolic and diastolic phases of the cardiac cycle? | SYSTOLIC:corresponds to the beat phase of the heart and period of great pressure*1st beat heard* DIASTOLIC: resting or filling action of the heart,period of the least pressure.*last beat heard*
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| What is blood pressure? | the fluctuating pressure the blood exerts against the arterial walls as the heart contracts and relaxes.
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| What is mm Hg? | Millimeters of mecury
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| What artery is used for B/P? | Brachial
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| What is the number for normal b/p? | just below 120/80
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| What factors can increse body temp? | exercise, metabolic rate
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| What are the ranges for both hypertension stage 1 and 2? | stage 1: 140/90-159/99 stage 2: 160/100 and up
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| What reading could show that the pt has hypotension? | 90/60
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| The first clear sound you hear when taking b/p is the? | systolic
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| What are the exam positions and what are they used for? | ANATOMICAL:visual inspection HORIZONTAL:RECUMBENT/SUBINE: breast or abd DORSAL RECUMBENT:digital exam of rectum or vagina. PRONE:examine the spine SIMS:colonoscopy,enemas KNEE TO CHEST:sigmoidoscopy FOWLERS:pt. w/ cardiac or resp conditions
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| What are the exam positions and what are they used for? | LITHOTOMY:OB/GYN,speculum insertion,femal catherizaton. TRENDELENBERG OR SHOCK:low b/p, synscope & testingfor faulty valves. KRASKE/JACK KNIFE:exam make urethra, treatment of hemorrhoids.
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| What age are fecal occult blood test done(begin)? | age 50, then anually.
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| What is the force of the pulse called? | volume
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| What side should the patient be on when taking rectal temp? | left side
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| 20\200 vision with corrective lenses indicates? | your legally blind
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| Biopsy forceps are used for? | promote removal of tissue samples.
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| When should a woman have a mammogram? | age 40. Every 1-2 years, annually at age 50
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| What measurements are taken during a well-child visit? | ht./wt., circumfernece of head/chest
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| what are signs of neglect? | malnutrition, lack of dental, poor hygiene, neglected immunizations, lack of concern from parent
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| what are signs of abuse? | bruises, burns, internal abdominal pain, frequent injuries, suspicious stories of injuries, reports of abuse
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| what are signs of visual deficiency? | tilting the head to the side or forward, blinking or watering eyes, frowning or puckering of face, closing of one eye when testing both eyes, straining or squinting
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| what is the snellen chart used for? | to measure pt.'s distant vission
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| how does a person use the snellen E chart? | pt. indicates with 3 fingers of which way the letter "E" is facing.
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| CBC is done on a pregnant woman to check her? | iron/hemoglobin
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| The EED is determined by? | Nagales Rule
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