Standardized Client Assessment breakdowns
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| All entries in a medical record must include | Date and MILITARY time (Ex 2200 hrs = 10pm)
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| Weight (WT): A quick approximation conversion lb-->kg is | Halving the patients weight (WT)
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| Weight (WT): A exact conversion lb-->kg is achieved by | Dividing the patients weight in pounds by 2.2
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| Ambulation assistance devices include; | Cane, walker, extremity braces or wheelchairs
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| Sensory aids include; | glasses, contacts, hearing aids
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| Lethargy / lethargic (NVS) | Mental sluggishness
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| Stupor / stuporous (NVS) | Mental grogginess
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| Unconscious (NVS) | asleep but responds to stimili
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| Coma / comatose (NVS) | Asleep but does not respond to stimili
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| Syncope / syncopal episode (NVS) | To faint, pass-out
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| Orientation to the three spheres include; (NVS) | person, place and time (x3)
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| Speech difficulties include; (NVS) | Slurred, dysphasia, and aphasia
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| Gait (manner of walking) is described as; (NVS) | Stable, unstable, or shuffling
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| Vertigo (NVS) | Dizziness
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| Parasthesia (NVS) | Numbness or tingling
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| Hand grasp (NVS) | Strong, weak, and equal
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| PEARRLA (NVS) | Pupils Equal and Round, Reactive to Light + Accomidation
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| Accommodation means; (NVS) | The patients ability to focus / visual acuity
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| HOH stands for; (NVS) | Hard of Hearing
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| Tinnitus | Ringing or buzzing in the ears
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| When recording current medications, you should include; | OTC, herbal medications and vitamins
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| Current prescription information should include; | 1. Name
2. Dosage
3. Route of administration
4. Frequency
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| Dosage: mg | milligram
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| Dosage: g | gram
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| Dosage: gr | grain
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| Dosage: supp | suppository
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| Dosage: Tsp. | teaspoon
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| Dosage: Tbsp. | tablespoon
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| Dosage: oz. | ounce
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| Route of administration: PO | orally
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| Route of administration: SL | sublingual
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| Route of administration: subQ | subcutaneously
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| Route of administration: Transdermal | Through the skin
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| Route of administration: INH | inhalation
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| Route of administration: Top | topical
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| Route of administration: PR | per rectum
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| Freq. of Administration; Q.D | everyday
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| Freq. of Administration; B.I.D. | twice a day
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| Freq. of Administration; T.I.D. | three times a day
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| Freq. of Administration; Q.I.D. | four times a day
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| Freq. of Administration; a.c. | before meal
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| Freq. of Administration; p.c | after meal
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| Freq. of Administration; h.s | bedtime / hours of sleep
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| The order that medications should be documented is; | Routine medications first, followed by medications as needed (PRN)
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| Freq. of Administration; PRN | as needed
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| Breath sounds are described as; | Clear, Rales, Rhonchi, wheezing, stridor
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| Breath sounds; Rales | Crackling heard on auscultation
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| Breath sounds; Rhonchi | Whistling sound caused by airway constriction
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| Breath sounds; Stridor | High pitched sound indicating obstruction
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| When auscultating Breath sounds as the patient to; | Breath with the mouth open
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| Breathing descriptions include; | 1.Eupnea/eupnic
2.Dyspnea/dyspnic
3.Hypoventiation
4.Bradypnea/bradypnic
5.Tachypnea/tachypnic
6.Orthopnea/orthopnic
7.SOB/shortness of breath
8.DOE/Dyspnea on exertion
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| Breathing descriptions; Eupnea/eupnic | Normal breathing
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| Breathing descriptions; Dyspnea/dyspnic | Difficult or painful breathing
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| Breathing descriptions; Hypoventilation | Shallow breathing
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| Breathing descriptions; Bradypnea/bradypnic | Slow breathing (Hypopnic)
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| Breathing descriptions; Tachypnea/tachypnic | Fast breathing (Hyperpnic)
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| Breathing descriptions; Orthopnea/orthopnic | Easier breathing when sitting straight
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| Breathing descriptions; DOE | Dyspnea on exertion
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| Cough descriptions include; | 1.Productive (producing sputum)
2.Non-productive
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| Sputum described as; | Color, viscosity, and amount
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| Croup described as; | A seal bark cough
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| Circulation descriptions include; | 1.Warmth, color, cyanosis, capillary refill, pulse
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| Circulation; Capillary refill is described as; | Refill from pink to white;
slow measure time or immediate
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| Circulation; Weak pulse | Thready or feeble
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| Circulation; Strong pulse | Bounding pulse
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| Circulation; Apical pulse is located | Just inferior to the left papilla
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| Circulation; Tachycardia / tachycardic | Fast pulse or heart rate(HR)
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| Circulation; Bradycardia / bradycardic | Slow pulse or heart rate
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| Circulation; Palpable pulses include: | 1.Carotids
2.Radials
3.Brachials
4.Femorals
5.Popliteals
6.Posterior tibials (ankles)
7.Dorsalis pedis
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| Circulation; Doppler ultrasounds detect what? | Blood flow within the arterys
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| Gastrointestinal description; Appetite | Daily diet
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| Gastrointestinal description; Dentures | Upper, lower, partial, and fit
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| Gastrointestinal description; Anorexia | Loss of appetite
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| Gastrointestinal description; N+V | Nausea and vomiting {F,D,R,}
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| Gastrointestinal description; F,D,R | Frequency, Duration, Remedies
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| Gastrointestinal description; Fruity breath | May indicate diabetes mellitus(DM)
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| Gastrointestinal description; Bowel sounds(BS) | Present or absent
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| Gastrointestinal description; Bowel movements(BM) | Frequncy,color,Form
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| Gastrointestinal description; Diarrhea | Loose watery stools {F,D,R}
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| Gastrointestinal description; Constipation | Difficult defecation {F,D,R}
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| Gastrointestinal description; Melena | Black, tarry, pungent stools {F,D}
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| Gastrointestinal description; Eructation | Belching {F,D}
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| Gastrointestinal description; Flatulence / flatus | Gas expelled through the anus {F,D}
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| Gastrointestinal description; Dyspepsia | Indigestion {F,D,R}
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| Gastrointestinal description; Fecal incontinence | The inability to control defecation {F,D}
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| Gastrointestinal description; abdominal extension | Measured as; abdominal circumference or girth
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| Gastrointestinal description; Soft abdomen is considered | Optimal
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| Gastrointestinal description; Abdominal guarding | Flinshing
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| Gastrointestinal description; Rigid abdomen indicates | Gastrointestinal pathology
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| Genitourinary (GU) description; Urine | Described as clear, yellow, amber, or cloudy
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| Genitourinary (GU) description; Dysuria | Painful or difficult urination - Indicates possible UTI {F,D}
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| Genitourinary (GU) description; UTI | Urinary tract infection {F,D}
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| Genitourinary (GU) description; Hematuria | Blood in the urine {F,D}
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| Genitourinary (GU) description; Pyuria | Pus in the urine - Indicates possible UTI {F,D}
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| Genitourinary (GU) description; Glucosuria | Sugar in the urine - Indicates possible diabetes mellitus(DM)
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| Genitourinary (GU) description; Ketonuria | Ketones (acetone) in the urine - Indicates possible diabetes mellitus(DM)
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| Genitourinary (GU) description; Urinary hesitancy | Difficulty initiating urination - Indicates possible benign prostatic hypertrophy(BPH) {F,D}
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| Genitourinary (GU) description; Urinary frequency | Frequent urge to urinate - Indicates possible UTI or pregnancy {F,D}
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| Genitourinary (GU) description; Urinary urgency | Sudden urge to micturate - Indicates possible UTI or BPH
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| Genitourinary (GU) description; Urinary retention | Inability to urinate - Indicates possible BPH {F,D}
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| Genitourinary (GU) description; Nocturia | Chronic / persistant night urination - indicates possible BPH or UTI {F,D}
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| Genitourinary (GU) description; Enurisis | Involuntary / uncontrolled micturation ; urinary incontinence
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| Genitourinary (GU) description; ED | Erectile dysfunction / impotence
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| Genitourinary (GU) description; LMP | Last menstrual period
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| Genitourinary (GU) description; Menses | Description includes; regular, irregular, # of days, # pads, # tampons used
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| Genitourinary (GU) description; Vaginal discharge | Description includes; color, leukorrhea, thrombi, pungent
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| Genitourinary (GU) description; Dyspareunia | painful coitus
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| Genitourinary (GU) description; Gravida | Number of pregnancies
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| Genitourinary (GU) description; Para | Number of viable births (survivable)
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| Genitourinary (GU) description; Type of birth | Vaginal delivery or cesarean cestion
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| Genitourinary (GU) description; Contraceptive | Type and duration
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| Genitourinary (GU) description; Abortion information | Spontaneous (miscarriage) or voluntary
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| Genitourinary (GU) description; PAP | Last done and frequency
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| Genitourinary (GU) description; Mammogram | Last done, results
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| Integumentary skin descriptions; | Warm, cool, cold, dry, clammy, or diaphoretic
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| Integumentary descriptions; Turgor | Skin elasticity and in indicator of hydration (immediate or slow)
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| Integumentary descriptions; Pruritus /pruretic | Itching
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| Integumentary descriptions; Erythema / rubeosis | Redness
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| Integumentary descriptions; Jaundice / icterus / xanthoderma | Yellow skin and/or sclerea
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| Integumentary descriptions; Pallor | Paleness
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| Integumentary descriptions; Macule /macular | Flat, usually erythematous skin lesion
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| Integumentary descriptions; Papule / papular | A raised lesion <1 centimeter(cm)
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| Integumentary descriptions; Nodule / nodular | A raised lesion >1 centimeter(cm)
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| Integumentary descriptions; Abscess | A collection of pus
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| Integumentary descriptions; Types of abscess | 1.Pustule / pustular
2.Furuncle /boil
3.Carbuncle
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| Integumentary descriptions; Pustule | A papule filled with pus
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| Integumentary descriptions; Furuncle | An infection of a hair follicle and adjacent tissue AKA a boil
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| Integumentary descriptions; Carbuncle | A cluster of furuncles
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| Integumentary descriptions; Vesicle /vesicular | A raised lesion filled with a clear liquid (blisters)
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| Integumentary descriptions; Types of vesicles | 1.Bleb <1 cm
2.Bulla(e) >1 cm
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| Integumentary descriptions; Crustation | A scab
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| Integumentary descriptions; Abrasion | Mechanical superficial damage to the skin (scrape)
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| Integumentary descriptions; Excoriation | Chemical ssuperficial damage to the skin
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| Integumentary descriptions; Nevus / nevi | Mole(s)
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| Integumentary descriptions; Verruca(e) | Wart(s)
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| Integumentary descriptions; Ulcer | An erosion (wearing away) of the skin or musous membrane
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| Integumentary descriptions; Decubitus ulcer | Pressure ulcer (bed sore)
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| Integumentary descriptions; Xeroderma | Dry skin
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| Integumentary descriptions; Ichthyosis | Dry, scaly skin
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| Integumentary descriptions; Cyst | A thickening or lump
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| Integumentary descriptions; Cicatrix /cicatrices | Scars
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| Integumentary descriptions; Keloid | Exaggerated or hypertrophied scar
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| Integumentary descriptions; Urticaria | Hives or wheals
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| Integumentary descriptions; Urticaria indicates | Allergic reaction
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| Integumentary descriptions; Vitiligo | a localized loss of skin pigmentation
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| Integumentary descriptions; Albinism | A genetic absence of skin pigmentation
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| Integumentary descriptions; Edema | An accumulation of fluid (swelling)
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| Integumentary descriptions; Ecchymosis | Bleeding under the skin, hematoma, contusion, or bruise
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| Integumentary descriptions; Initially a bruise will be | Erythematous (red)
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| Integumentary descriptions; In 1-2 days a hematoma can become | Blue or purplish
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| Integumentary descriptions; At day 6 a contusion can fade to | Green
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| Integumentary descriptions; At day 8-9 a bruise will become | Brownish - yellow
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| Integumentary descriptions; Petechia(e) | Pinpoint hemorrhages
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| Integumentary descriptions; Purpura | Combination of ecchymoses abd petchia
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| Integumentary descriptions; Alopecia | Hair loss
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| Integumentary descriptions; Gangrene / gangrenous | Tissue putrifaction (rot)
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| Integumentary descriptions; Gangrene is caused by | Microbial proliferation
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| Integumentary descriptions; Fissure | A crack or groove
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| Integumentary descriptions; Laceration | A cut, rip, tear
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| Integumentary descriptions; Callus / callosities | Hypertrophied skin
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| Integumentary descriptions; Comedo(nes) | Whitehead / blackhead
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| Information to be documented about any skin lesion includes; | Location, size, duration
1' = 2.54 cm
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| Pain Descriptions include; | 1.Frequency
2.Duration
3.Sharp
4.Stabbing
5.Dull
6.Burning
7.Throbbing
8.Pressure
9.Achy
10.Radiating
11.Intermittent
12.Chronic (recurring)
13.Acute (sudden)
14.Continues
15.Numeric intensity 1-10
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| Patient history should include past surgeries including; | Date of last surgery
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| Patient history should include past illnesses including; | Date of last illness
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| Past Family and Social History (PFSH) should include; | Bronchitits, asthma, emphysema, pneumonia, epilepsy, cirrhosis, mental illness, CA, CAD, MI, AP, CHF, TIA, CVA, PAD, URI, COPD, HTN, TB, STI, HIV, AIDS, CKD, OA, PID, PUD, GERD, HAV, HBV, HCV, OSA, UC, Alcohol consumption, Tabacco use, Exercise
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| Disease abbreviations: CA | Cancer
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| Disease abbreviations: CAD | Coronary artery disease
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| Disease abbreviations: MI | Myocaridial infarction
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| Disease abbreviations: AP | Angina pectoris
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| Disease abbreviations: CHF | Congestive heart failure
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| Disease abbreviations: TIA | Transient ischemic attack
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| Disease abbreviations: CVA | Cerebral vascular accident
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| Disease abbreviations: PAD | Peripheral artery disease
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| Disease abbreviations: URI | Upper respiratory infection
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| Disease abbreviations: COPD | Chronic obstructive pulmonary disease
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| Disease abbreviations: HTN | Hypertension
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| Disease abbreviations: TB | Tuberculosis
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| Disease abbreviations: STI | Sexualy transmitted infection (STD)
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| Disease abbreviations: HIV | Human immunodeficiency virus
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| Disease abbreviations: AIDS | Aquired immune deficiency syndrome
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| Disease abbreviations: CKD | Chronic kidney disease
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| Disease abbreviations: OA | Osteoarthritis
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| Disease abbreviations: PID | Pelvic inflammatory disease
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| Disease abbreviations: PUD | Peptic ulcer disease
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| Disease abbreviations: GERD | Gastroesophageal reflux disease
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| Disease abbreviations: HAV, HBV, HCV | Hepatitis A/B/C
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| Disease abbreviations: OSA | Obstructive sleep apnea
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| Disease abbreviations: UC | Ulcerative colitis
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| Anatomical location: Anterior | Front / ventral
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| Anatomical location: Posterior | Back / Dorsal
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| Anatomical location: Superior | Above
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| Anatomical location: Inferior | Below
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| Anatomical location: Proximal | Beginning of a structure
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| Anatomical location: Distal | End of a structure
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| Anatomical location: Medial | Middle
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| Anatomical location: Lateral | Side
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| Anatomical location: Hypochondriac region | Superior R+L lateral regions of the abdomen
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| Anatomical location: Lumbar region | Medial R+L lateral regions of the abdomen
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| Anatomical location: Inguinal (iliac) region | Inferior R+L lateral regions of the abdomen
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| Anatomical location: Epigastric region | Superior medial region of the abdomin
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| Anatomical location: Umbilical region | Medial region of the abdomin
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| Anatomical location: Hypogastric region | Inferior medial region of the abdomin
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| Directional terms are always used from who's point of view? | The patient's point of view
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