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Final Review..

clinical 2

What is subjective information? Information supplied by the pt.
What is objective information? Information obtained by the doctor or M.A. by examination
What does POMR mean? Problem Oriented Medical Record
What goes on the right side of the chart? Progress sheet, cc, vitals, history
What does SOAP Mean? Subjective Objective Assessment Plan
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.
What are the steps for filing? Inspection, Indexing, coding, sorting, storing
Inspection of filing? Divide reports information
Indexing? organizing by name, subject, or other identiffication which to file under
Coding? Marking the index identiffier
Sorting? sort the material, i.e. alphabetically
Storing? locate file in appropriate location. i.e. draw or shelf.
What is purging? Means clean out. Thining our charts.
How long are the charts kept? 6 years
What is chronological filing? filling according to date
What is alphabetic filing? Names are organized like a telephone book.
What filling offers the most privacy? Numerical
What does CHEDDAR mean? Cheif complaint History Exam Details Drugs Assessment Return
How does a chart provide legal protection? It is a legal document for both pt. and provider
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.
Vital signs are an indication of? the measurement of body functions that are essential to life
What does febrile mean? above normal body temperature
What does Afebrile mean? normal body temperature
What are the sites for body temperature? oral, axillary(armpit), rectal, temporal(forehead), aural/tympanic(ear)
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
What is the heat regualtion center of the body? Hypothalamus
What are the types of fever and ranges? SLIGHT:99.6-101 MODERATE:101-102 SEVERE:102-104 DANGEROUS:104-105 FATAL:106(+)
What is Rales? noisy breathing
What is Dyspena? difficulty or labored breathing
What factors can affect pulse rate? anxiety, fear, anger
Pulse is measured by what? beats per minute
What is the irregularity of pt.'s heart rhythem called? arrhythemia
What is the normal adult range of pulse? 60 to 100 beats per minute
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
What is tachycardia? rapid heart beat
What is bradycardia? slow heart beat
What is the noraml respiratory rate for adults? 16-20rpm
One respiration consists of? 1 total inspriation(inhale) 1 total expiration(exhale)
Orothopnea? difficulty breathing when lying straight
Hyperpnea? excessive breathing
Bradypnea? slow breathing
Tachypnea? rapid breating
Apnea? absence of breathing
What is the O2 saturation range of a healthy individual? 95 and up
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*
What is blood pressure? the fluctuating pressure the blood exerts against the arterial walls as the heart contracts and relaxes.
What is mm Hg? Millimeters of mecury
What artery is used for B/P? Brachial
What is the number for normal b/p? just below 120/80
What factors can increse body temp? exercise, metabolic rate
What are the ranges for both hypertension stage 1 and 2? stage 1: 140/90-159/99 stage 2: 160/100 and up
What reading could show that the pt has hypotension? 90/60
The first clear sound you hear when taking b/p is the? systolic
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
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.
What age are fecal occult blood test done(begin)? age 50, then anually.
What is the force of the pulse called? volume
What side should the patient be on when taking rectal temp? left side
20\200 vision with corrective lenses indicates? your legally blind
Biopsy forceps are used for? promote removal of tissue samples.
When should a woman have a mammogram? age 40. Every 1-2 years, annually at age 50
What measurements are taken during a well-child visit? ht./wt., circumfernece of head/chest
what are signs of neglect? malnutrition, lack of dental, poor hygiene, neglected immunizations, lack of concern from parent
what are signs of abuse? bruises, burns, internal abdominal pain, frequent injuries, suspicious stories of injuries, reports of abuse
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
what is the snellen chart used for? to measure pt.'s distant vission
how does a person use the snellen E chart? pt. indicates with 3 fingers of which way the letter "E" is facing.
CBC is done on a pregnant woman to check her? iron/hemoglobin
The EED is determined by? Nagales Rule
Created by: bpstears