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Flashcards made for studying for CCMA exam through NHA

CC Chief Complaint
HPI History of Present Illness
History of Present Illness This is an explanation of the chief complaint to determine the onset of the illness, associated symptoms, what the patient has done for treatment, etc.
PFSH Past,Family, and Social History
Past Medical History Includes all health problems, major illnesses, surgeries the patient has had, current medications complete with reasons for taking them, and allergies
Family History Summary of health problems of siblings, parents, and other blood relatives that could alert the physician to hereditary and/or familial diseases
Social History Includes marital status, occupation, educational attainment, hobbies, use of alcohol, tobacco, drugs, and lifestyles
ROS Review of Systems
Review of Systems This is an orderly and systemic check of each organ and system of the body by questions. Both positive and negative findings are documented
Vital signs reflect the functions of three body processes necessary for life: Body Temperature, Respiration, Heart Function
The Four Vital Signs of Body Function are: Temperature, Pulse, Respiration, Blood Pressure
Body Temperature is A balance between heat production and heat loss in conjunction with each other
Maintains and regulates body temp Hypothalamus
Sites to take temp Mouth,Rectum, Ear(Tympanic Membrane),and the Axilla(underarm)
Normal Rectal Temp 37.0 C to 38.1 C (98.6 F to 100.6 F)
Normal Oral Temp 36.5 C to 37.0 C (97.6 F to 99.6 F)
Normal Axillary Temp 35.9 C to 37.0 C (96.9 F to 98.6 F)
Normal Tympanic Membrane 37 C (98.6)
Febrile presence of fever
Afebrile absence of fever
Fever Elevated body temp beyond normal range
Intermittent Fluctuating fever that returns to or below baseline then rises again
Remittent Fluctuating fever that remains elevated; it does not return to baseline temperature
Continuous A fever that remains constant above the baseline; it does not fluctuate
Oral temp is the most common method of measurement however it is not taken from the following patients: Infants and children less than 6,Patients who have had surgery or facial,neck,nose,or mouth injury, Patients receiving oxygen, Patients with nasogastric tubes,Patients with convulsive seizure,Hemiplegic patients,and Patients with altered mental status
With patients that have just finished eating, drinking, or smoking: Wait for 30 minutes to take their oral temp
Rectal Temperature is not taken in the following patients With heart disease, with rectal disease or disorder or has had rectal surgery, and with diarrhea
The least accurate temp and only taken when no other site can be used: Axillary Temp
Used for children and confused patients: Tympanic Temp
Normal pulse rate Between 60 and 100 bpm
The site most commonly used for taking pulse: Radial Artery, found in the wrist on the same side as the thumb
What is a more accurate measurement of the heart rate? Apical Pulse, taken over the apex of the heart by auscultation using the stethoscope
Apical Pulse is used for: Patients with irregular heart rate and for infants and small children
Normal Range for adult respiratory rate is: 12 to 20 per minute
One inspiration(inhale) and one expiration(exhale) counts as: One respiration
Respiration Rate abnormalities are the following: Apnea, Tachypnea, and Bradypnea
This is a temporary complete absence of breathing, which may be a result of a reduction in stimuli to the respiratory centers of the brain Apnea
This is a respiration rate of greater than 40/min. It is transient in the newborn and may be caused by the hysteria in the adult: Tachypnea
Decrease in numbers of respirations. This occurs during sleep. It may also be due to certain diseases. Bradypnea
Some abnormalities in the rhythm of repiration: Cheyne-Strokes, and Orthopnea
Cheyne Stoke
Created by: 100001037870109
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