COMPLETE SOLUTIONS LATEST UPDATE
Chief Complaint (CC)
- has to be in quotes as to why the patient is visiting
- Ex.) "I am having chest pains"
HPI
History of Present Illness
- history that relates to the reason why he's in hospital
Past Health to Ask For
- overall general health
- childhood illnesses
- accidents
- serious or chronic illnesses
- hospitalizations
- operations
- obstetric history
- allergies
What operations are most common?
appendix or gallbladder
Thyroidectomy scar
,front side of throat
Carotid endarterectomy scar
side of neck
Line on abdomen means what?
stabbed
Knee surgery scar
- knee replacement
- straight on knee
Open heart surgery scar
- line down the middle of the chest
Abortions
termination of pregnancy
- means stillbirths, miscarriages, surgical terminations of that child
what does 12 gravita 0 term mean?
12 abortions (could mean 12 miscarriages) or could mean 6 abortions, 6 miscarriage,
etc.
Anorexia
- malnourishment
- all patients that have cancer can be considered this
- see every bone, every rib
- diagnosed with anorexia and dehydration
Retarded
,- medicinal word
- slowing down of the growth
WNL
within normal limits
What are you looking for when listening for heart sounds?
S1, S2, S3, S4
- murmurs, gallops, clicks, rubs
S3
extra sound in the end
S4
extra sound at the beginning
Irregular regular rhythm
can tell when irregularity will occur
- IRR reg.
What do you ask when a patient says they're allergic to something?
- what happens when you take this drug? Diarrhea (not really an allergy)
- still write it down and write down reaction so everyone else knows
what is the #1 medication patient's don't tell you they're taking?
aspirin
alert and oriented x3
- eyes are open, aware, oriented to place and time
Review systems of health - what does this mean?
, - multitude of questions trying to gather information about each individual system.
- gives a good picture of the overall health of the patient at the moment.
- respiratory system, cardiovascular system, peripheral vascular system
DYS
dysfunctional - abnormal
Dysmenorrhea
abnormal periods (abnormal menstrual cycle)
Dyspnea
- abnormal breathing
- sleep apnea
Pnea
Breath
Amenorrhea
absence of period
Hyper
fast/high or more than
- hyperthermia - high temperature
Hypo
low/less than
- hypothermia - low temperature
Brady vs Tachy
slow vs fast
bradypnea