Use LEFT and RIGHT arrow keys to navigate between flashcards;
Use UP and DOWN arrow keys to flip the card;
H to show hint;
A reads text to speech;
93 Cards in this Set
- Front
- Back
Questions to ask patients with cultural influence |
1. What do you think caused your problem? 2. When do you think it started? 3. What effect does it have on you? 4. What are your concerns about this problem? 5. What kind of treatment do you expect? |
|
Demographic Data Form
|
Registerspatient’s: name, address, mailing address if different, home and work phone,cell phone, dob, last 4 of social, all insurance info, and release of info signature
|
|
Financial Information Form
|
Financialpolicy of the practice, including billing, insurance billing, co-paymentbilling, and any finance charges added to monthly billing
|
|
Privacy Information Form
|
Describespatient’s rights, the facilities’ practices related to PHI, and where and howto file a complaint if patients feel their rights have been violated (Example –brochure) Sometimes requires signature
|
|
Release of Information Form
|
Sentto former provider to obtain past medical records and can be used to allowsharing of information with family members at the request of the patient.
|
|
Medical History Form
|
-Present healthhistory, including why the patient is being seen -Health history,both personal and family -Social historyincluding marital status, sexual orientation, and occupation -Military service,including dates and assignments (alerts provider so screen for common veteranillnesses and to inquire about Agent Orange exposure) -Body systemsreview/questionnaire -Medicationscurrently being taken, including OTC andprescription -Provider’s review of systems (ROS) (Completed byprovider) |
|
Computerized Health History Patient Generated
|
Patient responds on the computer to various questions and then reviews information with the medical assistant for completeness |
|
Computerized Health History Provider Generated |
Medical Assistant completes the information on the screen during the patient interview
|
|
Chief Complain
|
Then problem that brings the patient to the provider; in patients words for specificity |
|
Characteristics of a CC
|
Location: Area where symptom is Radiation: Size of area Quality: Describe symptom (tingling, ache, throbbing, stabbing, etc) Severity: Of symptom, (keeps me awake atnight..);Scale 1-10 Associated Symptoms: Other symptomscaused by CC Aggravating/Alleviating Factors: Whatmakes the symptoms worse/decrease Timing: When symptoms started and what patient wasdoing at the time |
|
Medical Health History
|
Chief Complaint as noted at each visit by MA Present Illness; meds, allergies, other providers Medical History Family History Social and Occupational History Review of Systems by physician or provider |
|
SOAP/SOAPER
|
Very common; SOAPERis becoming more commonSubjective data: in patient’s words; cannot be seen Objective data: observable, measurable findings Assessment: probable diagnosis (based on S and O)Plan for treatment: Meds, instructions, FU Education: educating patient Response:patient response to E and care given |
|
Medical History
|
Includes all of the patient's health problems, major illnesses, and surgeries, meds and dosages and reasons for taking them, allergies to meds and specific allergic reactions |
|
Review of Systems (ROS)
|
The provider will check the cardiovascular, respiratory, gastrointestinal, genitourinary, neurologic systems, extremities, musculoskeletal, and skin. (Not necessarily in this order) |
|
Clinical Diagnosis |
Results of examination and lab tests, together with history and patient symptoms help determine diagnosis |
|
Medical Records |
-Informed consents forms -Physical Examination Outcomes -Lab and Diagnostic test results -Providers diagnosis and plan of treatment -Surgical Reports -Progress Reports -Follow up care -Phone calls relate to care -Discharge Summary -Other communications (from other providers, labs, agencies_ -Patient records form other providers -Medication History |
|
Continuity of Care
|
-American Academy of Family Physicians -American Academy of Pediatrics Standard for creating electronic records of patient's health; used for transporting between providers; intended to improve the continuity of patient care, reduce errors, and assure a minimum standard of information to be shared Includes: - Patient and provider info - Insurance data - Patient's Health Status - Recent Care Given - Recommendations for future care - Reason for referral or transfer |
|
Source-Oriented Medical Record (SOMR)
|
|
|
Problem-Oriented Medical Record |
-Database: medical history, results from labs, and results of physical exams -Problems list: each problem is listed individually and assigned a number and dated -Diagnostic and Treatment Plan: lab and diagnostic test completed and providers plan for treatment -Progress Notes: entered for every problem; includes patent's complaint, problems, condition, treatment, and responses |
|
Electronic Medical Records (EMR)
|
A different mode of documenting and saving information related to patient's care; computer storage |
|
Baseline
|
Impression of overall well-being of the patient
|
|
Temperature
|
-Convection -Conduction -Radiation -Evaporation: -Elimination Hypothalamus monitors blood temp and will trigger heat loss/production with as little as .04 degress F change in blood temp |
|
Convection |
Heat loss through skin; (fan on a hot day) |
|
Conduction
|
Transfer of heat (from body to clothes |
|
Radiation
|
Heat loss to cooler environment
|
|
Evaporation |
Heat loss through vaporization of perspiration (sweating)
|
|
Elimination |
Heat loss through intestinal, urinary, and respiratory tracts |
|
Average Body Temp for Adults
|
OR 37.0 C |
|
Afebrile |
Absence of fever |
|
Febrile |
Fever is present |
|
Pyrexia |
Fever; body temp is increased beyond normal range |
|
Onset |
Time when fever begins |
|
Lysis |
Body temp gradually returns to normal after a period of fever |
|
Crisis |
Body tem decreases suddenly to normal levels; patient may perspire profusely |
|
Intermittent |
A fluctuating fever that returns to or below baseline, then increases again |
|
Remittent |
A fluctuating fever that does not return to the baseline temperature; fluctuates but remains increased |
|
Continuous |
A fever that remains above the baseline; does not fluctuate but remains fairly constant |
|
Disposable Thermometers
|
Individually wrapped strips with heat sensitive dots that change color to indicate temperature |
|
Electronic/Digital Thermometers |
Hand-held unit with a probe tip that is inserted into the ear securely to make a seal |
|
Temporal Artery Thermometer |
Measures the temperature of the skin surface over the temporal artery
|
|
Oral Temperature
|
Disposable strips; Electronic thermometer |
|
Aural Temperature |
Measures the infrared waves produced by the tympanic membrane and records the temp in less than 2 to 3 seconds on a digital screen; through the ear |
|
Rectal and Axillary Thermometers
|
Temperature taken through the rectum and under the arm pit |
|
Abbreviations for Temp Taking
|
-R: Rectal -A: Axillary -Tym: Tympanic -TA: Temporal Artery |
|
Abbreviation R
|
Rectal |
|
Abbreviation Ax
|
|
|
Abbreviation Tym |
Tympanic |
|
Abbreviation TA
|
Temporal Artery |
|
Average Oral Temperature |
96.6 F |
|
Average Rectal Temperature
|
99.6 F |
|
Average Axillary Temperature
|
97.6 F |
|
Average Tympanic Temperature
|
98.6 F |
|
Average Temporal Artery Temperature
|
99.4 F |
|
Pulse |
Increased pressure passes through the arteries in a wave like movement resulting in a slight expansion of the arterial wall (contraction) when the heart relaxes, (relaxation), the pressure is decreased in the arteries, resulting in the wall returning to its previous position; one contraction and one relaxation of the heart together is equal to one heart cycle or heart beat |
|
Pulse Sights |
-Temporal Artery (head) -Carotid Artery (neck) -Apical Artery (apex of heart) -Brachial Artery (inner elbow; antecubital) -Radial Artery (wrist) -Femoral Artery (groin area) -Popliteal Artery (behind knee) -Dorsalis Pedis (top of foot) |
|
Arrhythmia
|
Abnormal rhythm in heart rate |
|
Average Pulse Rates |
-Infants: 100-150 bpm -Children: 1yr: 120-160 bpm 2yr: 80-140 bpm 3yr: 70-120 bpm 7-14yr: 50-90 bpm -Adults: 60-100 bpm Should be recorded after temp |
|
Bradycardia
|
Less than 60 bpm |
|
Tachycardia |
Greater than 100 bpm |
|
Eupnea |
Normal respiratory rate |
|
Normal Respiratory Rates |
-Newborns: 30-60 rpm -Infants: 24-40 rpm -Children (1-7yrs): 22-34 rpm -Adults: 14-20 rpm |
|
Apnea |
Complete absence of breathing |
|
Tachypnea |
Greater than 40 rpm |
|
Bradypnea |
Less than 12 rpm |
|
Cheyne-Stokes |
Breathing pattern that starts with a period of apnea lasting 10-60 sec, followed by increasing depth and rate of respiration, which is then followed by a decrease in rate with apnea starting the cycle once again |
|
Orthopnea |
Severe dyspnea |
|
Dyspnea
|
Labored breathing
|
|
Hypoventilation |
When respiration is decreased in rate and shallow in depth |
|
Hyperpnea |
Respiration that is increased in both depth and rate |
|
Hyperventilation
|
Type breathing in which the amount of oxygen drawn in during inspiration is greatly increased, resulting in a decrease in the amount of blood carbon dioxide
|
|
Sleep Apnea
|
Air flow during respiration that stops for more than 10 seconds |
|
Narcolepsy |
Causes excessive sleepiness and daytime sleep attacks |
|
Rales (rawles) |
Clicking or rattling sounds during respiration or expiration when the lung passageways contain secretions
|
|
Rhonchi
|
Sounds similar to snoring, usually produced by rattling in the throat |
|
Wheezes |
High pitched musical sounds heard on expiration |
|
Stridor
|
Crowing sound heard on inspiration |
|
Stertorous |
Snoring sound with labored breathing
|
|
Respiratory Sounds Through Auscultation |
-Rales -Rhonchi -Wheezes -Stridor -Stertorous |
|
Systole |
Force exerted on the arterial walls during cardiac contraction (highest) |
|
Diastole |
Force exerted during cardiac relaxation (lowest) |
|
Blood Volume
|
Amount of blood within the arteries |
|
Peripheral Resistance
|
Resistance to blood flow within the arteries |
|
Lumen |
Inside space of the vein |
|
Vessel Elasticity |
Ability of the arteries to expand and contract to provide a stead flow of blood |
|
Atherosclerosis |
Causes an increase in arterial wall resistance resulting in an increase in blood pressure |
|
Viscosity |
The property of a fluid that offers resistance to flow; thickness |
|
Aneroid Manometer
|
A cuff containing a rubber bladder attached to a dial |
|
Digital Sphygmomanometer
|
Automatic and registers blood pressure in digital form on a screen |
|
Pulse Oximeter |
Noninvasive method for measuring the amount of oxygen that is saturating the hemoglobin molecules contained in a red blood cell |
|
Korotkoff Sounds |
-Phase I: First sound heard; sharp tapping sound; systolic reading -Phase II: Soft swishing sound; increasing blood flow as cuff deflates -Phase III: Rhythmic tapping sound; more blood flowing through; can be mistaken as systolic if phase I and II are missed -Phase IV: Muffling and fading of the tapping sounds; blood flowing fairly easy and cuff is fully deflated Phase V: No sounds; blood flowing freely; diastolic reading |
|
Normal Blood Pressure Readings
|
-Adolescent: 16 yr - 118/75 -Adult: Less than 120/ less than 80 -Prehypertension: 120-139/80-89 -High blood pressure: above 140/90 |
|
Hypertension |
5 types: -Primary: No cause or cure, but treatable -Secondary: Underlying issues; once underlying issue is gone BP returns to normal -Benign: Slow progression but may have same result as malignant -Malignant: Rapid progression with severe damage to cardiovascular system, possibly to the point of death - White Coat Hypertension: Caused by anxiety or fear when having BP measured |
|
Hypotension
|
BP consistently below normal; patient is unable to perform normal activities without dizziness and extreme fatigue |