Intro to Med Medical Records (All of it with a few extra questions and fixes)

Primary diagnosis is?

What is going on today; with ruled out possibilities

Secondary diagnosis is?

Chronic underlying conditions already diagnosed

Components of Plan

Diagnostic studies, pharmacological treatment, non-pharmacological treatment, patient education, and follow up instructions

SOAP stands for?

Subjective, Objective, assessment, and plan

Introductory statement involves?

Patient name, age, ethnicity, gender, pertinent past medical history, and chief complaint with duration

LNMP means?

Last normal menstrual period

NKDA means?

No known drug allergies

WD means?

Well developed

WN means?

Well nourished

WF means?

White female

WM means

White male

NAD means

No apparent distress

PMHx means?

Past medical history

What’s written when someone has a medication in a SOAP note?

Drug name, strength, dose, route, frequency, and indication

What’s in general statement?

Age, habitus, ethnicity, gender, and distress level

All parts of an objective section of SOAP

Vital signs, general statement, problem specific physical exam, and diagnostic studies

Pieces of diagnostic process

Symptoms, signs, diagnostic tests, diagnosis, and treatment and management

Steps of the diagnostic process

Gather information, analyze the information, and make judgements and decisions

How do you set the stage of an exam

Establish a rapport, properly introduce yourself, and provide the purpose of visit

Steps of subjective exam

Chief complaint, HPI (7 factors), past medical history (allergies and medications), personal and social history, and family history

Chief complaint is?

Main reason for patient’s visit

HPI is?

History of present illness (7 factors)

Name all 7 factors

Setting, chronology, location, quality, quantity, aggravating/alleviating factors, and associated manifestations

The first factor is?

Setting

The second factor is?

Chronology

The third factor is?

Location

The fourth factor is?

Quality

The fifth factor is?

Quantity

The sixth factor is?

Aggravating/Alleviating factors

The seventh factor is?

Associated manifestations

Setting (In HPI) is?

Where the patient’s symptoms started and what they were doing at the time

Chronology (In HPI) is?

The story of the chief complaint and how it has changed and developed

Location (In HPI) is?

Where the patient’s symptoms are located

Quality (In HPI) is?

How the patient describes symptoms

Quantity (In HPI) is?

Numerical value of complaint

Aggravating/Alleviating factors (In HPI) is?

What makes symptoms better or worse

Associated manifestations (In HPI) is?

Other complaints and symptoms patient denies

Name the four physical examinations for normal visit

Inspection, palpation, percussion, and auscultation

In what order do the 4 physical examination go when it is an abdominal examination?

Inspection, auscultation, percussion, and palpation

Objective things are?

What you see, hear, feel, and smell

Subjective things are?

What the patient says

What are the vital signs? (no abbreviations)

Pulse, respiratory rate, temperature, blood pressure, height, weight, body mass index, and pulse oximeter

What are the vital sings? (with abbreviations)

P, R, T, BP, Ht, Wt, BMI, and POx

Why do we order diagnostic testing?

To support, confirm, and rule out

What are the steps of analysis of information

Patient’s history, PE and testing, interpretation, possible causes, further questions, and diagnosis

Assessment is?

What is wrong with the patient

Plan is?

What we are going to do for the patient

Meaning of Rx

Prescription

Meaning of OTC

Over the counter

Top line of a prescription

Drug name and strength

Middle line of a prescription

Sig: Dose, route, frequency, and duration

Bottom line of a prescription

Dispensing quantity

What does 1 kg equal to in pounds

2.2 lbs

What does “AM” mean on a prescription?

Morning

What does “cap” mean on a prescription?

Capsule

What does “gm” mean on a prescription?

Gram

What does “gtts” mean on a prescription?

Drops

What does “IM” mean on a prescription?

Intramuscularly

What does “IV” mean on a prescription?

Intravenously

What does “mcg” mean on a prescription?

Microgram

What does “PM” mean on a prescription?

Afternoon

What does “prn” mean on a prescription?

As needed

What does “QID” mean on a prescription?

Four times a day

What does “Sig:” mean on a prescription?

Label

What does “subcut” mean on a prescription?

Subcutaneously

What does “TBSP” mean on a prescription?

Tablespoon

What does “tsp” mean on a prescription?

Teaspoon

What does “O.S.” mean on a prescription?

Oral suspension

What should be inspected on a medication?

Medical indication, contraindication, precautions, interaction, and adverse reactions

Medical indication for a medicine is?

Reasons to use

Contraindication for a medicine is?

Reasons to avoid

Precautions for a medicine is?

Reasons to avoid or take caution using

Interaction for a medicine is?

How the medication interacts with other drugs

Adverse reactions on a medication is?

Side effects

Tylenol’s generic name

Acetaminophen

Motrin’s generic name

Ibuprofen

Glucophage’s generic name

Metformin

Coumadin’s generic name

Warfarin

Prilosec’s generic name

Omeprazole

Synthroid’s generic name

Levothyroxine

Acetaminophen’s brand name

Tylenol

Ibuprofen’s brand name

Motrin

Metformin’s brand name

Glucophage

Warfarin’s brand name

Coumadin

Omeprazole’s brand name

Prilosec

Levothyroxine’s brand name

Synthroid

Schedule I drugs are?

Most abused

Schedule V drugs are?

Least abused

Name all major forms of administration routes

Oral, inhalation, topical, transdermal, suppository, and parenteral

Name all oral routes

Tablet, capsule, solution, and suspension

Name all inhalation routes

Gas, liquid, and powder

Name all topical routes (all the ones that are labeled topical in slides)

Lotion, gel, cream, ointment, transdermal, and suppository

Name all parenteral routes

Subcutaneous, intramuscular, and intravenous

What form of administration is this

Subcutaneous parenteral

What form of administration is this?

Intramuscular parenteral

What form of administration is this?

Intravenous parenteral

What form of administration is this?

Oral tablet

What form of administration is this?

Oral capsule

What form of administration is this?

Oral solution

What form of administration is this?

Oral suspension