Domain 3

demographic information

name, address, telephone number, insurance information, and emergency contact

health history

chief complaints, present illness, past medical history, family history, social history, review of systems

correspondence

any correspondence related to the patient (from the patient’s insurance company, attorney, or from the patient themselves)

patient identifiers

two methods of verification (most commonly full name and DOB)

administrative section

notice of privacy practices form, advance directives, consent forms, medical records release form

clinical section

includes medical, family, social, occupational history

medical history

past illnesses and surgeries

family history

illnesses or diseases relevant to immediate family

social history

diet, exercise, caffeine intake, smoking, use of alcohol or recreational drugs

occupational history

any occupational employment hazards or exposures

chief complaint

subjective information that identifies the reason the patient come in

medication reconciliation

comparing patient’s list of medication to the medical record to reduce the risk of improperly prescribing an incorrect or contraindicating prescription

patient health questionnaire-2

measures the patient’s frequency of depressed mood over two weeks; initial survey that can lead to Patient Health Questionnaire-9

Patient Health Questionnaire-9

screening that asks additional questions to assess if patient meets criteria for depressive disorder diagnosis

symptoms of depression

difficulty going to sleep, staying asleep, or getting up in the morning; profound sadness and fatigue; change in appetite; loss of energy

GAD-7

questionnaire that screens patients for anxiety

common anxiety symptoms

heightened ability to observe or make connections, difficulty focusing on details, sense of panic, irritability, feeling cold or sweaty, heart palpitations, shortness of breath

blood pressure

measure the force of blood circulating through arteries

systolic pressure

the first sharp tapping sound when blood begins to surge into the artery that has been occluded

diastolic pressure

noted when the last sound disappears completely and blood flows freely

normal blood pressure

less than 120 systolic and less than 80 diastolic

elevated blood pressure

120-129 systolic and less than 80 diastolic

HBP Stage 1

130-139 systolic and 80-89 diastolic

HBP Stage 2

greater than 140 systolic; greater than 90 diastolic

Hypertension Crisis

higher than 180 systolic and higher than 120 diastolic

Systolic BP range for 1-3 yrs old

90-105

Diastolic BP range for 1-3 yrs old

55-70

Systolic BP for 3-6 yrs old

95-110

Diastolic BP for 3-6 yrs old

60-75

Systolic BP for 6-12 yrs old

100-120

Diastolic BP for 6-12

60-75

Systolic BP for older than 12

110-130

Diastolic BP for older than 12

65-80

orthostatic hypotension

significant drop in BP during positional changes with a at least a 10 bpm increase in pulse rate and at least 20 point decrease BP when switching from standing to lying down

radial pulse

located on the thumb side of the wrist (most common site for adults)

brachial pulse

inside the upper arm (most common for measuring the pulse in children)

carotid

located in the neck below the jawbone (most commonly used in emergency procedures)

temporal artery

side of the forehead

femoral artery

inner groin area

popliteal artery

located behind the knee

posterior tibial artery

located behind the ankle

dorsalis pedis artery

located on the top of the foot

apical pulse

determined by listening with a stethoscope to the heartbeat; commonly measured in children, infants, and adults with irregular heartbeats

pulse range for infants

100-180

pulse range for toddlers

98-140

pulse range for preschoolers

80-120

pulse range for school-aged

75-118

pulse range for adolescents and older

60-100

describing pulse

rate, rhythm, and strength

ex: 70 bpm, regular, and thready

describing respiration

rate, rhythm, and depth

hyperventilation

fast/rapid breathing

causes of hyperventilation

intense pain, anxiety, panic attacks

hyperpnea

excessively deep breathing

causes of hyperpnea

extreme pain or anxiety

dyspnea

difficult or painful breathing

causes of dyspnea

COPB, pneumonia, asthma, high altitudes, physical exertion

orthopnea

difficulty breathing unless in upright position

causes of orthopnea

congestive heart failure; COPD

wheezing

whistling sound during breathing

causes of wheezing

asthma

rales

small clicking, bubbling, or rattling sounds

causes of rales

fluid in air sacs and pneumonia

rhonchi

large airway sounds

causes of rhonchi

COPD, chronic bronchitis, pneumonia

respiratory rate for adolescents or older

12-20

respiratory rate for school-age children

18-25

respiratory rate for preschoolers

20-28

respiratory rate for toddlers

22-37

respiratory rate for infants

30-53

pulse oximetry

measurement of oxygen saturation (should be greater than 90%)

converting between temperatures

° C = (° F − 32) ÷ 1.8

impact of wrong cuff size

systolic and diastolic can be impacted by up to 6.9 mm Hg

documenting pain

must record location, onset, duration, and other characteristics

which indicates the last menstrual period

the first day of the last menstrual period

circumference of child’s head should be measured until what age

3 years

converting from pounds to kg

multiplying by 2.2

calculating BMI

weight(lbs)/(height (in))² * 703 OR weight (kg)/(height (m))²

underweight classification

less than 18.5

normal BMI

18.5 to 24.9

overweight BMI

24.9-30

obese BMI

greater than 30

dermal punch biopsy

used in dermatology

dermal cutter

used in dermatology

scalpel

used in dermatology

gauze

used in dermatology

incision and drainage tray

used in dermatology

specimen collection swabs and containers

used in dermatology

three-channel electrocardiograph

used in cardiology

electrode

used in cardiology

EKG paper

used in cardiology

Holter monitor

used in cardiology

glucometer

used in endocrinology

adhesive strips

used in endocrinology

test strips

used in endocrinology

lancets

used in endocrinology

otoscope

used in neurology

ophthalmoscope

used in neurology

percussion hammer

used in neurology

penlight

used in neurology