intro 1 medical records quiz 1

intro to diagnostic processes, intro to medications, intro to prescriptions

primary care

first initial point into medicine; ex- pediatrician, family practice

types of primary care visits

preventative care or health maintenance- yearly physical, flu shot; problem specific visits- sick visits; disease monitoring- chronic diseases like diabetes, high cholesterol, high BP; follow up appointments- in hospital for days after surgical reason needs follow up

steps of the diagnostic process

symptoms- subjective, what patient complains of, patient’s experience;
signs- what you find on physical exam, like palpating neck to feel for lymph nodes, listen to lungs, palpate abdomen, look in ears or nose;
diagnostic tests- things that we order;
diagnosis;
treatment/management

setting the stage- patient’s medical history

establish rapport with patient, introduce yourself properly (as a PA student), provide the purpose of the visit; “hello mr./ms./mrs. name. i am lily, a physician assistant student from saint francis university. i will be asking you a few questions and completing a physical exam to help figure out what is causing the problem that brought you into the office today”

chief complaint- patient’s medical history

main reason patient visits and how long it has been going on (subjective); use the 7 factors to gather information for the history of present illness (HPI); gather other pertinent background information (social history, family history, past medical history); patient history is subjective information- what patient tells you (chief complaint, HPI, background info, 7 factors)

the seven factors

1. chronology (most important)- story of the pain= when it started, where it went, sudden or gradual (ex- abdominal pain x3 days)

2. setting- location where you were when it started

3. location- where on body it hurts

4. quality- descriptive adjective for the discomfort (short, dull, piercing)

5. quantity- scale 0-10 (0= no pain, 10= worst pain ever)

6. alleviating and aggravating factors- what makes it better/worse

   1. associated manifestations

performance of a problem specific exam- physical exam

based off the chief complaint; exam findings are objective signs- objective= what provider finds on physical exam, vital signs (BP, HR, temp, SpO2, resp)

systematic physical exam

inspection, palpation, percussion, auscultation

abdominal physical exam

inspection, auscultation, percussion, palpation

diagnostic testing

rapid test, urinalysis, cultures (wound, throat, urine), blood work, imaging (xray, ultrasound, PET scan, MRI, CAT scan), biopsies, endoscopy, EKGs, stress test, basic metabolic panel

why do we order diagnostic tests

support, confirm, rule out

analysis of information

stepwise method for analyzing the information, information is gathered via subjective, objective, and diagnostic studies

analysis of information chain

patient’s history, PE and testing, interpretation, possible causes, further questions, final result= diagnosis; constant reassessment based on new information

analysis and judgement of data

after analyzing the information gathered via the history, physical exam, and diagnostic tests → the provider will develop the assessment (what’s wrong with the patient) and plan (what we’re going to do about it)

primary diagnosis (1° Dx)

after analyzing the information, what is the diagnosis; includes differential diagnosis (DDx) AKA rule outs (R/O)- conditions you need to investigate; ex- primary diagnosis: acute bronchitis R/O bacterial pneumonia

secondary diagnosis (2° Dx)

conditions that the patient has/ known medical problems- already have them when they walk in to clinic; ex- secondary diagnosis: hypertension, well controlled

making a judgement- plan

how are we going to manage the diagnosis and/or symptoms- diagnostic studies (xray, bloodwork), pharmacological treatments (antibiotics), nonpharmacological treatments (don’t need from pharmacy- humidifiers, increase fluids), patient education, follow up instructions

brand name medications

trade name, only the original manufacturer of the particular drug can use this name

generic name

name given to medication that can be used by other manufacturers

generic name for tylenol

acetaminophen

generic name for motrin

ibuprofen

generic name for glucophage

metformin

generic name for coumadin

warfarin

generic name for prilosec

omeprazole

generic name for synthroid

levothyroxine

why do we have two different forms of a medication if it’s essentially the same drug compositions

when new drugs are created, they are patented by the manufacturer- set drug cost with no competition for x number of years because they want to recoup the money they lost from failed drugs, so they make most of their money on daily use drugs; other companies can manufacture the drug once the patent has expired

over the counter medications

medication available to patients at a pharmacy without a provider’s approval

examples of over the counters

claritin, zyrtec, benedryl, mucinex, dramamine, allegra, hydrocortisone, famotidine

prescription medications

medication available only after a provider orders it via a prescription

examples of prescription meds

atorvastatin, metformin, metoprolol, gabapentin, prednisone, amoxicillan, sumatriptan, lisinopril

classification systems for medication

abuse potential drug classification system- schedule I-V, providers require a DEA license to write for controlled substances; schedule I most abuse potential, schedule V least abuse potential

DEA

drug enforcement administration

category x safety in pregnancy classification

contraindicated in pregnancy; do not use; teratogens

examples of teratogens

accutane, warfarin, thalidomide

drug allergy

hypersensitivity- reaction to a drug, can be mild to a severe reaction; hives, rash, anaphylaxis; happens only to certain people

drug side effect

unwanted effect from the drug; adverse symptoms; stomach ache, nausea, headache; can happen to everyone who takes it

why use antihistamine and why use epinephrine for allergic reaction

use epinephrine to reverse life-threatening allergic reaction- acts fast (schedule II); antihistamine used for mild symptoms, works slowly, treat isolated hives, mild itching

what to do when person has allergic reaction of rash on skin

check airway for anaphylaxis, look at lips and tongue

drug administration routes

oral (PO), inhalation, topical, transdermal, parenternal (subcutaneous, intramuscular, intravenous), topical lotion, topical gel, topical cream, topical ointment, suppository

what is a prescription

can be written or electronic, abbreviated Rx (latin symbol for recipe)

elements of a prescription

identifying information about the provider, identifying information about the patient, date of prescription, drug name, drug strength, Sig: (doses, route, frequency, duration), quantity of the medication to be dispensed, signature, refills

elements of a prescription- provider

identifying information about the provider- name, office address, phone number, license #/DEA license if applicable

elements of a prescription- patient

identifying info about the patient- full name, DOB, address

elements of the prescription- drug name

generic or brand name

elements of the prescription- drug strength

the amount of drug in each form

elements of the prescription- Sig=

dose, route, frequency, duration; latin for signetur- “let it be labeled”

elements of the prescription- drug dose

the amount given at one time (ex- one tablet, 5 mL)

elements of the prescription- drug route

orally (po), topically, subcutaneously

elements of the prescription- frequency

how often

elements of the prescription- duration

how long

Sig example

Sig: T (with dot over T) tab po BID x 10 days

elements of the prescription- dispense

quantity of the medication to be dispensed; dose x frequency x duration= total amount to dispense; ex- Sig: T tab po BID x 10 days, 1 × 2 × 10= 20, Disp: #20 (twenty) tablets

elements of the prescription- signature

electronic prescriptions are electronically signed

elements of the prescription- refills

number of times thre patient can fill the prescription before needing re-evaluated by the provider, if no refills- write “zero”, if 2 refills write 2 (two)

medical indication

reasons for use

contraindication

reasons to avoid

precautions

may want to avoid or use with caution

interactions

how the medication interacts with other drugs

brand name for acetaminophen

tylenol

brand name for ibuprofen

motrin

brand name for metformin

glucophage

brand name for warfarin

coumadin

brand name for omeprazole

prilosec

brand name for levothyroxine

synthroid

perenteral

any drug that is not delivered and absorbed through the digestive or integumentary system (sub q, IV, IM)

oral (PO)

by mouth (tablets, capsules, suspension, etc); the most commonly used route

inhalation

medication is inhaled through the mouth and into the lungs where it is absorbed

topical

medication is applied directly to the skin or mucous membranes (creams, eyedrops, suppositories)

transdermal

medication is applied to a patch and sits directly on the skin for a period of time; enters the bloodstream

lotion

high water content, thin consistency, easily spreadable, may contain alcohol for a drying effect (hydroalcoholic)

gel

high water content, usually contains cellulose ethers, dries quickly on skin

ointment

mainly consists of oil, used for dry skin conditions or rashes, forms a greasy residue that is water resistant

suppository

used for localized treatment or if unable to take meds orally- rectal, vaginal