Medical Documentation

X ray images

X ray images

________ show the dye as it flows through the heart arteries.

Auscultation

________: involves listening for normal and abnormal sounds with a stethoscope.

PERRLA

________= pupils equal, round, and reactive to light and accommodation.

Percussion

________: used to produce sounds, elicit tenderness, or assess reflexes in a patient.

Physical exam

________: assess the four quadrants of the abdomen.

Antimicrobial stewardship

________= improve how antibiotics are prescribed by clinicians and used by patients.

Angioplasty

________ or percutaneous coronary intervention (PCI): when a catheter is used to clear a narrowed or blocked artery or a cardiac stent is placed.

HPI

________: follow- up after receiving a screening at ONU Healthwise mobile clinic on 8 /19 /22.

Palpation

________: use of the sense of touch in the evaluation of the patient.

Chest radiograph

________ (CXR): very common when evaluating lung conditions.

Pleural effusion

________: fluid in the space between the chest wall and lungs.

Atelectasis

________: partially or fully collapsed lung.

Consolidation

________: areas of the lung where air should be, but it is not.

sample

A(n) ________ is collected from the source of the infection and sent to the microbiology lab.

Infiltrate

________: dead cell, debris, pus commonly seen with pneumonia.

Aspiration

________: inhalation of food particles or stomach contents.

Throat neck

________: inspection of mouth & pharynx, palpation of lymph nodes & glands.

vascularity

Inspection: color, texture, ________, contour.

Inspection

________: general observation of patient.

Coronary angiography

________: contrast dye is injected through a catheter.

Chief complaint (CC)

in patients own words

May be short

or long-term goals

Avoid listing multiple treatment options

pick one

CC

"I am here to have my blood pressure checked again and see if I need any new medicine"

HPI

follow-up after receiving a screening at ONU Healthwise mobile clinic on 8/19/22

PMH

high blood pressure

SH

eating out 1-2 times per week, cup of coffee & can of soda q day; walk 2-3 times q week; no cigs or nic; no drugs; 1-2 beers q weekend; no cost issues, no insurance issues

Meds

Lisinopril 10 mg po qhs; Tylenol for headaches 1-2 times q month; no herbals

Allergies

NKDA

Immunizations

Pfizer covid Vaccine 6/22, flu shot 10/21

ROS

deferred

Temp

98.6

Ht

511"

Wt (kg)

100 kg

Physical exam

deferred

Labs

WNL

Disease assessment

controlled HTN (116/70)

Goals

Maintain BP < 130/80; reduce overall lifetime risk of heart attack and stroke

Inspection

general observation of patient

Palpation

use of the sense of touch in the evaluation of the patient

Percussion

used to produce sounds, elicit tenderness, or assess reflexes in a patient

Auscultation

involves listening for normal and abnormal sounds with a stethoscope

Head

Hair, scalp, skull, face, skin

Eyes

general inspection, reactivity of pupils, ophthalmoscopy, extraocular muscles

Ears

internal inspection, otoscopy

Nose

external inspection/palpation, otoscope

Throat/neck

inspection of mouth & pharynx, palpation of lymph nodes & glands

Physical exam

inspection, palpation, and auscultation

Chest radiograph (CXR)

very common when evaluating lung conditions

Consolidation

areas of the lung where air should be, but it is not

Infiltrate

dead cell, debris, pus commonly seen with pneumonia

Atelectasis

partially or fully collapsed lung

Pleural effusion

fluid in the space between the chest wall and lungs

Aspiration

inhalation of food particles or stomach contents

"Echo"

echocardiogram

EKG or ECG

electrocardiogram

Coronary angiography

contrast dye is injected through a catheter

Angioplasty or percutaneous coronary intervention (PCI)

when a catheter is used to clear a narrowed or blocked artery or a cardiac stent is placed

FEV1

forced expiratory volume in 1 second

FVC

forced vital capacity

Physical exam

assess the four quadrants of the abdomen

Inspection

color, texture, vascularity, contour

Auscultation

bowel sounds, vascular sounds

Percussion

fluid, gaseous distention, and masses

Palpation

areas of tenderness, muscle spasms, or the presence of fluid or masses

DVT

deep vein thrombosis