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PCM test 1 > History, SOAPS, DPR, Int medicine > Flashcards

History, SOAPS, DPR, Int medicine Flashcards

1
Q

Components of comprehensive history (subjective)

A
  • patient info
  • CC
  • HPI
  • PMH
  • meds, allergies, social history, family history
  • ROS
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2
Q

HPI Mnemonic - OLD CARTS

A 
Onset
Location
Duration
Character/Quality
Alleviating/Aggravating
Radiating
Timing
Severity
Associated/Other symptoms
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3
Q

SOAP note

A

Subjective (provided by patient) “symptoms”
Objective (provided by examiner/findings) “signs”
Assessment (diagnoses)
Plan (treatment and education)

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4
Q

Objective

A
  • Vitals, GA, heart, lungs, osteo, abdomen, neuro, other area pertinent to CC
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5
Q

Assessment

A
  • Diagnosis, 3 differentials, Correlation of osteopathic Somatic disfunctions, other problems that need to be addressed
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6
Q

Plan

A
  • tests, treatment, patient education, follow up
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7
Q

CTA

A

clear to auscultation

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8
Q

CVA

A

cerebrovascular accident

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9
Q

c/o

A

complaining of

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10
Q

CABG

A

coronary artery bypass graft

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11
Q

CCU

A

cardiac care unit

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12
Q

CHF

A

congestive heart failure

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13
Q

COPD

A

coronary obstructive pulmonary disease

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14
Q

CXR

A

chest xray

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15
Q

DTR

A

deep tendon reflexes

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16
Q

HEENT

A

head, eyes, ears, nose, throat

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17
Q

HVLA

A

high velocity, low amplitude

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18
Q

h/o

A

history of

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19
Q

HTN

A

hypertension

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20
Q

LMP

A

last menstrual period

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21
Q

NKA

A

no known allergies/ NKDA

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22
Q

NSR

A

normal sinus rythm

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23
Q

po

A

orally

24
Q

PT/PTT

A

prothrombin time/pratial prothrombine time

25
Q

ROT

A

rotated

26
Q

RRR

A

regular rate and rhythm

27
Q

WNL

A

within normal limits

28
Q

yo

A

year-old

29
Q

what is a profession?

A
  1. possession of a specialized body of knowledge

2. a commitment to service`

30
Q

challenges to professionalism

A

commercialism, consumerism, beureaucratization, industrialization

31
Q

20 pack years

A

= 1 ppd for 20 years …or 2 ppd for 10 years

32
Q

General ROS

A
  • weight change, appetite change, fever, chills, fatigue, weakeness, general health, night sweats
33
Q

Skin ROS

A

itching, rashes, brusing, sores, discoloration, mole changes, changes in hair texture/loss, lumps, dry skin, color changes

34
Q

Head

A

headache

35
Q

Eyes

A
  • glasses, vision changes, double vision, pain, redness, discharge, last eye exam
36
Q

Ears

A

ringing, changes in hearing, infections, discharge, pain, dizziness

37
Q

Nose

A

nosebleeds, congestion, sinus infections, polyps, injury, nasal obstruction

38
Q

Mouth/Throat

A

frequent sore throats, hoarseness, bleeding gums, voice changes, postnasal drip, sores in mouth, dental problems

39
Q

chest/pulmonary

A

cough, sputum, difficulty breathing/shortness of breath (dyspnea), coughing up blood (hemoptysis), chest pain with breathing (pelurisy), wheezing

40
Q

cardiac

A

chest pain, palpitations, exertional dyspnea, orthopnea (shortness of breath when lying flat), paroxysmal nocturnal dyspnea at rest, last EKG

41
Q

GI

A

nausea, vomiting, diarrhea, constipation, heartburn, blood in stool (hematochezia), melena, abdominal pain, change in appetite, rectal pain, hemorrhoids, food intolerance, hematemesis, dysphagia, odynophagia, jaundice

42
Q

Urinary

A

frequent urination, urgency, incontinence, dysuria, hesitancy, blood in urine, nocturia, flank pain, change in color/odor

43
Q

MSK

A

weakness, paralysis, joint stiffness/pain, joint swelling, limitation to movement, back pain, muscle cramps

44
Q

Neuro

A

fainting, dizziness, loss of consciousness, paralysis, memory changes, tremors, unsteady gait, disorientation, headaches

45
Q

Personal Zone

A

appropriate for interactions: 1.5-4 ft

46
Q

proper body language: SOLER

A
  • positioned SQUARELY
  • OPEN posture
  • LEAN towards patient
  • EYE CONTACT
  • RELAXED
47
Q

constitutional symptoms

A

symptoms that commonly occur that are non-specific to a particular body system

48
Q

signs

A
  • that what the examiner can see or feel
49
Q

DDX

A

hypothesis of problems

50
Q

nonverbal communication skills

A
  • awareness: self and others
  • proximics: use of space
  • kinesics: use of body, eye contact, etc.
  • para linguistics: tone, rhythm, pace, volume, etc - reflect those of patient
51
Q

questioning

A

open ended –> direct –> forced

52
Q

marasmus

A
  • stunted growth, extreme muscle wasting, loss of adipose with no peripheral edema –> combined energy and protein malnutrition
53
Q

Kwashiorkor

A
  • marked by growth failure, peripheral edema, hair discoloration, hypoalbuminemia, and preservation of subcutaneous fat resulting from protein malnutrition.
54
Q

three major causes of death

A

ischemic heart disease, cerbrovascular disease, lower respiratory infections

55
Q

Three major infectious diseases

A

HIV, TB, Malaria

PCM test 1 (5 decks)

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