Documentation
Terminology
Blood pressure
Body parts
Miscellaneous
100
Subjective, Objective, Assessment, Plan (Intervention, Eval)
What is SOAP(IE) notes?
100
Noct & Diurnal
What is med term for night and day?
100
5 phases
How many Korotkoff phases are there?
100
Pulse located in the AC fossa
What is brachial pulse?
100
Mensuration
What is the word for measuring?
200
Portion of note that involves lifestyle factors (smoking, drinking, drugs, diet, education, etc)
What is included in the social history?
200
Disease (enlarged) lymph nodes
What is lymphadenopathy
200
Force produced by heart at contraction vs at rest.
What is systolic over diastolic?
200
Site auscultated by stethoscope (usually in infants)
What is apical pulse?
200
Mastication
What is "to chew"?
300
Listening and privacy
What are keys to obtaining HPI?
300
Loss of ability to speak due to structural damage? (Typically overuse)
What is aphonia?
300
millimeters of mercury
What is mmHg?
300
Popliteal fossa
What is area behind the knee?
300
Also known as snoring
What is stertorous breathing?
400
Size and shape of wound go into this area of the note
What is Objective?
400
Loss of speach
What is aphasia?
400
Headache, dizziness, blurred vision, nosebleeds, sometimes "silent"
What are sx of HTN?
400
Pedal pulse
What is the foot pulse called?
400
Episodes of not breathing
What is apnea?
500
Location, duration, severity, timing, modifying factors belong in this area
What is subjective?
500
"Hardening of blood vessels" aka clogged arteries
What is atherosclerosis?
500
Caused by hypertension, secondary
What is renal disease?
500
Normal color is gray/silver
What is regular color of the eardrum/tympanic membrane?
500
Asian patients have difficulty maintaining eye contact during an interview
What is a racist question they will ask that is NOT true?