History Taking
This is who you should introduce yourself to first when dealing with a pediatric patient presenting with their parent(s).
What is the child?
These are the sounds you hear when taking a blood pressure
This stage of pressure injury is defined as full-thickness skin loss, with visible adipose in ulcer and granulation tissue and rolled wound edges.
What is stage 3 pressure injury?
This type of benign skin lesion is described as mobile cysts that on excision, reveal pearly white balls.
What is pilar cyst?
This type of patient note, also known as a handoff note, is written during an intra-hospital transfer.
What is transfer-of-care note?
This is the format in which a chief complaint should be documented.
What is "Chief complaint" x duration
This is the gold standard of keeping track of a patients BP.
What is ambulatory blood pressure monitoring (ABPM)?
This kind of vesicle presents in groups in a single dermatomal distribution that does not cross midline.
What is Herpes zoster (shingles)?
This precursor to squamous cell carcinoma is defined as a scale of keratin that mimics warts.
What is Cutaneous horn/keratotic scale?
What are admission, discharge, or transfer?
These two Ps in OPQRST go hand and hand and describe what makes the pain get better or worse.
What are palliative and provocative?
This is how significant weight loss is defined
What is the loss of 5% or more of usual body weight over a 6 month period?
This type of benign skin leison is a tethered subcutaneous cyst, often with a malodorous whitish-yellowish substance/discharge.
What is epidermal inclusion cyst?
This type of basal cell carcinoma is non-healing and results in rolled borders/edges. Its mimic is squamous cell carcinoma.
What is ulcerated basal cell carcinoma?
This is never used to describe a patient who is not presenting with symptoms at the time. Instead, this should be described as what it means.
What is "normal" or "within normal limits"?
A 48-year-old male answers 'yes' to feeling he should cut down on drinking and 'yes' to having an 'eye opener' drink in the morning, but 'no' to feeling guilty or being annoyed by criticism. His score of 2 on the CAGE questionnaire suggests this.
What are lifetime alcohol abuse and dependence alcohol use disorders.
This type of breathing is defined as fast and shallow, converting to slow, deep, and gasping.
What is Kussmaul's respiration?
This type of nail abnormality is associated with liver disease, heart failure, and diabetes. It presents as a white nail plate with ground-glass appearance and a distal reddish brown color, with obliteration of the lunula.
What is terry nails?
What is Acral melanoma?
These help you rule out alternative diagnoses in the ROS, and should be listed last.
What are pertinent negatives?
The acronym FICA stands for this.
What is faith, importance and influence, community, and address?
This is the calculation for BMI using weight in lbs.
What is (Wt in lbs x 700 / height in inches) / height in inches?
This characteristic distinguishes scarring alopecia from alopecia areata.
What is shiny skin with complete obliteration of visible hair follicle openings?
This mimic for melanoma is defined as a macular base with a central "fried egg."
What is dysplastic nevus?
This is an example of this part of documentation:
24-year-old male presenting with 24h worsening RLQ pain, fever, nausea, vomiting, localized peritonitis exam findings, leukocytosis, and CT/US confirmation of appendicitis.
What is summary statement?