Term
| what are some purposes for a SOAP note |
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Definition
legal document
account of baseline condition
communicate with other professionals
reimbursment
status assessment
quaility assurance
clinical presentations |
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Term
| what are the parts of subjective |
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Definition
| HIP, MH, SH, ALLERGIES, MEDS, SH, FH, ROS |
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Term
| what are the parts of objective |
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Definition
| general survery, skin hair nails, HEENNT, breast, heart, lungs, abdominal, extremities, neuromusculoskeletal, osteoptathic, urogenital, labs and other studies |
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Term
| what is involved in an assessment |
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Definition
consider living enivornment and concurrent illnesses
differential diagnosis (VINDICATED)
final diagnosis |
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Term
| what is involved in a plan |
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Definition
| testing, consults, treatment, long and short term, meds, follow up, recommendations, patient understanding and compliance, caregivers |
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Term
| list some things one should do in a patient interview |
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Definition
professional dress and conduct
knock, smile, welcome
identify self and patient
maintain eye contact
adjust enivornment
ensure privacy
dont interrupt |
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Term
| what are some clerical rules for writing a SOAP note |
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Definition
| no white out, black ink, no blank lines, avoid hypoens, date, time and sign everything, |
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Term
| what is the function of a progress note |
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Definition
daily evaluation or subsequent visits
focused history and exam |
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Term
| what are the rules of a clinical presentation |
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Definition
dont read notes
provide complete medial history for a new patient
follow up patient adress chief complaint and active issues
hospital follow up present active, new, changes, concerns, and new data |
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Term
| what is included in a clinical presentation |
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Definition
gender, race, age
pertinent positive and negative findings
pertinent positive and negitive from SOAP note
pertinent positive and negatives from physical exam PLUS level of conciousness, stress, mood, vitals
pertinent positive and negative lab results
3-5 differential diagnosis, assessment, plan |
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Term
| what are the parts of an admissions order |
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Definition
1. admission to ___ to service of ___
2. diagnosis
3. condition: satisfactory, serous,
4. consultations
5. vital signs: which, how often, parameters on when to call
6. allergies
7. activity allowed
8. nursing orderes
9. diet
10. drugs: how, what, how much, interactions
11. IV: what, rate, time
12. sedation: when, why
13. elimination
14. labs |
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Term
| what does VINDICATED stand for |
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Definition
vascular
infectious / inflammatory
neoplasm / neurologic
I...
congeital
trauma
endocrine / medatolic
DO / somato-visceral
and sometimes P... psych |
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Term
| ***WHAT ARE THE 3 DIFFERENT TYPES OF STROKE, WHAT IS THE MOST COMMON |
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Definition
THROMBOTIC: MOST COMMON
EMBOLISM/
CARDIOEMBOLISM
HEMMORHAGIC |
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Term
| WHAT CAUSES THROMBOTIC STROKE |
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Definition
| 51% ARE THROMBOSIS IN ANTERIOR, MIDDLE, OR POSTERIOR CEREBRAL VESSELS |
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Term
| WHAT IS THE HIGHEST CAUSE OF MCA STROKES, WHAT IS IN SECOND PLACE |
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Definition
EMBOLISM
SECOND: CARDIOEMBOLISM (50%) |
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Term
| WHAT PERCENT OF STROKES ARE CAUSED BY EMBOLISM |
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Definition
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Term
| WHAT IS THE CAUSE OF CARDIOEMBOLISM STROKES, WHAT IS A COMMON COMPLICATION |
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Definition
CAN COME FROM ATHLEROSCLEROTIC PLAQUE
65% OF PATIENTS HAVE AFIB |
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Term
| what does the location of a cardioembolism stroke depend on |
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Definition
side
stem occlusion is larger
small in cardiogenic, marantic embolis, fungal endocarditis, dissectionof aortic artery |
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Term
| WHAT IS THE MOST COMMON ARTERY FOR A STROKE, what does it supply |
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Definition
MIDDLE CEREBRAL
outer brain surface, basal ganglia, internal capsule, putamen (with lenticulostriate arteries) |
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Term
| WHAT IS THE JOB OF THE DOMINANT HEMISPHERE, HOW CAN YOU TELL WHICH ONE |
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Definition
RIGHT HANDED MEANS LEFT HEMISPHERE DOMINANT AND VICE VERSE
SPEECH AND LOGIC FUNCTIONS |
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Term
| WHAT IS THE JOB OF THE NON-DOMINANT HEMISPHERE |
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Definition
MEMORY, ERROR RECOGNITION, INHIBITION
neglect, fabrication (can't recognize error), dressing apraxis (left right up down), attention and vigilance (confusion), persistance (motor) |
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Term
| what are the signs of a problem with the dominant hemisphere |
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Definition
global aphasia
anterior: expressive aphasia, contralateral paralysis, loss of sensation
posterior: werinke's aphasia, visual field defect |
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Term
| what are the signs of a problem with the non-dominant hemisphere |
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Definition
| confusion, dressing aphasia, spatial deficits, neglect, fabrication |
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Term
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Definition
supportive: IV fluids, O2, BP control
tissue plasminogen activator (TPA) (CT first!), PT, OT, speech therapy, recreatin therapyo |
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Term
| common symptoms after stroke |
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Definition
| depression, poor adjustment to enivornment, reflex sympathetic dysttopathy, seizure, |
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Term
| what can increase and decrease changes of stroke |
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Definition
increase: marijuana binging
decrease: exercise
most die within first 30 days |
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Term
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Definition
| INJURY TO SYLVIAN FISSURE CAUSING DYSPHASIA (NO G) |
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Term
| what are the types of aphasia and their symptoms / functions of the area |
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Definition
brocas: comprehend and express language
werickes: fluent speech
conductive: disruption of arcuate fasiculus, sensory and motor areas disconnected |
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Term
| what is the cause and symptoms of a hemiparesis |
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Definition
| superior division infarct: contralateral upper extremity and face defects, partial sapring of contralateral lower extremity |
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Term
| WHAT ARE THE SYMPTOMS OF APRAXIA |
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Definition
CANT PERFORM PREVIOUSLY LEARNED TASK DESPITE PRESERVED STRENGTH, VISION, AND COORDINATION
DISCONNECT BETWEEN PLAN AND EXECUTION |
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Term
| WHAT IS THE RELATIONSHIP BETWEEN APHASIA AND APRAXIA |
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Definition
| THERE ISNT! THEY OCCUR INDEPENDENTLY. |
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