Class 1 Flashcards
What are the 2 types of visits and what is the difference between them?
The 2 types of visits are diagnostic and health management visits.
DIAGNOSTIC - A NEW PROBLEM, GOAL IS TO DETERMINE CAUSE OF THE PROBLEM AND APPROPRIATE TREATMENT, chief complaint ( NEW SYPTOM)
HEALTH MANAGEMENT - A ROUTINE CHECK UP, goal is PREVENTATIVE CARE and/ or assessing progress of ongoing medical problems. chief complaint (routine physical or management of chronic problems
Stages of a visit
CHECK IN & COMPLAINT HISTORY & PHYSICAL ORDERS & RESULTS ASSESSMENT AND PLAN CHECK OUT
S.O.A.P
SUBJECTIVE COMPLAINTS - (history of present illness & review of symptoms) PAST HISTORY OBJECTIVE EVALUATION -physical examination -orders and results ASSESSMENT -current diagnosis PLAN -treatment and follow up
PATIENT SAYS…SCRIBE WRITES
- HIGH BLOOD PRESSURE- HYPERTENSION (HTN)
- HIGH CHOLESTEROL - HYPERLIPIDEMIA (HLD)
- DIABETES - DIABETES MELLITUS (DM)
“I ONLY TAKE PILS FOR MY DIABETES” - NON-INSULIN DEPENDENT DIABETES MELLITUS (NIDDM)
“I TAKE SHOTS (INSULIN) FOR MY DIABETES” - INSULIN DEPENDENT DIABETES MELLITUS. (IDDM)
CARDIAC AND PULMONARY
HEART DISEASE - CORONARY ARTERY DISEASE. (CAD)
HEART ATTACK - MYOCARDIAL INFARCTION. (MI) & (CAD)
HEART FAILURE - CONGESTIVE HEART FAILURE (CHF)
IRREGULAR HEARTBEAT - ARRHYTHMIA
- EMPHYSEMA OR CHRONIC BRONCHITIS - CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD)
BLOOD CLOT IN THE LUNG - PULMONARY EMBOLISM (PE)
PNEUMONIA OR LUNG INFECTION - PNEUMONIA (PNA)
GASTOINESTINAL & DENITOURINARY
- REFLUX - GASTRESOPHAGAEL REFLUC DISEASE (GERD)
- ULCERS - GASTRIC ULCER OR PEPTIC ULCER DISEASE (PUD)
- IRRATIONAL BOWEL - IRRITABLE BOWEL SYNDROME (IBS)
- BLADDER INFECTION - URINARY TRACT INFECTION (UTI)
- KIDNEY INFECTION - PYELONEPHRITIS
- “IM ON DIALYSIS” - CHRONIC KIDNEY DISEASE (CKD) ON DIALYSIS
ENLARGED PROSTATE - BENIGN PROSTATIC HYPERTROPHY (BPH)
Neurological & Vascular
Stoke - Cerebrovascular accident (CVA)
Blood clot in the brain - Ischemic CVA
Brain bleed - Hemorrhagic CVA
Mini stroke - Transient Ischemic Attack (TIA)
Blood clot in my leg - Deep vein Thrombosis (DVT)
Bulge in my aorta - Aortic Aneurysm
Bad blood flow in my legs - peripheral vascular disease (PVD)
Cancer
Cancer - cancer or Carcinoma (CA) Spread to my - with metastasis to the.. Chemo - chemotherapy They cut it out - status (post surgical resection It’s gone - in remission
Common PSHx
Tonsils removed - tonsillectomy
Adenoids removed - Adenoidectomy
Neck arteries cleaned - carotid endarterectomy
Leg amputated - above knee amputation (AKA), below knee amputation - (BKA)
Joint repair - Arthroplasty
Cardiac & Pulmonary
Balloon in my heart - Angioplasty
Stents in my heart - Coronary stents
Heart Bypass - Coronary Artery bypass Graft (CABG)
Breast removal - Mastectomy
Part of my lung removed - partial lobectomy
GI &GU PSHx
Appendix removed - appendectomy Gallbladder removed - Cholecystectomy Part of my colon removed - partial colectomy Spleen removed - splenectomy Kidney removed - nephrectomy Uterus removed - hysterectomy Ovary removed - oophorectomy
Comorbidity
Complex
Systolic blood pressure
Measures the pressure in the arteries when the heart contracts
Diastolic blood pressure
Measures the pressure in the arteries when relaxed
Hypotensive BP
SYS: LESS THAN 90
DIA: LESS THAN 60
Normal BP
SYS: 90 TO 120
DIA: 60 TO 80
Prehypertensive BP
SYS: 121 TO 140
DIA: 81 TO 90
Hypertensive BP
SYS: GREATER THAN 140
DIA: GREATER THAN 90
ACE Inhibitors
relaxes arteries and block reabsorption of water by kidneys
Lotensin (benazepril)
Zestril - (Lisinpril)
Ca Channel Blockers
Dilate the arteries and reduce the force of the heart’s contractions
Norvasc (amlodipine)
Cardizem (diltiazem)
Diuretics
Reduce the volume of fluid in the blood vessels by urinating excess fluid
Hydrochlorothiazide (HCTZ)
ARBs
Dilate the arteries
Cozaar (losartan)
Benicar (olmesartan)
Type 1 vs Type 2 DM
Type 1 - insulin insufficiency, pancreas is unable to produce insulin which moves glucose from the blood into the cells, found early.
Type 2- insulin resistance, consistently high blood glucose levels cause cells to become resistant to insulin. Can be treated with non insulin meds, diet change or insulin.
Injected management of DM
Hum along - rapid acting insulin, injected IMMEDIATELY before or after meals
Lantus - long acting insulin, injected once daily
Sliding scale - insulin dosage based on current glucose
