Lecture part 5

Question 1

Lets say the first two consecutive beats were at 160 and then they went away and they came back at like 138 you would be wrong if you say the systolic is 138 it was the 160 of those two consecutive beats…a patient could come in immersive week that has an auscultatory gap and it typically happens in older adults…this is why its important to point of maximal inflation

Question 2

Follow up when?in a ______ or ________

Answer 2

in a week or two

Question 3

If someone has a high blood pressure and pt had a lot of processed foods,ham, etc when would you bring back patient to check blood pressure

Question 4

Sources of information helps to determine where in that note the information is going to be

Question 5

The best source is ideally the patient if the pt can’t communicate for whatever reason perhaps it’s the family member maybe you have a pt that is the ICU and is intubated and can’t talk and then information is coming from the medical record so depending on what that source of information is…it could be from a variety of different sources

Question 6

Clinical interview…scholarmac where you interviewing and counseling and putting all those pieces together

Question 7

Standardized format like ScholarMac so you had a systematic approach

Question 8

(ROS)=

Answer 8

Review of Systems

Question 9

Review of Systems is a head to toe interview with the patient

Question 10

Review of Systems is always in subjective part of a note. The subjective part of a note is the information that’s coming from the patient or the family member or the caregiver

Question 11

_________is what the patient is telling you

Answer 11

Subjective

Question 12

___________notes is piece of communication btwn one healthcare provider to another as the drug expert we are communicating what we think the drug therapy should be or how it should be adjusted, stopped, or started

Answer 12

SOAP

Question 13

The subjective part is anything and everything that the patient tells you

Answer 13

subjective

Question 14

The _________ part of a note is things that you perform as physical exam or their labs or tests or their calculations

Answer 14

objective

Question 15

Medications and allergies should be listed in the subjective or objective depending on the source of information

Question 16

Let’s say Ron is my patient…Ron what allergies do you have? Pt says penicillin…you ask ron what happens when you take penicillin? Rash… Ron is my patient and told you that…what section does that go in…the ____________

Answer 16

subjective

Question 17

Now if Ron is in the ICU intubated and I’m in the chart and I see penicillin rash…what section would that go it would be ___________ because its coming from the chart

Answer 17

objective

Question 18

So subjective is anything that your getting from your patient

Question 19

With allergies there are two parts that are important to include…what patient is allergic to and what happens