PD3- Midterm Flashcards
goals of pt documentation: provide ? thru accurate doc capture ? of pt illness/improve security levels assure appropriate ? to institutions justify ? consumed assure appropriate ?
quality of care severity comparisons hospital resources reimbursement
comorbid cond is secondary dx when:
- pt receives ? at time of admission
- list under ?
- do not use ?
- develops subsequent to?
- affects ? and/or ?
Tx PMH of H&P has a history of hospital admission tx received/LOS
for dictation you must write a ? in pt chart
short note
admissions discharges and operative notes- can report via?
dictation
? must be countersigned with in 24h
admission orders
admission orders - mneumonic?
adc vaandilm admit to dx condition vitals activities allergies nursing orders diet iv labs meds
condition - 2 statuses?
condition
code
vitals
every hr on ?
do NOT write
freq of ? status assessment
unstable pt
per nursing order
neuro
don’t write ? orders
STAT
include ? under assessment of admission H&P
risk factors
each DRG is give a ?
1.0 = lump sum ?
relative weight (RW) $4500
discharge note similar to a ?
daily progress note
discharge orders- MUST indicate that pt is ?
being discharged
discharge SUMMARY is a ? that summarizes pt’s ? hospital stay/ complete w/in ?
SEPARATE, entire
30D of discharge
complete h&p, nfo on labs, tests, assessment & plan ?
admission NOTE
adc vaandilm?
admission ORDER
SOAP note, specify all discharge info and instructions in plan
discharge NOTE
medical order to discharge pt to where and with whom, discontinuation orders
discharge ORDERS
written form or dictation summarizing pts hospital stay, w/in 30 days
discharge SUMMARY
acute abdomen w/out pain
geriatrics
diabetes
steroids
capsular swelling- type of ?
pain
pain gripping? dull, aching? crampy, contricting? biliary usually starts as?
intestinal obstruction
pyelonephritis
biliary or renal colic
epigastric
pain after eating- possible ? of and viscera
vascular dz
green vomit- obstruction distal to ?
ampulla of vater
periodic peritonitis in?
familial mediteranean fever
malabsorption syndrome?
CF, celiacs
aganglionic megacolon
hirschsprungs dz
liver 4-8cm at ?
6-12cm at?
hepatomeg when percussed ? below costal margin?
midsternal line
midclavicular line
2-3cm
f/e of cervical spine?
lateral flexion?
70 degrees
50 degrees
right shoulder pain? 3
GB dz, peptic ulcer, liver abscess/tumor
in alley’s (shoulder) document level of ?
thoracic vertebra reached
cross chest/horizontal adduction test for ?
ac joint impingement
arm extended and forearm supinated w/ elbow slightly flexed, resists shoulder forward flexion
speeds test- biceps tendonitis
thoracic outlet syn test? head rotated to face tested shoulder extend and laterall rotate head examiner extends pt shoulder pt takes a deep breath and pos = ?
adson maneuver
loss of radial pulse
anterior and superior dislocation of radial head
nursemaid’s elbow
test this by resisting wrist flexion and pronation?
golfer’s elbow
hoffman’s dz tested via ? ; tests ? tendons
finkelsteins; APL,EPB
pt makes fist, hcp pressing radial and ulnar artery and releases one at a time; delay/ absence of flushing = ?
allen test
partial/complete occlusion
inflammation of flexor tendon and synovial sheath, finger catches as it extends
trigger finger
avulsion of flexor tendon of 4/5 finger
jersey finger
collaterals of knee
apley’s distraction
neuromata of knee
tinel’s sign
ballottment- tapping/clicking, patella ‘floats’ outward when pressure released = ?
effusion
lachman’s pulls tibia anteriorly and stabilizes femus; lax its of ? indicates ?
> 5cm, ACL injury
thickening on posterosuperior aspect of calcaneus?
pump bump - Haglund’s deformity
flexion deformity of PIP joints toes 2-5; causes hyperextension of MTP
hammertoes
hyperextension of MTP joint of great toe w/ possible tearing of flexor tendon?
turf toe
geri pt may be lucid but ?
disoriented
~4+ dz in 70% greater than?
65
ADLs- primary responsibility?
promoting safety
polypharmacy- 13% US population but takes almost ? of all meds Rx
30%
to prevent poly pharm, ? is key!
communication
refusal or failure to provide elderly person with life necessities i.e. food water, comfort, safety, etc
elder neglect
also abandonment, financial or material exploitation
decubitus ulcer- final common p/w? irreversible changes in ?
ischemia, 2 hrs uninterrupted pressure
prevent decubitus ulcers- pressures less than ?
30 mm Hg
leading cause of institutionalization in elderly
urinary incontinence
goal of palliative care?
best QOL
high rates of depression in ? and ? geri pts
dementia, PD
psychotherapy ? in geri depression
underutilized
associated with sig medical and psych morbidity
grief
MCC of suicide in geri
physical illness
lost loved one
collaborative
person centered form
elicits and strengthens motivation for change?
motivational interviewing
MI: express ? support? roll with ? develop ?
empathy
self-efficacy
resistance
discrepancy
key to lifestyle changes?
motivation
4 concepts in adult learning
- selfconcept moves from ? to ?
- use ? as a resource for learning
- motivation is influenced by ?
- ? of knowledge
dependency»>self-direction
life experience
societal roles
immediate application
colorectal ca study- pt perception of working well with dr- ?
commitment skills and relationship
SEGUE framework can also be used as ?
assessment tool
improved outcomes in smoking cessation and pos results in obesity counseling?
5 As
5 As ? risk ? change ? and collaborate on set goals ? in addressing challenge ? for f/u
assess advise agree assist arrange
in adult edu, HCP doesn’t consider?
lifespan development
