Test 2 Flashcards
Name the 4 mental status exam components and also the mini-mental state exam can be used and a normal score is ___-___
Checking the level of alertness, appropriateness of responses, orientation to person/place/time, and congruency of mood
24-29
^** Orientation, registration, attention and calculation, recall, language
To test CN1 what do you do?
Use non-irritating odors, have patient compress 1 nostril and sniff through the other to identify them
To test CN2 what 3 things do you do?
Visual acuity aka sharpness (via snellen chart)
Visual fields aka total area objects can be seen in the side vision (by confrontation)
Light reaction
To test visual acuity using the Snellen eye chart, the patient should be ___ feet from the chart and they are considered legally blind at ___/___
Test visual fields by confrontation via wiggling fingers at edge of fields
Light reaction is done by shining a light into the eye to check for direct reaction and consensual reaction in the other eye and CN 2 looks at ____ relay and constriction/dilation is CN __
20, 20/200
Sensory, 3
Cranial nerves ___, ____, and ___ are checked together using the ____
CN 4 is testing the ___ muscle and CN 6 is testing the ___ muscle
^** Remember, LR6, SO4, R3
3, 4, 6, cardinal signs of gaze
Superior oblique muscle, lateral rectus muscle
The constriction/dilation component of the light reaction is testing CN ___
^** If this nerve is lesioned, then the patient has ___, ___, and eyes turned ___ and ___
To test trochlear (4) patient ___ducts and ___ eye
To test abducens (6) patient __ducts eye
The Near reaction has the patient shift their gaze from a far object to a near one and the pupils should ____ and this tests CN ___ and accommodation
Double vision and head tilt = CN ___ lesion
3
Complete ptosis, mydriasis (pupil dilation), down and out
Adducts and depresses
Abducts
Constrict, 3
4
To test CN5 what 2 things do you do?
** Corneal reflex is also tested and the sensory input is through CN ___ and the output motor is through CN ___*****
Check sensation to the face and motor innervation for muscles of mastication
5, 7
For the motor innervation of the mastication muscles, you should palpate the ___ and ___ muscles, and then ask patient to clench their ___ and move ___ side to side in order to test ___
A unilateral weakness would indicate a ___ lesion, and a bilateral weakness would indicate a ___ disease
*To test sensory to the face for CN 5, you can do pain, temp, our light touch to the forehead, cheeks and jaw
If there is a cortical or thalamic lesion, facial sensory loss will be on the ___ side of the lesion and body sensory loss will be on the ___ side of the lesion
^**EX: Left cortical or thalamic lesion = R facial and R body sensory loss
If there is a brainstem lesion, facial sensory loss will be on the ___ side of the lesion and body sensory loss will be on the ____ side of the lesion
^**EX: Left brain stem lesion = L facial and R body sensory loss
Isolated facial sensory loss (no body loss) occurs in peripheral disorders like ____
Temporal and masster, teeth, jaw, lateral pterygoids
CNS Pontine (aka brainstem), cerebral hemispheric (aka cerebrum)
Contralateral, contralateral
Ipsilateral, contralateral
Trigeminal neuraglia
To test CN7 what 2 thing do you do?
Taste to anterior 2/3rds and motor innervation to muscles of facial expression
To test the motor innervation for the muscles of facial expression, you can have them raise ___, smile, frown, pucker ___, close eyes tightly, and purse lips
A lesion to the facial nerve can result in ___ and this would cause a loss of taste to the ___ of the tongue (affects upper and lower face)
^**A central lesion such as in a stroke affects mainly the ___ face
^** So realize that if the peripheral nerve affected is (like in bells palsy), the ENTIRE face will be affected, if it is going to the nucleus aka central facial palsy, you will only see the LOWER half affected (like in a stroke aka supranuclear facial palsy)
^** So once again, if you can raise ur eyebrows but face is droopy… The lower half of ur face is affected aka a central facial palsy****
*To test sensory innervation, have patient taste something
___ can be tested for via secretion of saliva and tears
Eyebrows, cheeks
Bell’s palsy, anterior 2/3rds
lower
Parasympathetics
To test CN8 (vestibulocochlear) what 3 thing do you do for the cochlear division?
So once again, cochlear division tests ___ and vestibular division tests ___
**Tests for hearing and includes the Whisper test, Weber’s test, and Rinne’s test
** Vestibular division tests balance, and it is often not included in the exam
Hearing, balance
First conduct the whisper test or finger rub test in order to determine if hearing loss is present
If there is, one conducts the weber’s test to look for ___ damage or ___.
This is done by striking a tuning fork and placing it in the middle of the patients forehead and diminished tone in the affected ear indicates ___ loss and a louder tone in the affected ear indicates ___ deafness
The ___ test checks air and bone conduction and confirms the presence of conduction deafness in the affected ear and this is done by placing the tuning fork on the ___ and then when tone is gone, place it over the external auditory meatus and if the patient can’t hear the sound, then conduction deafness is present
Sensorineural or lateralization
Sensorineural, conductive
Rinne’s, Mastoid process
The gag reflex tests CN __ and ___ together and CN 9 is the ___ portion of the reflex and CN 10 is the ___ portion of it
9 and 10, sensory, motor
The only muscle CN 9 innervates is the ___ muscle and this aids in swallowing
CN 9 also supplies taste to the ___terior __/___ of the tongue
Stylopharyngeus, posteiror 1/3
However unlike CN 9, which a lesion results in loss of gag reflex, loss of sensation to posterior 1/3rd of tongue, and slight dysphagia (difficulty swallowing)… CN 10 results in loss of gag OR ___ reflex, ____, dysphagia, and dyspnea
^** One can test the vagus nerve via a water test, gag reflex, evaluating presences of hoarseness, or the inspecting palate and uvula symmetry
^** If uvula fails to rise, think bilateral lesion and if it deviates to one side, it is a unilateral lesion and the uvula is deviating ___ from the affected side (aka moves towards normal side)
Cough, dysphonia (hoarseness)
Away
To test CN11 what 2 thing do you do (one for each muscle)
Paralysis of the SCM results in difficulty turning head to the ___ side
^** AKA if you can’t turn your head to the right, the left SCM is messed up and therefore the lesion is on the left side
Weakness of the traps from a CN 11 lesion results in ___ shoulder drop
^** AKA if the right CN11 is damaged, the right shoulder will drop
Shrug shoulders (testing for traps) and turn head against resistance (testing for SCM)
Opposite
Ipsilateral
To test CN12 what 1 thing do you do?
Look for tongue symmetry
Since CN 12 innervates the intrinsic tongue muscles, if one were to have a lesion it would cause the tongue to deviate towards the ____ side (lick its wound)
Affected
Full muscle strength is graded a +___/___ and name each number on the scale
3,4,5 = gravity alive
+5/5
0 = no contraction 1 = barely detectable flicker or trace of contraction 2 = Active movement with no gravity 3 = Active movement against gravity 4 = Active movement against gravity and some resistance 5 = Active movement against gravity and full resistance
**KNOW THESE**
For the upper extremity, name the Nerves associated with the movements
1) Shoulder shrug of traps
2) Deltoids
2) Flexion and extension of elbow
3) Flexion and extension of wrist
4) Hand grip
5) Finger abduction
6) Thumb opposition
For lower extremity, same thing
1) Hip flexion
2) Hip extension
3) Hip adduction
4) Hip abduction
5) Knee flexion
6) Knee extension
7) Ankle plantar flexion
8) Ankle dorsiflexion
1) CN 11
2) C5
2) C5, C6 = flexion, C6, C7, C8 = extension
3) C6 and C7
4) C7, C8, T1
5) C8, T1
6) C8, T1
1) L2, L3, L4 - psoas and iliacus
2) S1 - glut max
3) L2, L3, L4
4) L4, L5, S1
5) L4, L5, S1, S2 - hamstrings
6) L2, L3, L4 - quads
7) S1 - gastrocs
8) L4, L5 - tibialis anterior
The lack of coordination or instability when walking is called ___ and can be due to a cerebellar disease
__ gait is when a patient walks heel-to-toe in a straight line to reveal ataxia previously not obvious
Also have the patient walk on their heels to test ___ and toes to test ___
** The inability to heel walk is a sensitive test for CST damage
Testing for cerebellar function finger-to-nose and heel-to-shin, along with rapid alternating movements can be performed, if a patient can not perform rapid alternating movements, they have ____
Ataxic
Tandem
Dorsiflexion, Plantarflexion
Dysdiadochokinesis
Dermatomes are a band of skin innervated by sensory roots of a single spinal nerve
First one would test for pain and temperature (____) and then one can test position aka proprioception and vibration (____)
^** Position is done by grasping big toe and should sense movement within ___ degrees or grasping index finger and sense movement within ___ degree
One can also use the ___ test to test proprioception where the patient stands with feet together and then closes eyes for 30-60 seconds and you note patients ability to maintain upright posture and not sway like crazy
Spinothalamic tract, Posterior columns
5, 1
Romberg
Name the dermatome
1) Shoulder top
2) Radial aspect of forearm and tumb
3) Long finger
4) Little finger
5) Nipple
6) Umbilicus
7) Great toe (aka Hallucis)
8) Posteriolateral calf/little toe
1) C4
2) C6
3) C7
4) C8
5) T4
6) T10
7) L5
8) S1
Normal DTR is +__/__ and name the scale from 0-4
+2/4
0 = No response 1 = Somewhat diminished 2 = Normal 3 = Brisker than average 4 = Very brisk
Name the major cranial nerve tested in each DTR
1) Biceps
2) Triceps
3) Brachioradialis
4) Patellar
5) Achilles
___activity is a CNS lesion
___ activity is a PNS lesion
1) C5
2) C7
3) C6
4) L4
5) S1
Hyperactivity
Hypoactivity
There are various cutaneous stimulation reflexes including the abdominal reflexes testing ___-___ and one should see contraction of the abdominal muscles with the umbilicus deviating towards the stimulus
Plantar reflex testing ___ and ___
Anal reflex testing ___ - ___ via contraction of the anal muscles which is useful for ___
T10-T12
L5, S1
S2, S3, S4, cauda equina
Plantar response is also referred to as ___ and this is tested by starting at the __ aspect of the sole from the heel to the ball of the foot (across the transverse arch) and the normal response would be for the patient to ____flex
If they ___ the big toe and fanning of toes is positive, then it is suggested of an** _____ dysfunction ****
Babinskis sign, lateral, plantarflex
Dorsiflex, Upper Motor Neuron
The ___ test is positive when there is rapidly alternating, involuntary contraction and relaxation of skeletal muscles
One would test for this if DTRs are +___/___ and it can be associated with an ___ motor neuron dysfunction
Colonus, +4/4 (aka hyperactive reflexes)
Upper
Coordination testing checks for ___ function
There are 3 main ways to test for this
1) The finger to nose test, which evaluates for ___/____ of voluntary movements
2) Heel to shin
3) Rapid alternating movements (move hands to pronation and supination as fast as possible) and abnormal results for this are called ___
Cerebellar
Dysmetria (Lack of coordination)/Dysataxia
Dysdiadochokinesis
___ sign is done by flexing the patients leg at the hip and knee to 90 degrees and then extending out the knee
If there is pain and increased resistance to knee extension, it is a positive sign
This test has ___ sensitivity and is involved with the ___ nerve
Kernig’s
Low, Sciatic
____s sign is when the physician flexes the patients neck forward…. If the patients knees begin to pop up, it’s a positive sign
This test has ___ sensitivity and is involved with the ___ nerve
Brudzinskis
Low, Femoral
Nuchal rigidity is tested for by flexing the patients neck and feeling for stiffness
If there is neck stiffness, it can be indicative of ____ or ____
This test has ___ sensitivity in suspected or moderate cases, but has an increased reliability with severe meningeal inflammation
This is associated with the ___ nerves
Acute bacterial meningitis or subarachnoid hemorrhage
low
Spinal
Name the type of gain
Symmetrical gaits:
1) Decreased arm swing, small steps, en bloc turns
2) Feet cross over with toes dragged often seen in cerebral palsy or MS
3) High steppage, broad based often seen with posterior column damage or peripheral neuropathy
Assymetrical:
4) Circumducted gait (leg swings in a circular pattern), decreased arm swing in ipsilateral arm to affected leg, and is associated with an ____ lesion like a stroke
5) Unable to keep foot up during heel walk and usually due to ___ lesion from peroneal neuropathy or L5 radiculopathy
1) Parkinsonians
2) Scissoring
3) Sensory ataxia
4) Hemiplegic, UMN
5) Foot drop, LMN
Vital signs is the first thing to include in the Head-to-Toe exam; including ___, ___, ___, ___, ___, ___, and ___ (name all 7)
Then the next thing to do when performing the Head-to-Toe exam is an initial observation for the ____ aspect of the Head-to-Toe exam, which includes posture/plane by looking at landmarks, symmetry, Kyphosis/lordosis/scoliosis, along with gait, and heel/toe walk (for balance and strength), gender, speech, mental alertness, age, etc will also be included
Next, you can begin the HEENT portion
Bp, P, R, T, Height, Weight, O2 saturation
General
For the HEENT (Head Eyes Ears Nose and Throat) portion of the exam, first look at head by feeling for any trauma and the shape of the head
Next you can shine a light in the eyes and use the opthalmoscope to check the eyes. You an also check EOM via the cardinal signs of gaze
Then you can check ears to look for the TM and the ear canal
Then you can shine a light and look in their nose at the turbinates, septum, sinus TTP, etc.
Finally you can have them open their mouth with tongue out to check buccal mucosa, tongue, uvula, teeth, posterior pharynx, and tonsils
After the HEENT, you can check the ___
Neck
For the Neck portion of the exam, one can check the Trachea, Thyroid, Lymph nodes, TTP, JVD (neck veins), and Carotids by palpating and listening for ____ (swishing)
Use the ___ of the stethoscope for this
After the neck exam, you can perform the ____ exam
Bruits
Bell
Cardiovascular
For the Cardiovascular exam, there are at least 4 posts one should listen to including the
Where is the best place to listen
1) Aortic v
2) Pulmonary v
3) Tricuspid v
4) Bicuspid (Mitral)
The location of the apex/left boarder can be found at the ___ and where do you find it?
1) 2nd ICS to right of sternum
2) 2nd ICS to left of sternum
3) 4th ICS at left sternal border
4) Apex of heart (5th ICS LSB and medial to mid clavicular line)
PMI (Point of maximal impulse), 4th-5th intercostal space in the mid-clavicular line
Edema is examined by pressing firmly for __ seconds over one of what three places?
Edema is graded on a scale of __-__ and name the mm for all of them
**+4/4 is a ___ edema
5
Dorsum of foot, behind medial malleolus, anterior tibia (shin)
0-4
0 = none \+1 = 2mm (disappears rapidly) \+2 = 4mm (10-15 seconds) \+3 = 6mm (less than 1 min) \+ 4 = 8mm (2-5 min)
pitting
Normal capillary refill time is ___ seconds or less
** If longer, impairment in distal filling has occurred (arterial occlusion, hypovolemic shock, hypothermia, etc.)
2
Peripheral pulses are graded on a scale of __-__ with normal being __
Pulses to check include
1) Radial, Brachial
2) Femoral, Popliteal
3) Dorsalis Pedis
4) Posterior Tibial
0-4, +2/4
** \+4 = bounding \+3 = Strong/increased \+2 = normal \+1 = weak/diminished 0 = none
Name the grading system of murmers (1-6)
1) Loud and can be heard without a stethescope
2) Loud WITHOUT a thrill
3) Loud with thrill and minimal contact between stethoscope and chest
4) Barley audible, faint
5) Loud with a thrill
6) Soft, but easily heard with a stethoscope
Systolic murmurs are between __-___ and diastolic between __-__
1) 6
2) 3*
3) 5
4) 1
5) 4*
6) 2
1) S1-S2
2) S2-S1
The diaphragm is used for __ pitched sounds like S__ and S__, AR (Aortic regurgitation), MR (Mitral regurgitation), and friction rubs
The bell is used for __ pitched sounds like S__ and S__, MS (mitral stenosis) and carotid bruit
High, S1, S2
Low, S3, S4
After cardiovascular exam, you can do a chest and breast exam to look at the chest wall, nipple discharge, masses or lumps, skin changes, lymphadenopathy, etc
Then you can do a pulmonary exam and then a GI exam after
**Name the order you would conduct a pulmonary exam ***
Also name the order you would conduct a GI exam***
Inspect, palpate, percuss, auscultate
Inspect, Auscultate, Percuss, and Palpate
Palpable vibrations transmitted through the bronchopulmonary tree to the chest wall as the patient speaks (99 or 1-1-1) occurs in __
COPD, Pleural effusions, fibrosis, pneumothorax, or infiltrating tumor is indicated when fermitus is __
**^ Increased space prevents sound transmission
Pneumonia, which is increase transmission through consolidated tissue, is indicated when fremitus is __
So to recap, pneumonia has a ___ fremitus and a pleural effusion/pneumothroax has a ___ fremitus
Tactile Fremitus
Decreased/Absent
Increased
Increased, decreased
There are 5 types of percussion sounds including Resonant, Flat, Dull, Typanic, and Hyperresonant
When fluid or solid tissue replaces air-containing lung or occupies space beneath percussing fingers, a __ sound is now heard
In patients with hyperinflated lungs such as COPD or asthma, a __ sound can be heard
** If hyperresonance is heard on one side only then ___ or large air filled ___ is most likely cause
dull
hyperresonant
Pneumothorax, bulla
__ suggest narrowed airways like in asthma or COPD
___ suggest secretions in large airways
__ suggests partial obstruction in larynx or trachea
^**crackles and rales are same thing and are defined as being discontinuous, intermittent, nonmusical, and brief.
**Wheezes and Rhonchi are defined as being continuous, musical, and prolonged
Wheezes
Rhonchi
Stridor
What two sounds are we listening for while percussing the abdomen?
___ is a high pitched sound caused by air filled viscera and is found in the majority of the abdomen
___ is heard over solid organs as a non-resonating/flat sound without echos.
^** The liver and splen, fluid in the peritoneum, or feces gives a dull note***
Protuberant abdomen with tympanic sounds throughout can indicate ___
Tympany and dullness
Tympany
Dullness
Intestinal obstruction (since huge loops of air build up)
When auscultating for bowel sounds, use the ___ of the stethoscope to listen to all 4 quadrants. A normal bowel sound is __-___ clicks or gurgles per minute and abnormal sounds are ___ pitched or decreased/absent sounds and this can suggest early ____
Grating sounds with respiratory variation called ___ can be indicative of inflammation of the ____ surface of an organ
Venous hum, a soft humming nose, can be indicative of increased collateral circulation between portal and systemic venous systems
Also where would you listen on the stomach for Bruits? Friction Rubs? Or Venous Hums?
Diaphragm
5-35
High, intestinal obstruction
Friction rub, peritoneal
Bruits = Abdominal arteries (Renal, iliac, femoral)
Friction Rubs = Liver and Spleen
Venous Hums = Epigastric and Umbilical Regions
____ is pain upon removal of pressure, rather than the application of pressure to the abdomen
** This tests for ___
Patients can also guard voluntarily or involuntarily
An abdomen that is hard, is called rigidity and this is a __ reflex
Rebound tenderness or pain at McBurney’s point, which is located __ of the distance from the __ to the ___, may suggest ____ or peritoneal irritation
Pain in the Right Lower Quadrant, where our appendix sits when we push on the Left Lower Quadrant is called a __ sign
^*** So both of these test for appendicitis
___ sign is tested for via deep palpation under the right costal margin during inspiration and if there is pain or a sudden stop in inspiration it is a positive sign and indicative of ___ or ___
___ sign is when the gallbladder is enlarged, but not tender and is due secondarily to ___ disease or cancer
Kidney punch/Lloyd’s punch is done via tapping on the ____ which produce pain and suggest a kidney infection (perinephric abscess) or pyelonephritis or renal stones
The heel strike can indicate ____
Rebound tenderness
Peritoneal inflammation
Involuntary
1/3, ASIS, Umbilicus, appendicitis
Rovsing’s sign
Murphy’s sign, Cholecystitis (gallbladder inflammation) or Cholelithiasis (gallstones)
Courvoisiers, pancreatic
Costovertebral angels
Appendicitis
When performing the MSK exam, you can check for kyphosis, lordosis, scoliosis, along with the extremities, ROM, and joint changes, Muscle strength/tone/mass etc.
After performing the MSK exam, you can do a neurologic testing, which includes cranial nerves, Motor, Sensation (fingertips, bottom of feet, and monofilament test), DTRs graded on a scale of ____, with +___/___ being normal, Gait (tandem aka walk heel to toe in a straight line) vs normal, ____ testing (heel to shin, finger to nose, rapid alternating movements), and mental status (person, place, time, MMSE)
0-4, +2/4, cerebellar
If a patient comes in with a headache, what 3 tests would you want to perform for sure?
If a patient comes in with back or neck pain, what 3 tests would you most likely want to do (especially if HPI includes GI or GU system)
If a patient comes in with an extremity complaint, what 6 things could you test for?
HEENT and Neuro exam (Cranial nerves, DTRs, Muscle strength), Structural exam
Abdominal, Neuromusculoskeletal, Strctural Exam
Clubbing, Cyanosis, Edema, Pulses, Capillary refill, and TART (OSE)
For the ____ part of the SOAP note, list the Cheif COmplaint and at least three DDXs (Differential Diagnoses)
For the ___ part of the SOAP note, list labs, diagnostic studies (imaging), medications, guidance/counseling, OMT, Follow up, Etc.
Assessment
Plan
Name what section the abbreviations would go under
1) NAD
2) Affect, mood congruent and appropriate
3) 5/5 strength UE/LE b/l
4) Pulses +2/4, no PTE, no C/C/E (realize that clubbing, cyanosis, edema, pulses, and cap refill are listed commonly under a different heading)
5) RRR, no M
6) Supple LAD
7) NC/AT
8) PERRL
9) JVD, bruits, thyromegaly
10) A&Ox3
11) CTAB, w/c/r
12) Soft, NT/ND
13) EOMI, TMs clear b/l
14) nml BS x 4, no R/R/G/mass
15) nml gait, biceps/triceps/brachiorad DTRs +2/4 b/l
16) Nares patent, throat not injected, no exudate
17) No HSM, No Murphys, No Lloyds sign
18) No rash or jaundice, nml tugor
1) GEN (NAD = no acute distress)
2) Psych
3) MSK
4) EXT (extremities) (PTE = pretibial edema) (C/C/E = clubbing/cyanosis/edema)
5) CV
6) NECK
7) HEENT
8) HEENT (PERRL = pupils equal, round, reactive to light)
9) NECK
10) NEURO
11) Lungs
12) ABD
13) HEENT (EOMI = Extraocular muscles intact)
14) ABD
15) NEURO
16) HEENT
17) ABD
18) Skin
Why do we present a patient?
Realize when we present a patient, attending preferences DO EXIST!!!
1) Relay clinical info
2) Get a second opinion
3) Demonstrate your skills (critical thinking, decision making, basic science knowledge)
Three types of patient presentations
1) New patient
2) Follow-up
3) Bed side
^** When presenting bedside, should you include the patient?
Yes
The basic template for an oral presentation includes
1) Patient description
2) Chief complaint/HPI
3) Pertinent ROS
4) Pertinent Medical, Social, and family history
5) Physical exam
6) Labs and tests
7) Assessment and plan
…
What is the admission order mnemonic?
ADC VANDALISM Here
Admit Diagnosis Condition Vitals Allergies Nursing Diet Activity Labs IV Special Medications House officer
Admit - WHERE are you admitting them and to WHO are you admitting the patient to?
Diagnosis - This is what is getting them admitted to the hospital (aka WHY are they here?)
Condition - How is your patient?
Vitals - How often do you want vitals? Do you need other vitals taken?
Allergies - MEDICATION allergies, also possibly food allergies
^** Note that there is cross reactivity between shellfish allergies and ___ so this is important because if they are getting a CT scan with contrast, they must be prepped with steroids etc…
Nursing orders - Special stuff nurses need to do like monitoring, dress changing, etc
Diet - diet stuff (NPO - nothing by mouth)
Activity - Can they move around? (Up ad lib - can move around)
Labs - WHAT kind of labs do you need? WHEN do you need them?
IV fluids - Kind of fluids, what RATE?
^** Saline lock means there is an IV in place with saline flushed through it, but it is connected to ___ and this is different from a KVO (Keep vein open) which is where an IV IS hooked up to the patient but ran very slowly
Special - Catch all area so radiology/diagnostics/consults
^** Example: EKG, Wound care, surgery, etc…
Medications - Home medications. What new medications are needed?
House officer - When do you want the nurse to call you?
^** Don’t put down “when labs are back”… It’s mainly the emergency type of stuff
IV contrast
Nothing
SCDs (sequential compression devise) goes under the ___ orders for DVT prophylaxis
Ad lib goes in what section?
Accucheck AC and HS goes in which section?
SVN goes in what section?
Ordering O2 goes in what section?
Nursing
Activity (ad lib means they can walk around however much they like)
Labs
Medications (it means small volume nebulizer)
Meds
