PCAM Midterm

(subjective)1) Patient Demographics: name, address (not p.o. box), phone #, DOB, etc2) CC (chief Complaint)3) HPI (History of Present Illness)4) PMH (Past Medical History)5) FH (Family History)6) SH (Social History)7) ROS (Review of Systems; head to feet)

1) Current Prescription and Non Prescription (OTC, herbals, diet restrictions) medications2) Past prescription and non prescription medications (things that may not have worked)3) Allergies (to what and type of reaction); drugs like antibiotics that didn't cause rxn4) ADRs (adverse drug rxns; to what and type of rxn)5) Medication Compliance

Level of Consciousness

No Apparent Distress

Well developed, well nourished

~beats per minute (bpm)~normal=60-100~3 fingers in groove of forearm for 15 seconds~irregular pulse do for 1 min

~Breaths per minute (bpm)~normal=12-20 ~count for 15 seconds; act like still doing pulse

Physician Examination: performed by systems in the same manner as the ROS; always record both negative and positive findings~Inspection: look at it~Palpation: feel it~Percussion: tap it~Auscultation: listen to it

Vital Signs1) Blood Pressure (BP): mmHg, systolic over diastolic P; 120/802)Heart Rate (HR) or Pulse (P): bpm3) Respiratory Rate (RR): bpm4) Temperature (T): normal=98.6 F or 37 C5) Weight and Height: pounds or kg; feet and inches or inches only, or centimeters

Will produce a rapid and irregular pulse causing inaccurate BP readings

In pts with respiratory problems, there can be a lower systolic pressure on inspiration

A temporary absence of sound during the release of cuff pressure possibly due to atherosclerosis; mostly in older ppl

(pseudo hypertension) the inability to compress the artery enough to stop the pulse due to atherosclerosis; if get pulse even when cuff is at 180 they prob have this

Na+, Cl-, BUNK+, CO₂-, sCr Glucose~elements in mEq/L~sCr, BUN and Glucose in mg/dL (100mL)

135-145 mEq/L~just because have low [Na+] doesn't mean there's low Na+