Documente Academic
Documente Profesional
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HASMINE
HBR
HGB
I/O
IBW
ICP
IM
IVF
2
IVTT
KPS
KSS
KUB
KVO
LBM
LLQ
LMP
LOC
LOF
LUQ
METHODS
MGH
MHBR
MI
ML
MSCC
MVA
NABS
NBS
NCCF
neb
NGT
NIL
NOD
NPO-PM
NPO-PS
NSS
NSVD
o.d.
o.s.
o.u.
OD
OGT
OGTT
ORS
OTC
PB
pc
PERRLA
PL148
PLR
PLT
PNSS
po
post-BT
PRN
PTA
PTB
PTC
PUD
PUFT
Px
q 2H
q 4H
qH
QID
RLQ
ROD
RTC
RUQ
Rx
3
S.O.S.
S/E - OPEH
S/P
S/S
SBR
SOB
SQ
ss.
Sx
T.S.
TAHBSO
TBSA
TID
TPN
TPR
TSB
TSE
TTS
ttt
TURP
TWC
U/A
U/S
URTI
UTI
UTZ
V/S
WCR
attending physician
family medicine intern on-duty/family medicine intern in-charge
family medicine resident on-duty/family medicine resident in-charge
medical intern on-duty/medical intern in-charge
medical resident on-duty/medical resident in-charge
OB intern on-duty/OB intern in-charge
OB resident on-duty/OB resident in-charge
Ophtha intern on-duty/Ophtha intern in-charge
Ophtha resident on-duty/Ophtha resident in-charge
post-graduate intern
surgical intern on-duty/surgical intern in-charge
surgical resident on-duty/surgical resident in-charge
significant other
4
Dosage calculations
a. Conversion between systems of measurement
METRIC
1ml
5ml
15ml
30ml
240ml
500ml
1000ml
APOTHECARY
15m (minim)
1 dr
1 oz (ounce)
8oz
1pt (pint)
1 qt
HOUSEHOLD
1 tsp
1 tbsp
2 tbsp
1 measuring cup
1qt
METRIC (GRAMS)
1g
0.6g
0.5g
0.3g
0.2g
0.1g
0.06g
0.05g
0.03g
METRIC (MILLIGRAMS)
1000mg
600mg
500mg
300-325mg
200mg
100mg
60-65mg
50mg
30mg
0.4mg
APOTHECA
RY
1 gr
15.4 gr
1 oz.
1 lb
2.2 lbs
15 gr
480 gr
1.33 lbs
2.7 lbs
METRI
C
0.06 or
0.065 g
1g
28.35 g
454 g
1 kg
APOTHECARY
15gr
10gr
7.5gr
5gr
3gr
1.5gr
1gr
3/4gr
1/2gr
1/150gr
5
METRIC CONVERSIONS
1 milliliter
1000 milliliters
100 centiliters
10 deciliters
10 liters
100 liters
1000 liters
1000 micrograms
1000 milligrams
100 centigrams
10 decigrams
10 grams
100 grams
1000 grams
1 cubic meter
1 liter
1 liter
1 liter
1 dekaliter
1 hectoliter
1 kiloliter
1 milligram
1 gram
1 gram
1 gram
1 dekagram
1 hectogram
1 kilogram
TEMPERATURE CONVERSIONS
F = [(1.8)(C)] + 32
C = (F 32) (0.555)
6
b. Calculation of Dosages
Guidelines:
1. Check whether all measures are in the same system. Convert if necessary.
2. Write the problem in equation form using the appropriate formula and labeling all parts, and
complete the necessary calculations.
3. Check the accuracy of your answer for reasonableness, and have someone else verify your
calculations.
Basic formula:
Desired dose x quantity on hand
OR
D xQ
On-hand dose
OH
Example 1:
The physician orders aspirin gr 10q4h PRN for fever over 101F. On hand are aspirin gr 5 tabs.
1. Check to see if all measurements are in the same system. No conversion is necessary. Both
measures are in grains.
2. Use the formula and label all parts.
D
10gr
OH
X 1 tab
10gr
5 gr
X 1 tab
5gr
Example 2: The order reads Ampicillin 0.5g. The unit dose packet reads 250 mg/cap.
1. Check to see if all measurements are in the same system.
Convert grams to milligrams.
1g=1000mg
0.5g X 1000mg= 500mg
1g
2. Use the formula and label all parts.
D
X
Q
500mg X 1 tab
500mg X 1 cap
2X1 cap = 2 caps
OH
250mg
250mg
Example 3: The preoperative order reads Demerol 60mg IM on call. The narcotics locker contains
ampoules labeled meperidine (Demerol) 100mg/2ml.
1. Verify that all measures are in the same system. No conversion is necessary.
2. Set up the problem as a proportion and label all terms:
Dose on hand
=
Desired quantity
Known quantity
Unknown quantity
100mg
2ml
60mg
x ml
100mg (xml)
100ml
60mg (2ml)
100ml
120ml
100
1.2ml
DEPARTMENT
Red
Orange
Pink
Yellow
Blue
White
Surgery
EENT
Family Medicine
Pediatrics
Internal Medicine
OB/Gyne
MEDICATION
TIMING
OD
BID
TID
QID; q4H
PRN
As specified
8
> Vascular Skin Lesions
Petechia
Ecchymosis
Hematoma
Cherry Angioma
Spider Angioma
Telangiectasis (Venous Star)
> Configuration of Skin Lesions
Linear
Annular
Zosteriform
Discrete
Polycyclic
Confluent
> Pressure Ulcer Staging
Stage 1
Stage 2
Stage 3
Stage 4
> Types of Wounds
Abrasion
Incision
Laceration
Puncture
Avulsion
Amputation
> REEDA Assessment of Skin Lesions
Redness
Ecchymosis
Edema
Discharge/Drainage
- Sanguineous
- Serous
- Serosanguineous
- Purulent
Approximation
2. Palpation
a. Moisture
b. Temperature
c. Texture
d. Thickness
e. Mobility & Turgor
f. Edema
E. Scalp & Hair Assessment
1. Inspection
a. Color
b. Distribution
2. Inspection & Palpation
a. Condition (cleanliness, dryness or oiliness, parasites & lesions)
> Common Hair Variations
Male Pattern Baldness
> Abnormal Findings:
Alopecia
Patchy Hair Loss
Pediculosis Capitis
Tinea Capitis
Hirsutism
F. Nail Assessment
1. Inspection
a. Color
b. Shape
> Abnormal Finding:
Clubbing
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2. Inspection & Palpation
a. Condition (nail grooming & cleanliness; texture; nail markings; nail plate attachment to
nail bed)
> Abnormal Findings:
Beaus Lines
Spoon Nails
Pitted Nails
Paronychia
II. ASSESSMENT OF THE HEAD & FACE
A. Anatomy & Physiology Overview & Landmarks
B. Head Assessment
1. Inspection
a. Configuration & Symmetry
2. Palpation
a. Consistency
C. Assessment of the Face
1. Inspection
a. Facial symmetry
b. Involuntary movements
2. Palpation
a. Temporomandibular joint (TMJ)
D. Abnormalities of the Head & Face
Acromegaly
Cushings syndrome
Pagets disease
Bells palsy
Parkinsons disease
Cachexia
III. Eye Assessment
A. Anatomy & Physiology Overview & Landmarks
B. Equipment
C. Assessment of External Eye Structures
1. Eyeballs (symmetry, protrusion & sinking)
> Abnormal Findings:
Exophthalmos
Sunken eyeballs
2. Eyebrows (color, symmetry, distribution)
3. Eyelids (position & appearance of eyelids & eyelashes; color changes; blinking)
> Abnormal Findings:
Ectropion
Entropion
Chalazion
Hordeolum
Blepharitis
Ptosis
Lagophthalmos
Eye trauma
4. Bulbar Conjunctivae & Sclerae (clarity, color, texture)
> Abnormal Findings:
Conjunctivitis (Pink Eye)
Pinguecula
Subconjunctival Hemorrhage
Episcleritis
5. Palpebral Conjunctivae (swelling, lesions, foreign bodies, trauma, discharges)
> Abnormal Findings:
Pallor (pale palpebral conjunctivae)
6. Lacrimal Apparatus (swelling, redness, drainage, tenderness)
> Abnormal Finding:
Dacryocystitis
7. Cornea & Lens (appearance)
> Abnormal Findings:
Arcus senilis
10
Corneal scar
Pterygium
Cataract
11
D. Assessment of Hearing
1. Whisper Test
2. Watch Tick Test
3. Weber Test
> Abnormal Findings:
Conductive Hearing Loss
Sensorineural Hearing Loss
4. Rinne Test
> Abnormal Findings:
Conductive Hearing Loss
Sensorineural Hearing Loss
V. Assessment of the Nose & Sinuses
A. Anatomy & Physiology Overview & Landmarks
B. Equipment
C. Assessment of Nasal Structures
1. External portion (nasal color, shape, consistency, tenderness)
2. Patency
3. Internal portion (mucosa, nasal septum & nasal passages; note position of septum, color,
consistency, lesions, perforations & presence of discharges/exudate)
D. Assessment of Sinuses (frontal & maxillary)
1. Percusion & Palpation (tenderness, crepitus)
2. Transillumination
E. Abnormalities of the Nose
Epistaxis
Deviated Septum
Perforated Septum
Nasal polyp
VI. Assessment of the Mouth & Pharynx
A. Anatomy & Physiology Overview & Landmarks
B. Equipment
C. Assessment Proper
1. Lips (consistency, color)
> Abnormal Findings:
Circumoral pallor
Bluish (cyanotic) lips
Reddish lips
Cheilosis
Herpes simplex
Cleft lip
2. Teeth & Gums (color, condition & alignment of teeth; color & consistency of gums)
> Abnormal Findings:
Dental caries
Malocclusion
Gingivitis
Receding Gums
Gingival Hyperplasia
3. Buccal mucosa (color & consistency; Stensons ducts)
> Abnormal Findings:
Aphthous Ulcer (Canker Sore)
Kopliks Spots
4. Tongue (color, moisture, size, texture, fasciculation, midline protrusion, lesions & induration;
ventral surface, frenulum, area under tongue, Whartons ducts & sides of tongue)
> Abnormal Findings:
Fissured Tongue
Black, Hairy Tongue
Smooth, reddish, shiny tongue w/o papillae (Beefy Red Tongue)
Leukoplakia
Candida Albicans Infection (Thrush)
Carcinoma of Tongue
5. Palate (color & integrity of soft & hard palate)
> Normal Variation:
12
Torus
palatinus
13
8. Percussion tone
9. Diaphragmatic excursion
10. Breath sounds (presence & location & bronchial, bronchovesicular & vesicular breath
sounds)
11. Adventitious sounds (presence & location of crackles, wheezes, & pleural friction rub)
12. Voice sounds (bronchophony, egophony & whispered pectoriloquy)
X. Heart, Neck Vessel & Peripheral Vascular Assessment
A. Anatomy & Physiology Overview & Landmarks
B. Equipment
C. Assessment of the Heart (Precordium)
1. Heaves (visible pulsations)
2. Apical Impulse (location & amplitude)
3. Abnormal Pulsations (presence of thrills & other unusual pulsations)
4. Rate & Rhythm of Apical Pulse
5. Pulse Deficit
6. S1 Sound (where heard best)
7. S2 Sound (where heard best)
8. Extra Heart Sounds (location & timing)
9. Murmurs (timing, intensity, pitch, quality, shape or pattern, location, transmission,
ventilation & position)
D. Assessment of Neck Vessels
1. Jugular Vein Distention (also assess for hepatojugular reflux)
2. Jugular Venous Pressure
3. Bruits (carotid arteries)
E. Assessment of Peripheral Vasculature
1. Arm/Leg Edema
2. Nail Beds & Capillary Refill Time (CRT)
3. Allen Test
4. Varicosities
5. Homans sign
6. Rate & Strength/Amplitude of Peripheral Pulses (temporal, carotid, brachial, radial,
femoral, popliteal, posterior tibialis,
& dorsalis pedis pulses)
XI. Abdominal Assessment
A. Anatomy & Physiology Overview & Landmarks
B. Equipment
C. Assessment Proper
1. Contour
> Abnormal Finding:
Ascites
2. Symmetry (protrusions, bulging or lumps w/ client supine & w/ head raised)
3. Striae
4. Umbilicus (color, location & contour)
5. Aortic pulsations
6. Peristaltic waves
7. Bowel sounds (note character & frequency)
8. Vascular sounds & friction rubs (bruits, venous hums, friction rub over liver & spleen)
9. Percussion tone
10. Liver span
11. Liver palpation (consistency, tenderness, enlargement, presence of nodules)
12. Spleen (percussion tone, tenderness, consistency, enlargement, presence of nodules)
13. Massess palpated (if palpable: location, size in cm, shape, consistency, demarcation,
pulsatility, tenderness, mobility)
14. Kidneys (tenderness on blunt percussion, enlargement, consistency & presence of nodules)
15. Urinary Bladder (tenderness & consistency)
16. Girth
17. Shifting dullness
18. Fluid wave test
19. Rebound tenderness
20. Psoas sign
21. Obturator sign
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D. Abnormal Findings
Umbilical Hernia
Epigastric Hernia
Diastasis Recti
Incisional Hernia
Hepatomegaly
Splenomegaly
Abdominal Aortic Aneurysm
XII. Rectal Assessment
A. Anatomy & Physiology Overview & Landmarks
B. Selected Positions for Anorectal Examination
C. Equipment
D. Assessment Proper
1. Perianal Area (lumps, ulcers, lesions, rashes, redness, fissures & thickening of epithelium;
presence of bulging, lesions & hemorrhoids as client performs Valsalva
maneuver)
2. Sacrococcygeal area (signs of swelling, redness, dimpling & hair)
3. Anus (tenderness, nodules, hardness & external sphincter tone)
4. Rectum (mucosa: tenderness, irregularities, nodules & hardness; stool: color & blood)
5. Abnormalities of the Anus & Rectum
External hemorrhoid
Perianal abscess
Anal fissure
Anorectal fistula
Rectal prolapse
Pilonidal cyst
XIII. Assessment of the Male Genitalia & Prostate
A. Anatomy & Physiology Overview & Landmarks
B. Equipment
C. Assessment of the Penis
1. Base & pubic hair (pubic hair growth pattern; presence of excoriation, erythema or
infestation)
2. Shaft (rashes, lesions, lumps; hardened & tender areas)
3. Foreskin & Glans (size & shape, lesions or redness of glans; color, location, integrity &
retraction of foreskin for uncircumcised client)
4. Urethral opening & discharge (location of urinary meatus; color, consistency, character &
odor of discharges)
5. Abnormalities of the Penis
Syphilitic chancre
Herpes progenitalis
Genital warts
Phimosis
Paraphimosis
Hypospadias
Epispadias
D. Assessment of the Scrotum
1. Size, shape & position (swelling, lumps or bulges)
2. Scrotal skin (color & integrity, lesions or rashes)
3. Testicles & Nearby Structures (size, shape, consistency, nodules & tenderness of each
testis & epididymis; nodules, swelling or tenderness of
each spermatic cord & vas deferens; auscultation &
transillumination if abnormal masse or swelling is noted)
4. Abnormalities of the Scrotum
Hydrocele
Scrotal hernia
Testicular tumor
Cryptochidism
Epididymitis
Orchitis
Small testes
Torsion of spermatic cord
15
Varicocele
Spermatocele
16
XVI. Neurologic Assessment
A. Anatomy & Physiology Overview & Landmarks
B. Equipment
C. Assessment of Mental Status/Cerebral Function
1. Levels of consciousness
> Alert
> Lethargic
> Somnolent
> Obtunded
> Stuporous
> Comatose
2. Glasgow Coma Scale (GCS)
3. Mood & Affect
4. Dress, Hygiene & Grooming
5. Facial Expressions
6. Speech (tone, clarity, pace of speech)
7. Vocabulary
8. Thought Processes (clarity, content)
9. Orientation (person, place, time)
10. Attention (ability to focus & stay attentive, ability to follow directions)
11. Memory (remote & recent)
12. Fund of Information (general knowledge)
13. Abstract Reasoning (proverb interpretation)
14. Judgment (sound answer based on hypothetical situations)
15. Visual Perceptual & Constructional Ability (ability to copy simple figures)
D. Assessment of Motor/Cerebellar Function
1. Rapid alternating movements
2. Finger-thumb test
3. Finger-nose test
4. Heel-to-shin test
5. Button-unbutton shirt
6. Tandem walk
7. Romberg test
8. Involuntary movements (fasciculations, tics, tremors)
E. Assessment of Sensory Function
1. Light touch sensation
2. Discrimination bet. sharp/dull sensations
3. Temperature sensation
4. Vibratory sensation
5. Two-point discrimination
6. Stereognosis
7. Graphesthesia
8. Kinesthesia
F. Assessment of Cranial Nerve Function
1. CN I (Olfactory)
2. CN II (Optic)
3. CN III, IV, & VI (Oculomotor, Trochlear, Abducens)
4. CN V (Trigeminal)
5. CN VII (Facial)
6. CN VIII (Vestibulocochlear)
7. CN IX (Glossopharyngeal)
8. CN X (Vagus)
9. CN XI (Spinal Accessory)
10. CN XII (Hypoglossal)
G. Assessment of Deep Tendon Reflexes
1. Biceps
2. Triceps
3. Brachioradialis
4. Patellar
5. Achilles
H. Assessment of Superficial Reflexes
1. Abdominal
2. Cremasteric
17
3. Plantar
I. Assessment of Pathologic Reflexes
1. Brudzinkis sign (test for meningeal irritation)
2. Kernigs sign (test for meningeal irritation)
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19
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