subjective, objective, assessment, plan - Answers SOAP
what the patient tells you - Answers subjective
Observable, measurable data. What can be seen or tested - Answers objective
Official diagnosis based on subjective and objective, test RESULTS - Answers Assessment
chief complaint - Answers CC
who, what, when, where, why, how - Answers Five W's and H
history of present illness - Answers HPI
past medical illness - Answers PMI
Chief complaint (cc), history of present illness (hpi), past family and social history (pfsh) and
review of systems (ros) - Answers Medical history includes
Significant medical issues-anything that "runs in the family"-among parents, children,
grandparents, grandchildren (heart disease, cancer, diabetes, stroke) - Answers Family history
includes
behavior that reveals a person's feelings without words, through facial expressions, body
language, and vocal cues - Answers non verbal behavior
May give clues for unspoken concerns - Answers Why is non verbal behavior important
temperature, pulse, respiration, blood pressure - Answers Vitals
Pulse ox, O2 sats - Answers What is oxygen saturation called
height and weight - Answers anthropometric measurements
body mass index (measurement of body fat based on height and weight) - Answers BMI
Up to 30 - Answers Normal BMI
basal metabolic rate, minimum calories needed for basic function - Answers BMR
How a person walks - Answers gait
Be specific, explain what the exam is for, how the gown needs to be worn, getting sheets to
cover patient, make sure patient understands directions - Answers What are some things to
consider when instructing a patient to change into a gown?
Illness, stress, depression, anxiety, exercise, age, gender, environment, time of day - Answers
, What can affect a person's temperature?
Fever of 102 or higher - Answers Pyrexia
Fever 105° and above - Answers hyperpyrexia
98.6 - Answers Normal oral temperature
99.6 - Answers Normal rectal temperature
97.6 - Answers Normal axillary temperature
98.6 - Answers Normal tympanic temperature
98.6 - Answers normal temporal temperature
100.4 - Answers Official start of fever
Anxiety, depression, stress, exercise, illness, time of day, position, medication, body type, blood
volume, alcohol, drugs - Answers What can affect a person's pulse
rate, rhythm, volume - Answers What are the characteristics of pulse
radial - Answers What artery is used most often for pulse rate
Apical preferred, or brachial - Answers What pulse point is used on babies
Lower, slower than normal - Answers What would you expect for pulse rate on an athlete
60-100 bpm - Answers Normal adult pulse
Age, elevated body temperature, sleep apnea, illness, knowing they are being watched - Answers
Things that can affect a person's respirations
20+ per minute - Answers normal infant respiratory rate
18-20 per minute - Answers Normal child respiratory rate
12-20 breaths per minute - Answers normal adult respiratory rate
Heart disease, age, activity, diet, alcohol, tobacco use, family history, stress, body position -
Answers What can affect a person's blood pressure
Lower than normal reading - Answers What happens if you use too large cuff for BP
Higher than normal reading - Answers What happens if you use too small of a cuff for BP
brachial artery - Answers What artery is used to measure blood pressure?
One and five - Answers What phases of korotkoff sounds are recorded as blood pressure