Medical Documentation

________ show the dye as it flows through the heart arteries.

________: involves listening for normal and abnormal sounds with a stethoscope.

________= pupils equal, round, and reactive to light and accommodation.

________: used to produce sounds, elicit tenderness, or assess reflexes in a patient.

________: assess the four quadrants of the abdomen.

________= improve how antibiotics are prescribed by clinicians and used by patients.

________ or percutaneous coronary intervention (PCI): when a catheter is used to clear a narrowed or blocked artery or a cardiac stent is placed.

________: follow- up after receiving a screening at ONU Healthwise mobile clinic on 8 /19 /22.

________: use of the sense of touch in the evaluation of the patient.

________ (CXR): very common when evaluating lung conditions.

________: fluid in the space between the chest wall and lungs.

________: partially or fully collapsed lung.

________: areas of the lung where air should be, but it is not.

A(n) ________ is collected from the source of the infection and sent to the microbiology lab.

________: dead cell, debris, pus commonly seen with pneumonia.

________: inhalation of food particles or stomach contents.

________: inspection of mouth & pharynx, palpation of lymph nodes & glands.

Inspection: color, texture, ________, contour.

________: general observation of patient.

________: contrast dye is injected through a catheter.

in patients own words

or long-term goals

pick one

"I am here to have my blood pressure checked again and see if I need any new medicine"

follow-up after receiving a screening at ONU Healthwise mobile clinic on 8/19/22

high blood pressure

eating out 1-2 times per week, cup of coffee & can of soda q day; walk 2-3 times q week; no cigs or nic; no drugs; 1-2 beers q weekend; no cost issues, no insurance issues

Lisinopril 10 mg po qhs; Tylenol for headaches 1-2 times q month; no herbals

NKDA

Pfizer covid Vaccine 6/22, flu shot 10/21

deferred

98.6

511"

100 kg

deferred

WNL

controlled HTN (116/70)

Maintain BP < 130/80; reduce overall lifetime risk of heart attack and stroke

general observation of patient

use of the sense of touch in the evaluation of the patient

used to produce sounds, elicit tenderness, or assess reflexes in a patient

involves listening for normal and abnormal sounds with a stethoscope

Hair, scalp, skull, face, skin

general inspection, reactivity of pupils, ophthalmoscopy, extraocular muscles

internal inspection, otoscopy

external inspection/palpation, otoscope

inspection of mouth & pharynx, palpation of lymph nodes & glands

inspection, palpation, and auscultation

very common when evaluating lung conditions

areas of the lung where air should be, but it is not

dead cell, debris, pus commonly seen with pneumonia

partially or fully collapsed lung

fluid in the space between the chest wall and lungs

inhalation of food particles or stomach contents

echocardiogram

electrocardiogram

contrast dye is injected through a catheter

when a catheter is used to clear a narrowed or blocked artery or a cardiac stent is placed

forced expiratory volume in 1 second

forced vital capacity

assess the four quadrants of the abdomen

color, texture, vascularity, contour

bowel sounds, vascular sounds

fluid, gaseous distention, and masses

areas of tenderness, muscle spasms, or the presence of fluid or masses

deep vein thrombosis