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AHN 568 Module 1 Exam with Questions and Answers| Latest Update
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AHN 568 Module 1 Exam with Questions and Answers| Latest Update
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AHN 568 Module 1 Exam with Questions andAnswers| Latest Update
parts of personal and social history - ✔✔education, job, living situation, family, smoking,
drugs, ETOH/CAGE, caffeine, sleep, exercise, and religion
Primary medical history (PMH) - ✔✔"AIM" + Health maintenance
A: Allergies and Rxs
I: Immunizations and Illnesses (child/adult)
M: Medications
+ health maintenance: surgeries, hospitalizations, ER visits, colonoscopy, pap smear, dentist,
fecal occult tests
Subjective Health History - ✔✔" I C Hungry Pigs Fly Past River"
I: identifying info
C: Chief complaint
H: History of Present Illness w/ OLDCARTS
P: Primary medical Hx with AIM "allergies, illness/immunizations, meds" + health maintenance
F: Family Hx
P: Personal/Social Hx
R: Review of systems
HPI - ✔✔History of present illness
OLDCARTS
O: ONSET
D: LOCATION
D: DURATION
,C: CHARACTER- how do they describe it?
A: AGGRAVATING/ALLEVIATING/ASSOCIATING
R: RADIATION
T: TIMIING
S: SEVERITY 0-10
Admission note - ✔✔ABC DAVID
A: admit to icu/floor/etc
B: Because...
C: Conditions
D: Diet
A: Allergies and activity (PT order)
V: Vitals (frequency with parmeters)
I: I/O frequency, IV fluids
D: Diagnostic labs, texts, meds, and goals of tx
Part of the "Assessment" note portion - ✔✔1. differential diagnoses (multiple)
2. Presumptive diagnosis (what u conclude it most likely)
the "Plan" must include what? - ✔✔-you must address all problems on problem list.
labs, meds with dose and frequency, followup
-label the acuity of Dx ("acute on chronic")
-goals of therapy for everything I order
What is episodic note? - ✔✔SUBJECTIVE
OBJECTIVE
ASSESSMENT
, PLAN
What to include in discharge summary? - ✔✔-why they were admitted
-pertinent dx
1. principal dx
2. secondary dx
-tx they had and their response, complications, consults
-condition at d/c
-placement- home or SNIFF etc
-instructions and referrals
-follow up apt
Objective data - ✔✔VS, HT, WT, BMI
ASSESSMENT FINDINGS
DIAGNOSTIC TESTS/LABS/IMAGING
MY IMPRESSION OF IMAGING
Murmur grades - ✔✔Grade I: barely audible. very faint and may not be heard by
professionals
Grade II: Quiet, soft, and audible.
Grade III: Moderately loud. audible w/o thrill
Grade IV: Loud, but still of intermediate intensity; palpable vibration or thrill; detection of a
palpable thrill indicates a murmur of grade IV or more
Grade V: Very loud, heard with a stethoscope partly off the chest; accompanied by a palpable
thrill
Grade VI: Heard with the stethoscope entirely off the chest and accompanied by palpable thrill
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