History and Vital Signs
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5 VITAL SIGNS:

1. PULSE-RATE, 2. BP, 3. RESPIRATION, 4. SKIN, 5. PUPILS

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AUSCULTATION:

THE ACT OF LISTENING TO INTERNAL SOUNDS OF THE BODY, TYPICALLY WITH A STETHOSCOPE

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BASELINE VITAL SIGNS:

THE VERY FIRST SET OF VITAL SIGNS OBTAINED ON A PATIENT

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BLOOD PRESSURE:

THE MEASUREMENT OF THE PRESSURE INSIDE THE ARTERIES, BOTH DURING CONTRACTIONS OF THE HEART AND BETWEEN CONTRACTIONS

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BP-DOC:

BLEEDING PAIN DEFORMITIES OPEN WOUNDS CREPITUS (AGAITING NOISE)

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BTLS:

BURNS TENDERNESS LACERATIONS SWELLINGS

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CAPILLARY REFILL:

THE TIME IT TAKES FOR THE CAPILLARIES TO REFILL AFTER BEING BLANCHED; NORMAL CAPILLARY REFILL TIME IS TWO SECONDS OR LESS

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CHIEF COMPLAINT:

THE MAIN MEDICAL COMPLAINT AS DESCRIBED BY THE PATIENT; ILLNESS OR INJURY FOR WHICH THE EMERGENCY MEDICAL SYSTEM WAS ACTIVATED

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CYANOTIC:

THE BLUISH COLORATION OF THE SKIN CAUSED BY AN INADEQUATE SUPPLY OF OXYGEN; TYPICALLY SEEN AT THE MUCOUS MEMBRANES AND NAIL BEDS

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DCAP:

DEFORMITIES CONTUSIONS ABRASIONS PUNCTURES

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DIAPHORETIC:

EXCESSIVE SWEATING; COMMONLY CAUSED BY EXERTION OR SOME MEDICAL PROBLEM, SUCH AS HEART ATTACK AND SHOCK

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DIASTOLIC:

THE PRESSURE THAT REMAINS IN THE ARTERIES WHEN THE HEART IS AT REST; THE RESTING PHASE OF THE HEART

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SAMPLE:

SIGNS/SYMPTOMS ALLERGIES MEDICATION PAST MEDICAL HISTORY/SURGERY LAST ORAL INTAKE EVENTS LEADING TO ILLNESS/INJURY

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MEDICAL HISTORY:

PREVIOUS MEDICAL CONDITIONS AND EVENTS FOR A PATIENT

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AVPU:

ALERT (PERSON, PULSE, TIME, EVENT) VERBAL PAIN UNRESPONSIVE

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MENTAL STATUS:

THE GENERAL CONDITION OF A PATIENT'S LEVEL OF CONSCIOUSNESS AND AWARENESS

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OPQRST:

A MNEMONIC USED DURING A SECONDARY ASSESSMENT TO HELP ASSESS PAIN; THE LETTERS STAND FOR ONSET, PROVOCATION, QUALITY, REGION/RADIATE, SEVERITY, TIME

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PAIN / DISCOMFORT ASSESSMENT - O,P,Q,R,S,T:

ON SET, PROVOCATION/PALLIATION, QUALITY OF PAIN, REGION/AREA OF PAIN, SEVERITY, TIME

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PALPATE:

TO EXAMINE BY FEELING WITH ONES HANDS

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PALPATION:

THE ACT OF USING ONE'S HANDS TO TOUCH OR FEEL THE BODY

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PERRLA:

PUPILS EQUAL ROUND REACTIVE LIGHT ACCOMMODATED

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PULSE:

THE PULSATION OF THE ARTERIES THAT IS FELT WITH EACH HEART BEAT

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RESPIRATION:

THE ACT OF BREATHING IN AND OUT; ALSO, THE EXCHANGE OF OXYGEN AND CARBON DIOXIDE WITHIN THE CELLS

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SIGN:

SOMETHING THAT CAN BE OBSERVED OR MEASURED WHEN ASSESSING A PATIENT

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STETHOSCOPE:

A DEVICE USED TO AUSCULTATE SOUNDS WITHIN THE BODY; MOST COMMONLY USED TO OBTAIN BLOOD PRESSURE

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SYMPTOM:

SOMETHING THAT THE PATIENT COMPLAINS OF OR DESCRIBES DURING THE SECONDARY ASSESSMENT

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SYSTOLIC:

THE PRESSURE WITHIN THE ARTERIES WHEN THE HEART BEATS; THE CONTRACTION PHASE OF THE HEART

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TRENDING:

THE ACT OF COMPARING MULTIPLE SETS OF SIGNS AND SYMPTOMS OVER TIME TO DETERMINE PATIENT CONDITION

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VITAL SIGNS:

THE FIVE MOST COMMON SIGNS USED TO EVALUATE A PATIENT'S CONDITION (RESPIRATIONS, PULSE, BLOOD PRESSURE, SKIN, AND PUPILS)

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WORK OF BREATHING:

THE EFFORT THAT A PATIENT MUST EXERT TO BREATHE

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CLASSIC SYMPTOMS ASSOCIATED FROM CARDIAC ISCHEMIA OR INFARCTION:

DULL SUBSTERNAL CHEST PAIN OR DISCOMFORT; RESPIRATORY DISTRESS; NAUSEA, VOMITING; DIAPHORESIS

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NON-CLASSIC (ATYPICAL) SYMPTOMS ASSOCIATED FROM CARDIAC ISCHEMIA OR INFARCTION:

NECK ACHE; PRESSURE IN THE CHEST; PAINS IN THE BACK, BREAST, OR UPPER ABDOMEN; TINGLING OF THE FINGERS; UNEXPLAINED FATIGUE OR WEIGHT GAIN; INSOMNIA

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SIGNS AND SYMPTOMS OF GENERALIZED HYPERTHERMIA:

MUSCLE CRAMPS; WEAKNESS OR EXHAUSTION; DIZZINESS OR FAINTING; RAPID HEART RATE; ALTERED MENTAL STATUS; MOIST COOL, PALE SKIN; NAUSEA AND VOMITING; ABDOMINAL CRAMPS;

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SIGNS AND SYMPTOMS OF INTERNAL BLEEDING:

SIGNS AND SYMPTOMS OF SHOCK; BLEEDING FROM ANY BODY ORIFICE; BLOOD-TINGED VOMIT OR FECES; COFFEE GROUND VOMIT; DARK, TARRY STOOL; ABDOMINAL RIGIDITY OR TENDERNESS; DISTENDED ABDOMEN

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SIGNS AND SYMPTOMS OF SHOCK:

RAPID AND WEAK PULSE; PALE OR CYANOTIC SKIN; COOL CLAMMY SKIN; RAPID SHALLOW BREATHING; RESTLESSNESS AND ANXIETY; MENTAL DULLNESS OR CONFUSION; NAUSEA, VOMITING, AND THIRST; LOW OR DECREASED BLOOD PRESSURE (LATE SIGN);

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SIGNS OF CARDIAC COMPROMISE:

SQUEEZING DULL PAIN, SUDDEN ONSET OF SWEATING, DIFFICULTY BREATHING, ANXIETY OR IRRITABILITY, FEELING OF IMPENDING DOOM, ABNORMAL OR IRREGULAR PULSE RATE, DISCOMFORT IN THE ABDOMEN, NAUSEA OR VOMITING;

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SIGNS OF INADEQUATE BREATHING IN A PATIENT:

DIFFICULTY BREATHING; RATE TOO FAST OR TOO SLOW, OR IRREGULAR; DIMINISHED OR ABSENT BREATH SOUNDS; UNEQUAL OR INADEQUATE CHEST EXPANSION; INCREASED EFFORT; CYANOSIS; NOISY RESPIRATIONS; A PATIENT IN THE TRIPOD POSITION; CHANGE IN LEVEL OF RESPONSIVENESS;

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SIGNS OF MILD HYPOXIA:

TACHYPNEA; DYSPNEA; PALE, COOL, CLAMMY SKIN; TACHYCARDIA; ELEVATED BLOOD PRESSURE; RESTLESSNESS AND AGITATION; DISORIENTATION AND CONFUSION

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SIGNS OF SEVERE HYPOXIA:

TACHYPNEA, DYSPNEA, CYANOSIS, TACHYCARDIA THAT CAN LEAD TO DYSRYHTHMIAS, CONFUSION, LOSS OF COORDINATION, SLEEPY APPEARANCE, ALTERED MENTAL STATUS

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BLOOD GLUCOSE:

THE LEVEL OF GLUCOSE IN THE BLOODSTREAM AND ANY GIVEN TIME

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CARDIAC MONITOR:

A DEVICE USED TO DISPLAY THE ELECTRICAL ACTIVITY OF THE HEART

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END-TIDAL CO2 DETECTOR:

A DEVICE USED TO DETECT THE PRESENCE OF CO2 IN THE EXHALED BREATH OF A PATIENT

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GLUCOMETER:

A DEVICE USED TO MEASURE AND DISPLAY THE AMOUNT OF GLUCOSE IN A GIVEN SAMPLE OF BLOOD

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PULSE OXIMETER:

A DEVICE USED TO MEASURE AND DISPLAY THE PERCENTAGE OF HEMOGLOBIN IN BLOOD THAT IS SATURATED WITH OXYGEN

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