` Medical Record Blunders

◦ Rectal exam revealed a normal size thyroid. (Long fingers?)

◦ Exam of genitalia reveals that he is circus sized. ◦ ◦ On the second day the knee was better and on the

third day it had completely disappeared. ◦ ◦ She is numb from her toes down.

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` History and Physical: pp. 41-43 ` Progress Note (SOAP format): pp. 43-44 ` Prescription: pp. 73-76

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` What each form is for. ` What are the component parts of each form. ` What kind of information goes in each

component part. ` The common abbreviations associated with

these forms.

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S: subjective – that which the patient describes O: objective – observable information, such as test results, blood pressure readings, etc. A: assessment – progress and evaluation of the effectiveness of the plan P: plan – decision to proceed or alter strategy

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` p.r.n. ` ad lib. ` noc. ` a.m. ` p.c. ` NPO ` q.1 h, q.1° ` q.i.d. (t.i.d.)

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` statim STAT ` pro re nata p.r.n. ` ad libitum ad lib ` noctis (nocte) noc. ` ante meridiem a.m. ` post cibum p.c. ` non/nihil per os NPO ` 1 quaque hora q.1 h, q.1° ` quarter in die (ter…) q.i.d. (t.i.d.)

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` h.s. (hour sleep or half-strength) ` qd and q.o.d (s.i.d. and q.a.d.) ` AD, AS, AU and OS, OD, OU

` N.B. oculus dexter, oculus sinister, oculus uterque; auris dextra, auris sinistra, auris utraque 9

ā p ̅

s ̅      c ̅ 10

ā p ̅ s ̅      c ̅

` ante post

` sine cum

` male female

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Physician’s written direction for dispensing or administering a medication for a patient

Must be written in a specific format ` Rx: prescription

◦ Dispensation: name, strength and amount

◦ Signa: patient instructions

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℞: medication Disp.: dispensing instructions Sig.: patient instructions

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` Mortar and Pestle ◦ L. recipe – receive, take

` cheirourgia, diaita, pharmakon (pharmac/o)

` Material ◦ foodstuff (wine, gruel),

parts of plants, parts of animals, minerals

` Simple vs. Compound

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Dioscorides (1st century AD), De materia medica

` theria, wild beast

` Mithradates VI (132-63 BC), King of Pontus in Asia Minor ◦ Mithradatism

` Galen’s (129-210 AD)

theriac ◦ Ingredients ◦ Experimentation ◦ Galenicals

` Medieval Panacea

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` aq. (L. aqua, water), water ` cap. (L. capsula, little box), capsule ` tab. (L. tabula, little table) tablet ` bol. (L. bolus, fr. Gr. bolos, lump) ` ung. (L. unguentum) ointment ` lot., lotion ` supp. (L. suppositorium), suppository ` gtt. (L. gutta, drop), drop ` en. (Gr. enema, clyster) enema

` Parenteral ◦ IM ◦ ID ◦ IV ◦ SC, SQ, Sub-Q

` SL ` PV ` PR ` p.o. ` top.

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` Parenteral ◦ IM – Intramuscular ◦ ID – Intradermal ◦ IV – Intravenous ◦ SC, SQ, Sub-Q – Subcutaneous

` SL – sublingual ` PV – per vaginam ` PR – per rectum ` p.o. – per os ` top. - topical

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` Clysters

` Suppository

` Uterine Fumigation

` Hypodermic?

` ii tab po q6h p.r.n. pain

` vi supp. PR q2d noc.

` ix tab t.i.d. p.c. 23

` I or i = 1 ` V or v = 5 ` X or x = 10 ` L or l = 50 ` C or c = 100 ` D or d = 500 ` M or m = 1000

` Subtraction rule: ` IV = 4, IX = 9, XL = 40, XC = 90, CD = 400, CM = 900

x 949 = DCCCCXXXXVIIII = CMXLIX

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` Here is wisdom. Let him who has understanding calculate the number of the beast, for it is the number of a man: His number is 666. (Rev.13:18-NKJV)

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