MedIcaI Record 8Iunders

RectaI exam reveaIed a normaI sIze thyroId. (Long

IIngersZ)

Exam oI genItaIIa reveaIs that he Is cIrcus sIzed.

On the second day the knee was better and on the
thIrd day It had compIeteIy dIsappeared.

She Is numb Irom her toes down.

1

HIstory and PhysIcaI: pp. 41-43
Progress Note (SOAP Iormat): pp. 43-44
PrescrIptIon: pp. 73-76

2
What each Iorm Is Ior.
What are the component parts oI each Iorm.
What kInd oI InIormatIon goes In each
component part.
The common abbrevIatIons assocIated wIth
these Iorms.
3
4

S: subjectIve that whIch the patIent descrIbes
O: objectIve observabIe InIormatIon, such as
test resuIts, bIood pressure readIngs, etc.
A: assessment progress and evaIuatIon oI the
eIIectIveness oI the pIan
P: pIan decIsIon to proceed or aIter strategy
5
6
p.r.n.
ad IIb.
noc.
a.m.
p.c.
NPO
q.1 h, q.1
q.I.d. (t.I.d.)




7
statIm STAT
pro re nata p.r.n.
ad IIbItum ad IIb
noctIs (nocte) noc.
ante merIdIem a.m.
post cIbum p.c.
non]nIhII per os NPO
1 quaque hora q.1 h, q.1
quarter In dIe (ter) q.I.d. (t.I.d.)



8
h.s. (hour sIeep or haII-strength)
qd and q.o.d (s.I.d. and q.a.d.)
AD, AS, AU and OS, OD, OU




N.8. ocuIus dexter, ocuIus sInIster, ocuIus
uterque; aurIs dextra, aurIs sInIstra, aurIs
utraque


9
p


s

10
p

s

ante post



sIne cum



maIe IemaIe
11
12
Physicians written direction for dispensing
or admInIsterIng a medIcatIon Ior a
patIent
Must be wrItten In a specIIIc Iormat
Rx: prescrIptIon
DIspensatIon: name, strength and
amount
SIgna: patIent InstructIons
13
14
: medication
Disp.: dispensing instructions
Sig.: patient instructions
15
Mortar and PestIe
L. recIpe receIve, take

cheIrourgIa, dIaIta,
pharmakon
(pharmac]o)

MaterIaI
IoodstuII (wIne, grueI),
parts oI pIants, parts oI
anImaIs, mIneraIs

SImpIe vs. Compound
16
Dioscorides (1
st
century AD), De
materia medica
therIa, wIId beast

MIthradates V (132-63 8C),
KIng oI Pontus In AsIa MInor
MIthradatIsm

Galens (129-210 AD)
therIac
ngredIents
ExperImentatIon
CaIenIcaIs

MedIevaI Panacea



17
18
aq. (L. aqua, water), water
cap. (L. capsuIa, IIttIe box), capsuIe
tab. (L. tabuIa, IIttIe tabIe) tabIet
boI. (L. boIus, Ir. Cr. boIos, Iump)
ung. (L. unguentum) oIntment
Iot., IotIon
supp. (L. supposItorIum), supposItory
gtt. (L. gutta, drop), drop
en. (Cr. enema, cIyster) enema



ParenteraI
M
D
V
SC, SQ, Sub-Q

SL
PV
PR
p.o.
top.
19
ParenteraI
M ntramuscuIar
D ntradermaI
V ntravenous
SC, SQ, Sub-Q Subcutaneous

SL subIInguaI
PV per vagInam
PR per rectum
p.o. per os
top. - topIcaI
20
21
22
CIysters

SupposItory

UterIne FumIgatIon

HypodermIcZ



II tab po q6h p.r.n. paIn

vI supp. PR q2d noc.

Ix tab t.I.d. p.c.







23
or I = 1
V or v = 5
X or x = 10
L or I = 50
C or c = 100
D or d = 500
M or m = 1000

SubtractIon ruIe:
V = 4, X = 9, XL = 40, XC = 90, CD = 400, CM = 900

949 = DCCCCXXXXV = CMXLX

24
25
26
Here Is wIsdom. Let hIm who has
understandIng caIcuIate the number oI the
beast, Ior It Is the number oI a man: HIs
number Is 666. (Rev.13:18-NK]V)





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