How To Write A SOAP Note
How To Write A SOAP Note
How To Write A SOAP Note
Introduction
A. General Procedures
B. Recording patients identification/admin data
C. Vital Signs
Temperature
Blood Pressure
Respiratory rate
Pulse
D. History of allergy to medications
E. Current medications
F. History of chronic disease or illness
G. Documentation using the SOAP method
Subjective
Objective
Assessment
Plan
H. Ordering laboratory tests
I. Ordering X-ray studies
J. Prescribing and dispensing of medication
K. Profiles, Quarters, and bed rest
L. Referral to supervising medical officer
M. Quality assurance
Guidelines When to Consult a Medical Officer
TABLE of CHIEF COMPLAINTS
ENT COMPLAINTS
Upper respiratory infection (URI)
Sore throat
Allergy/hay fever
Hoarseness
Sinus complaints
Epistaxis (nosebleed)
Ear pain, drainage, sense of fullness
Hearing loss
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4
4
4
5
5
5
5
6
6
6
6
7
8
8
9
9
9
10
11
11
12
13
18
19
20
22
23
25
27
28
30
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DERMATOLOGIC COMPLAINTS
Friction blisters
Corns and calluses
Superficial fungal infections
Tinea vesicolor
Acne
Sexually transmitted diseases
Crabs/lice
31
32
34
35
36
38
40
MINOR TRAUMA
Minor trauma
Shoulder pain
Low back pain
Hip pain
Knee pain
Ankle pain
42
45
47
49
50
52
MEDICAL COMPLAINTS
Fatigue
Headaches
Chest pain
Nausea and vomiting
Abdominal pain
Diarrhea and constipation
54
56
58
60
62
64
List of medications
67
Glossary of Terms
73
Medical Abbreviations
81
Anatomy
86
Notes
99
100
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A. GENERAL PROCEDURES
Patients reporting to the BAS/TMC will follow accepted routine designed to
enhance both the efficiency and quality of medical care. Upon arrival the patient
will proceed to front desk where he will present a valid ID card and sick call slip
(DD 689). The soldier's data will be entered in the sick-call log in accordance
with SOP. The medical record clerk will retrieve the patient's records from the file
room. The patient will be directed to the appropriate waiting or screening area.
Patients will generally be seen in order of arrival. It is extremely important for all
personnel working in the BAS/TMC to be able to recognize those patients who
require immediate care. In such cases the supervising Medical Officer will be
notified immediately. Routine sick-call patients will have their vitals taken and
their complaint(s) reviewed by qualified enlisted medical personnel IAW with
ADTMC. The screener may continue with the patient's interview and follow the
procedures as outlined in this text. Screens must realize their own personal
limitations and seek assistance from the medical officer whenever any doubt
exists. All patients may request to be seen by a medical officer.
B. RECORDING PATIENTS IDENTIFICATION AND ADMINISTRATIVE DATA
The recording of patient identification and administrative data should be
accomplished by the front desk or medical records clerk. Upon retrieval of the
patient's medical record from the file the clerk/screener should ensure that there
is a 5181 in the patient's chart. The clerk must insure that accurate, legible and
complete data is entered. The following entries are mandatory
Patient Identification
Name (LAST, First, MI)
SEX
SSN (complete 9 digits)
Rank
Unit
Unit Phone number
Administrative Data
Date
TMC/BAS
Stamp/Identification
Arrival Time
C. VITAL SIGNS
Vital signs which are accurately obtained and properly recorded are the
foundation of quality medical care. All patients reporting for treatment will have
vital signs taken and recorded in their charts for each visit to a TMC or BAS. It is
generally accepted practice during peak periods of sick-call to assign one medic
to obtain and record designated vital signs. This practice allows for the
centralization of equipment and the efficient use of manpower but may be
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OBJECTIVE: This portion of the note includes all the medic's observations and
physical findings. It may include the results of pertinent laboratory and x-ray
studies. A medical record is a legal document. Good intentions don't make good
medical notes. Remember, if you didn't do it, don't chart it, if it isn't charted then
you did not perform that part of the examination. An appropriate objective note
will demonstrate that the care provider has performed at least those parts of the
physical examination which are relevant to the chief complaint, and should
adhere to the guidelines listed under each complaint in this manual. SOME
OBJECTIVE FINDINGS WILL REQUIRE THE PATIENT TO BE REFERRED TO
A MEDICAL OFFICER. A complete objective note will contain the following
information.
GENERAL APPEARANCE
INDICATIONS OF OBVIOUS DISTRESS
PERTINENT PHYSICAL FINDINGS
RELEVANT LABORATORY RESULTS
RELEVANT X-RAY STUDIES
An example of a good OBJECTIVE note for the physical examination on our
soldier with an ankle injury would be
O Right ankle w/significant swelling over lateral malleolus. Ecchymosis
present. Neuor-vascularly intact distally. Significant pain limits FROM mild to
moderate laxity of the joint. No bony pain. Unable to bear weight. X-rays
show no bony pathology with a good mortise.
ASSESSMENT: This manual will generally provide the medic with the guidance
necessary to reach a reasonable assessment. The assessment should reflect your
findings during the history and your examination. It is assumed that the art of
arriving at more specific diagnoses will develop with experience. SOME
ASSESSMENTS WILL REQUIRE A REFERRAL TO A MEDICAL OFFICER.
An example of ASSESSMENT using our patient with the ankle injury would be:
A Grade II right ankle sprain
PLAN: This portion of the note includes all medications prescribed, treatments
given, special instructions, diets, physical limitations imposed, disposition, and plans
for follow-up. Immediately following the PLAN should be the care provider's
identification data, to include either stamped or printed the rank, name, MOS, SSN
and signature. MANY PLANS WILL REQUIRE CONSULTATION WITH A MEDICAL
OFFICER.
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U Splint x 3 days
Ice for 48 hours then alternate ice/heat
Motrin 800mg PO TID PRN
Crutches for 72 hours them increase activity
Profile TL3 for 2 weeks
RTC PRN
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Examples
CSR-PA and LAT
KUB upright/flat
Rt Hand, 3 views - isolate 2d finger
Lft Knee - 2 views
Rt ankle - 3 views
Lft wrist - 3 views
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Vital Signs
Chest Pain
Respiratory Complaints
Increased Blood Pressure
OB/GYN Problems
F. Urinary Complaints
G. Headaches
H. Fever
I. Overdose or Poison Ingestion
J. Trauma
K. Eye Complaints
L. Seizures
M. Bleeding
N. Psychiatric Problems
O. Pediatrics
P. Insect/Snake Bites or Allergic
Reactions
Q. Vomiting
R. Syncope
S. Pain
T. Neurologic
U. Infection
A. Vital Signs
NOTE: The medic should personally recheck abnormal vital signs manually.
(1) Adult:
Heart Rate <50 or > 120 resting or irregular
BP systolic <90 or diastolic >100
Respiratory Rate >24 or < 10
(2) Pediatric:
Less than 5 years: Heart Rate >140 or <80
Greater than 5 years: Heart Rate >120 or <60 or Resp Rate >40
B. Chest Pain
(1) Any chest pain
C. Respiratory Complaints
(1) Any difficulty breathing
D. Increased Blood Pressure (diastolic greater than 100mm Hg)
See A. Vital Signs
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E. OB/GYN Problems
(1) Imminent delivery or any complaints of labor (or abdominal cramping)
(2) Suspected ectopic pregnancy (pain, vaginal bleeding and know pregnancy)
(3) Any vaginal bleeding
(4) Alleged rape or sexual assault
(5) Pregnancy with blood pressure greater than 140/90 nn Hg or 20 mm rise from
patients baseline or proteinuria with headache or abdominal pain (think of toxemia
of pregnancy)
F. Urinary Complaints
(1) Unable to pass any urine
(2) Suspected renal stone (pain and hematuria)
(3) Toxic patients with UTIs
(4) Any patient with temperature over 101F with pyuria (pus in the urine)
G. Headaches
(1) With meningeal signs or suspected meningitis
(2) With persistent vomiting, fever, photophobia, neck pain with movement
(3) With associated neurologic alteration
(4) Associated with recent trauma
(5) In patients who relate abrupt onset of the most intense headache theyve ever
had or in patients with history of migraine headaches who have new type of severe
headache.
(6) Associated with diastolic blood pressure greater than 110 mm HG
(7) Associated with significant vision disturbances (decreased visual acuity greater
than 1 line from other eye or prior exam)
(8) Associated with syncope
H. Fever
(1) Adults (temperature >102F)
(a) In any suspected IV drug abuser
(b) Associated with threat to airway
(c) Associated with meningeal signs
(d) Associated with altered mental status
(2) Children (older than 24 months) who appear toxic at any temperature or with
temperature greater than 102F
(3) Toddler or infants (between 3 months to 24 months): a temperature (rectal)
greater than or equal to 101F or 39.5C OR if the patient appears toxic at any
temperature
(4) Neonates (less than 12 weeks) With temperatures greater than 100.4F (rectal)
or less than 96.5F (rectal)
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M. Bleeding
(1) Suspected posterior epistaxis (bleeding in the back of the nose)
(2) Epistaxis uncontrolled by 10 minutes of medically supervised nasal pressure (i.e.
bleeding does not stop during appropriately applied nasal pressure)
(3) Henatochezia (bloody stools) melena (dark, tarry stools), or history of same
(4) Hematemesis (vomiting blood)
(5) Anticoagulated patients with bleeding
(6) Any vaginal bleeding. See item E. OB/GYN Problems
N. Psychiatric Problems
(1) Patients who pose a threat to themselves or others
(2) Psychotic or delusional patients
(3) All paranoid schizophrenics with active symptoms
(4) Alcohol detoxification requests
O. Pediatrics
(1) Any toxic or lethargic child
(2) Fever - see item H. Fever
(3) Head injury in a two year old or younger or any age with neurological deficits
(4) Children with respiratory distress or wheezing
(5) Any child with recent viral illness and a single episode of vomiting, who behaves
unusually
(6) With cyanosis
(7) Child less than 5 years who is unable to use an extremity
(8) Suspected Child Abuse and/or Neglect (SCAN)
(9) Vomiting in first 8 weeks of lift (not regurgitating)
P. Insect/Spider/Snake Bites or Allergic Reactions
(1) Any bite within 4 hours
(2) or swelling above next major joint on extremity wounds
(3) or shortness of breath or wheezing
(4) or chest injuries
(5) or sense of swelling in throat
(6) or associated with generalized rash
(7) or with intense pain, as in black widow spider bites
(8) or history of allergic response to similar bite/sting
(9) With petechiae
(10) Suspected loxosceles envenomation (bite from Brown Recluse spider)
(11) All snake bites
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Q. Vomiting
(1) With associated loss of consciousness
(2) Hematemesis (vomiting blood)
(3) With associated head injury
(4) With systolic blood pressure less than 90 mm Hg
(5) With associated visual complaints
(6) With acute or surgical abdomen
(7) With orthostatic signs and/or symptoms
(8) With associated orthostatic pulse increase of greater than 20 or systolic blood
pressure drop greater than 10 mm Hg with ortostatic symptoms
(9) Suspected drug toxicity
(10) In cancer patients
(11) With associated altered mental status
R. Syncope
(1) In all patients without obvious vasovagal (e.g. needle stick) cause
(2) With associated trauma (either before or after)
(3) Secondary to heat injury
(4) With positive tilts (defined in Q. Vomiting (8)) or symptoms
S. Pain
(1) Any patient complaining of severe or significant pain
(2) Abdominal pain associated with mass especially if it is aulsatile
(3) Eye pain (not irritation)
(4) Suspected deep vein thrombosis
T. Neurologic
(1) Suspected current or recent TIA (transient ischemic attack) or Stroke
(2) Altered mental status
(3) Any paralysis
U. Infection
(1) Abscesses with fever or malaise/weakness especially in immunocompromised
patient (HIV, cancer, diabetic, or steroids, splenectomized, etc.)
(2) Peri-rectal abscess
(3) Pilonidal cyst
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ENT COMPLAINTS
Upper respiratory infection (URI)
Sore throat
Allergy/hay fever
Hoarseness
Sinus complaints
Epistaxis (nosebleed)
Ear pain, drainage, sense of fullness
Hearing loss
19
20
22
23
25
27
28
30
DERMATOLOGIC COMPLAINTS
Friction blisters
Corns and calluses
Superficial fungal infections
Tinea versicolor
Acne
Sexually transmitted diseases
Crabs/lice
31
32
34
35
36
38
40
MINOR TRAUMA
Minor Trauma
Shoulder pain
Low back pain
Hip pain
Knee pain
Ankle sprains
42
45
47
49
50
52
MEDICAL COMPLAINTS
Fatigue
Headaches
Chest pain
Nausea and vomiting
Abdominal pain
Diarrhea and constipation
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58
60
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SORE THROAT
Patients may present with the complaint of sore throat only. The examination should
include the following:
1. SUBJECTIVE (ask about a previous history for the same complaint)
a. Duration of symptoms
b. Difficulty swallowing or breathing
c. Inability to fully open mouth
d. Drooling
e. Smoking habits
f. Fever
2. OBJECTIVE (always include vital signs)
a. Neck supple
b. Elevated temperature
c. Oropharynx (injected edematous)
d. Lesions of oral mucosa
e. Tonsillar enlargement/exudate
f. Cervical adenopathy
g. Abdominal tenderness (splenomegaly) highly suspicious of mononucleosis
3. ASSESSMENT
a. No significant positive findings- presumptive viral or irritative pharyngitis
(i.e. heavy smoker)
b. Oropharynx injected tonsillar enlargement exudate -presumptive beta
hermolytic Streptococcal (BHS) pharyngitis. Must also have a fever
greater that 100F with tender cervical adenopathy. Rule out
mononucleosis if there is also abdominal discomfort.
4. PLAN
a. Presumptive ivral or irritative pharyngitis may be managed by having
the patient discontinue smoking, use warm saline or hydrogen peroxide
gargles and throat lozenges.
b. Presumptive BHS pharyngitis does not need to be confirmed by throat
culture if a fever, exudative tonsilities, and tender cervical adenopathy are
present. It may be treated with penicillin, or erythromycin if a penicillin
allergy exists. Medical officer consultation/referral is required
c. In certain cases mononucleosis must also be ruled out. A CBC with
differential is indicated, atypical lymphocytes noted suggest
mononucleosis. A mono spot should also be ordered. A positive reaction
is confirmation but a negative reaction does not exclude mononucleosis.
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HOARSENESS
The most common cause of hoarseness is acute laryngitis resulting from a viral
infection. Other causes include bacterial infections, excessive use of the voice,
allergic reactions and inhalation of irritating substances.
1. SUBJECTIVE (ask about a previous history for the same complaint)
a. Onset/precipitating factors
b. Duration
c. Associated symptoms (e.g., sore throat, cough, runny nose, muscle
aches, hay fever)
d. Pain with swallowing (dysphagia)
e. Smoking history
f. Contact with irritating substances
g. Fever history
2. OBJECTIVE (always include vital signs)
a. Hoarse voice (aphonia)
b. Temperature elevation
c. Dyspena
d. Drooling
e. Posterior oropharynx
f. Throat culture results
g. Cervical adenopathy
3. ASSESSMENT Based on subjective and objective findings. The key is to identify
treatable causes.
4. Plan
a. Viral laryngitis is self-limited and no specific treatment is indicated.
Some symptomatic relief may be gained with warm normal saline or
hydrogen peroxide gargles or throat lozenges. Cepacol gargles or
Chloraspectic may also be of benefit.
b. Bacterial laryngitis is rare, but is more frequently seen in children than
adults, and is treated with appropriate antibiotics
c. Avoidance of irritating inhaled substances (tobacco smoke) should be
stressed in those cases where this is the cause of the laryngitis.
d. All patients with laryngitis should have voice rest and be advised to stop
smoking, if applicable.
e. Chronic hoarseness may be due to dysfunction of the vocal cords from
tumor growth or neurologic deficit, and needs specialty care.
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HOARSENESS continued
5. MEDICAL OFFICER CONSULTATION IS INDICATED WHEN:
a. Pain with swallowing
b. Temperature greater than 100F
c. Stiff neck
d. Dyspnea, drooling
e. Positive culture for pathologic bacterial agent
f. Symptoms present over 10 days
g. When the medic is in doubt or is uncomfortable with the case
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SINUS COMPLAINTS
The patient who presents with the complaint of sinusitis may or may not have true
sinusitis. Most, in fact, do not. Sinusitis is an infection of the frontal, maxillary,
ethmoid or sphenoid sinuses. The most common pathogens are Staphylococcus,
Streptococcus, pneumococci and Haemophilus influenzae. Acute sinusitis may
follow URI, dental abscess or nasal allergy.
1. SUBJECTIVE (ask about a previous history for the same complaint)
a. URI complaints (nasal discharge, post-nasal drip)
b. Recent dental problems
c. Nasal allergy
d. Headache (location, radiation, relieving or aggravating factors)
e. Facial pain
f. Duration of symptoms
g. Feeling of nasal obstruction
h. Prior Hx of sinus infection
i. Fever history
2. OBJECTIVE (always include vital signs)
a. Fever
b. Purulent nasal discharge
c. Tenderness to percussion or palpation over frontal and/or maxillary
sinuses
d. Injected oropharynx without tonsillar enlargement or exadate
e. Appearance of nasal mucosa
f. Cough (productive or non-productive)
g. Cervical adenopathy
3. ASSESSMENT
a. Boggy, hyperemic nasal mucosa is consistent with allergic rhinitis, the
most common cause of sinus complaints. See discussion on
ALLERGY/HAY FEVER
b. Tenderness to percussion over frontal and/or maxillary sinuses is
consistent with acute sinusitis
c. Chronic sinusitis may have minimal findings such as a nasal discharge.
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EPISTAXIS (NOSEBLEED)
The most common sites of nasal bleeding are the mucosal vessels over the
cartilaginous nasal septum and the anterior tip of the inferior turbinate. Bleeding is
usually caused by external trauma, nose picking, nasal infection, from plucking nose
hairs, by vigorous nose blowing or drying of the nasal mucosa.
1. SUBJECTIVE (ask about a previous history for the same complaint)
a. Nasal infection
b. Trauma
c. Exposure to drying factors, i.e. sleeping in closed room with forced air
heating system
d. Duration of symptoms
e. Pain
f. Vigorous nose blowing
g. Previous nose bleeds
2. OBJECTIVE (always include vital signs)
a. Deformity of nose from trauma
b. Location of bleeding site
3. ASSESSMENT Most cases of epistaxis are uncomplicated. If the problem is
recurrent or chronic, other causes must be investigated.
4. PLAN
a. Most cases can be treated easily be having the patient sit up and lean
forward. Tip the head downward and pinch the nose for 5-10 minutes. If
this does not control the bleeding, then cauterization may be required. A
cold pack to the area may also slow the bleeding.
b. To prevent recurrence when the cause is dry nasal mucosa, the patient is
given Bacitracin ointment or NoseBetter Nasal spray (available over the
counter in most drug stores) to use as a protective coating for the nasal
mucosa
5. MEDICAL OFFICER CONSULTATION IS INDICATED WHEN:
a. History of significant trauma
b. Pain
c. B/P with systolic greater that 140 and diastolic greater than 90
d. Pulse greater than 100
e. Temperature greater than 100F
f. When pressure does not control bleeding
g. Recurrent bleeding episodes
h. When the medic is in doubt or uncomfortable with the case
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HEARING LOSS
When a patient complains of hearing loss, the following examination should be done.
1. SUBJECTIVE (ask about a previous history for the same complaint)
a. Onset
b. Trauma
c. Noise exposure
d. URI symptoms
e. Ear pain
f. Affected ear(s)
g. Current medications
h. Fever history
2. OBJECTIVE (always include vital signs)
a. URI signs
b. Perforation
c. Otitis media
d. Cerumen obstruction
e. Audiometry screen
3. ASSESSMENT If an obvious cause of hearing loss is not found, neurosensory
hearing loss must be considered.
4. PLAN Hearing losses with no apparent cause must be referred to the medical
officer for further evaluation. Other causes which are found on examination are
treated as appropriate.
5. MEDICAL OFFICER CONSULTATION IS INDICATED WHEN:
a. Audiogram shows a 10 dB loss at any frequency not previously
documented
b. NO apparent cause for the hearing loss is found
c. Temperature greater than 100F
d. Inflamed, bulging eardrum
e. Perforation
f. When the medic is in doubt or uncomfortable with the case.
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FRICTION BLISTERS
A blister will present as a bulla which may or may not be intact. Blisters are caused
by mechanical friction. Blisters on the feet are usually a result of poorly fitted
footwear.
1. SUBJECTIVE (ask about a previous history for the same complaint)
a. General (location, onset, duration)
b. Pain
c. Activity limitations
2. OBJECTIVE (always include vital signs)
a. Appearance of lesions (location, solitary, multiple, intact, weeping)
b. Signs or infection (warmth, erythema, pus)
c. Observe gait (able to bear weight) if blisters are on feet.
3. ASSESSMENT Based on observation
4. PLAN
a. Intact bullae are aspirated with a sterile needle and syringe after cleaning
the area with Betadine. The skin is not debrided. The area is painted with
sterile tincture of benzoin twice. A dry dressing is applied. Soft shoes or
duty limitations are not usually necessary, but may be indicated for 24
hours if the patient has difficulty bearing weight or walking.
b. Bullae which are broken are cleaned with Betadine. The skin is
preserved and the area painted with sterile tincture of benzoin and a dry
dressing applied. Soft shoes or duty limitations are not usually necessary,
but may be indicated for 24 hours if the patient has difficulty bearing
weight or walking.
5. MEDICAL OFFICER CONSULTATION IS INDICATED WHEN:
a. Extensive bullae formation
b. Moderate to severe pain
c. Infection
d. When medic is in doubt or uncomfortable with the case.
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TINEA VERSICOLOR
A superficial fungal infection most prominent on the upper trunk and arms, nonpuritic in most cases. Characterized by hypopigmented, minimally-scaling areas, it
is more common during hot, humid weather and often recurs from year to year.
1. SUBJECTIVE (ask about a previous history for the same complaint)
a. Onset
b. Duration
c. Relationship to sun exposure
2. OBJECTIVE (always include vital signs)
a. Distribution
b. Lesions
c. KOH prep
3. ASSESSMENT
T versicolor is based on hypopigmented, confluent, macular lesions. KOH may be
positive, with a spaghetti and meatballs appearance
4. PLAN T versicolor is treated with an oral antifungal agent called Ketoconazole
(Nizoral) which requires a prescription from a medical officer. After a course o f
Nizoral is completed, the soldier is usually instructed to bathe with selsum blue once
monthly
5. MEDICAL OFFICER CONSULTATION IS REQUIRED WHEN:
a. For a prescription for the antifungal agent
b. When the medic is in doubt or uncomfortable with the case
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ACNE
Acne is a very common skin condition of adolescents and young adults. It is a result
of hormonal influences increasing the activity of the oil glands. In women acne may
be worse during the menstrual cycle.
1. SUBJECTIVE (ask about a previous history for the same complaint)
a. Age at onset
b. Previous treatment
c. Relationship to menstrual cycle in women
d. Cammo face paint, oily hair preparations and cosmetics
2. OBJECTIVE (always include vital signs)
a. Distribution
b. Comedones (black heads)
c. Papulopustular lesions
d. Cystic lesions
e. Scaring
3. ASSESSMENT
Acne may be graded as follows:
a. Grade I is usually limited to the facial area and is characterized by
comedones and few papular lesions. Scarring is not present
b. Grade II consists of comedones, moderate amount of inflamed papules,
and occasional scarring
c. Grade III has the lesions described above plus pustules; papulopustular
formation is moderate and scarring is seen
d. Grade IV is the most severe form. In addition to the lesions above, cystic
lesions are present. Scarring may be severe
4. PLAN
a. Grade I may be treated with topical preparations containing benzoyl
peroxide, and/or with Retin-A
b. Grade II/III are treated with these topical agents but tetracycline PO is
added
c. Grade IV will require referral to a dermatologist for more intensive therapy.
d. All patients must be instructed to avoid picking or squeezing lesions, avoid
use of oily cosmetics, and practice meticulous cleansing of the face and
affected areas.
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ACNE continued
5. MEDICAL OFFICER CONSULTATION INDICATED WHEN:
a. Patient has Grade II/III acne (antibiotics will be required)
b. Patient has Grade IV acne (a referral to dermatology will be required)
c. When the medic is in doubt or is uncomfortable with the case
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CRABS/LICE
The crab louse is a tiny insect which lives only on humans, almost exclusively on the
moist, hairy areas of the body - the groin and axillae. Sexual contacts accounts for
99% of the transmission. Shared towels, lines, or underwear may rarely transmit the
louse. Lice die rapidly when removed from their human host; they do not hind in the
latrines or jump from bunk to bunk. They may be seen with the naked eye on skin or
hair and appear above the size of a pinhead. Because their life cycle takes 2 to 3
weeks, it may take as long as 4 to 6 weeks before the crab population is large
enough for the patient to notice the infestation. Use SEXUALLY TRANSMITTED
DISEASES as a cross-reference
1. SUBJECTIVE (ask about a previous history for the same complaint)
a. Mild to moderate pubic or penianal itching
b. Crabs noted by patient
c. Rash
d. Last sexual contact (LSC)
2. OBJECTIVE (always include vital signs)
a. Insects on skin or hair
b. Egg cases (nits) attached to hair
c. Above confirmed under microscope, if necessary
d. Mild erythema of skin around insect (bite marks)
3. ASSESSMENT
a. Crabs (pubic lice) Consistent with the above symptoms and signs.
Vigorous scratching may result in secondary infection
b. Scabies This is an infestation by the scabies mite, which is smaller than
the crab louse and burrows into the skin. Scabies is not limited to the
pubic region but spreads everywhere except the scapl, causing a very
itchy rash.
4. PLAN
a. Crabs. Apply a lindane cream or lotion (such as Kwell) from the umbilicus
to the knees, as well as to the armpits, if those are involved. This should
be left on for 8-12 hours, then washed off. RID may be used as an
alternate to Kwell. Very hairy individuals may have to apply these from the
neck down. A repeat application in 1 week is recommended
b. Scabies. Apply a lindane cream or lotion (such as Kwell) from the neck
down, including the arms, for 8-12 hours, then wash off. Repeat
application is usually not necessary
c. Patient must be cautioned to follow instructions carefully to avoid lindane
skin reactions.
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CRABS/LICE continued
PLAN continued
d. All bedding and clothing to be used within the next 30 days must be
washed thoroughly in hot, soapy water or dry cleaned. It hot water
is unavailable, a disinfectant may be added to the wash.
Laundering of clothes is to be done during the 12 hour treatment
period.
5. MEDICAL OFFICER CONSULTATION IS INDICATED WHEN:
a. Suspected scabies
b. Secondary infection
c. When the medic is in doubt or is uncomfortable with the case
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MINOR TRAUMA
Minor trauma is a very broad topic, the detailed discussion of which is beyond the
scope of this manual. Most minor trauma is self-limited and treatment largely
designed to alleviate pain and protect the patient from further injury. The medic
must take caution, however, to rule out more significant injuries, such as a fracture,
which might be hidden. Blunt trauma to the chest, abdomen, back, most burns, and
significant head injuries always require consultation/referral with a medical officer.
The related discussions on joint pain should be used as cross-reference
1. SUBJECTIVE (ask about a previous history for the same complaint)
a. Type of trauma (blunt, stretching, compressing, lacerating, penetrating,
burn)
b. Location(s) of injury
c. Where, when, and how injury occurred
d. Associated bleeding, loss of consciousness (LOC), nausea and vomiting
e. Present pain (severity, location, quality, radiation)
f. History of prior trauma to same area
g. Last tetanus shot (date)
2. OBJECTIVE (always include vital signs). A complete exam of the injured
area(s) should be done. If a joint has been injured, always exam the joint above
and below the injured joint.
a. Vital signs
b. Describe size and appearance of wounds
c. Swelling, ecchymosis, deformity
d. Active bleeding
e. Tenderness to palpation, bony point tenderness
f. Pain with voluntary/involuntary motion
g. Signs of infection (redness, pus)
h. Distal neurovascular exam (sensation, pulse, capillary refill)
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SHOULDER PAIN
A frequent complaint among soldiers is shoulder pain usually following strenuous
physical activity. The causes of non-traumatic shoulder pain are limited but there
are multiple conditions of traumatic origin, both acute and chronic. Some of the
most common causes are listed here.
1. SUBJECTIVE (ask about previous history for the same complaint)
a. Onset and duration of pain
b. Exact location and radiation
c. What relieves, what makes it worse
d. History of activity or trauma
e. Prior episodes
f. Functional limitations
2. OBJECTIVE (always include vital signs)
a. Erythema, hot shoulder
b. Deformity
c. Effusion, pain to palpation (location)
d. Active and passive ROM; crepitus
e. Strength
f. X-ray results, if indicated
3. ASSESSMENT
a. Rotator cuff tear. Usually presents with shoulder pain/tenderness, a
history of trauma, and patient is unable to abduct the arm or hold it
abducted against gravity
b. Acute bursitis. Usually produces pain with movement and follows
overuse in most instances. Most frequently tender to palpation over
subdeltoid bursa.
c. Calcific tendonitis. The shoulder may appear swollen and inflamed, and
the pain may be severe. X-ray often shows ectopic calcifications.
d. Septic arthritis. Should be considered if the patient has a fever or other
signs and symptoms of inflammation.
e. Dislocation. Usually follows a history of trauma but may occur
spontaneously in some people. Sudden onset of pain with gross deformity
of shoulder joint and severe limitation of motion. X-ray should be done to
R/O associated fracture if a history of trauma.
f. Referred pain. Shoulder pain may occur with abdominal
(subdiaphragmatic) or chest disease/injuries. In these cases the pain is
often unrelated to a Hx of shoulder trauma or to shoulder motion, and there
are usually abdominal or chest symptoms.
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HIP PAIN
Traumatic hip pain in young adults usually follows overuse (i.e. sports, running, or
other strenuous physical activity. Hip fractures or dislocations in young adults with
normal bones occur with high energy trauma and are usually associated with other
severe injuries.
1. SUBJECTIVE (ask about a previous history for the same complaint)
a. Character of pain
b. Onset/activity
c. History of trauma or arthritis
d. Involvement of other joints
2. OBJECTIVE (always include vital signs)
a. Palpable tenderness (exact location)
b. ROM and associated pain
c. Gait
3. ASSESSMENT
a. Trochanteric bursitis. Usually presents with local pain over the greater
trochanter with radiation down the lateral aspect of the thigh to the knee.
Palpable tenderness is present. Internal rotation and abduction also
causes pain.
b. Tendonitis. Any of the muscles or tendons surrounding the hip joint may
become strained and inflamed. Pain localized to affected part on
palpation, aggravated with motion.
c. Slipped femoral epiphysis. A limp with hip pain develops. Usually seen
in young males who are obese or tall and thin, and rarely occurs over age
20. X-ray confirms diagnosis.
4. PLAN
a. Bursitis/tendonitis. Treatment consists of anti-inflammatory drugs, warm
compresses, and reduction of aggravating factors until pain free.
b. A slipped epiphysis will require an orthopedic consult.
5. MEDICAL OFFICER CONSULTATION IS INDICATED WHEN:
a. Inability to bear weight
b. Decreased ROM
c. Evidence of infection
d. Crepitus present in joint with motion
e. When the medic is in doubt or uncomfortable with the case
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KNEE PAIN
Most unilateral knee pain is traumatic in origin. Acute trauma usually causes
ligament sprains/strains or meniscal damage. Repeated mild trauma over long
periods of time can lead to chondromalacia, chronic arthritis or other problems.
1. SUBJECTIVE (ask about a previous history for the same complaint)
a. History of "locking" or "giving way"
b. History of trauma
c. Prior knee surgery
d. Precipitating factors
e. Aggravating factors; deep knee bends, stair climbing
f. Pain without weight-bearing
2. OBJECTIVE (always include vital signs)
a. Discoloration (ecchymosis, erythema), swelling, deformity
b. Effusion, crepitus
c. Tenderness to palpation over joint line
d. Warm to touch
e. Tenderness over medial/lateral collateral ligaments or menisci
f. Patellar shift; tenderness with patellar compression
g. Ligamentous instability with lateral/medial stress (lateral/medial collateral
ligaments)
h. Drawer and Lachmann's sign (cruciate tear)
i. McMurray's sign; Apley's sign (meniscal damage)
j. Quadriceps symmetry (measured in centimeters)
3. ASSESSMENT
a. Hot, tender knee with or without swelling may indicate intraarticular
infection
b. Inability to fully extend knee and joint line tenderness may indicate
meniscal injury
c. Tenderness over MCL/LCL without laxity may indicate grade I sprain or
strain
d. If mild laxity and tenderness of MCL/LCL is present, possible grade II
sprain
e. If ecchymosis, effusion present with laxity, possible grade III sprain (torn
ligament)
f. Positive drawer sign, positive Lachmann's sign, probable cruciate injury
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ANKLE SPRAIN
Ankle sprains are common in the active duty population due to the increased level of
physical activity. Ankle sprains can be grouped as Grade I simple sprains, or as
Grade II or Grade III sprains which are significant. Fractures are frequently
associated with significant sprains.
1. SUBJECTIVE (ask about a previous history for the same complaint)
a. Mechanism of injury, position of foot at time of injury (inverted, supinated)
b. Time of occurrence
c. Past trauma
d. Pain - discomfort
2. OBJECTIVE (always include vital signs)
a. Inability to bear weight
b. Swelling (edema)
c. Ecchymosis
d. Localization of tenderness, pain (medial or lateral maleolus, anterior joint
margin)
e. Range of motion, passive and active
f. Stability, drawer sign
g. Distal neurovascular exam (sensation, pulses, capillary refill)
h. X-ray results, if indicated
3. ASSESSMENT
a. Grade I sprain. Antalgic gait. Able to bear weight, minimal if any edema,
no ecchymosis, mild tenderness of either malleolar area, no drawer sign,
neurocascular status and ROM intact.
b. Grade II sprain. Unable to bear weight - edema, possible ecchymosis,
acute tenderness, no drawer sign, neurovascular status intact. ROM
reduced. An X-ray should be done to R/O an associated fracture.
c. Grade III sprain. Unable to bear weight - edema, ecchymosis present,
acute tenderness, positive drawer sign. ROM markedly decreased,
instability present, neurovascular status may be compromised. An X-ray
is necessary to R/O an associated fracture.
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FATIGUE
Fatigue is one of the most common symptoms for which adult patients seek medical
attention. It may be described as a general tiredness, lack of energy, weariness, or
a subjective sense of weakness, and is often accompanied by a strong desire to
sleep. Fatigue is normal when it is the result of a full day's work or sustained
physical activity. Chronic fatigue, however, is not normal. The medic's objective is
to separate those normal individuals from those with significant anxiety, depression
or organic illness.
1. SUBJECTIVE (ask about a previous history for the same complaint)
a. General (onset, duration, character of fatigue)
b. Associated fever, loss of appetite, weight loss, headache, sore throat,
muscle aches, or joint pains
c. Sleep patterns (insomnia, early awakening)
d. Anxiety (current stressful situations)
e. Depression (feeling blue, loss of interest)
f. Medications (sedatives, antihistamines, antidepressants)
g. Living conditions - what is used for heat (woodburning, coal, gas, etc.)
h. Do other people in the household have the same complaint
2. OBJECTIVE (always include vital signs)
a. Vital signs
b. Appearance of patient (sick, tired, depressed)
c. Pale skin, nail beds, or mucosae
d. HEENT exam (erythema of the throat)
e. Lynphadenopathy (swollen, lender lymph nodes)
f. Lungs (rales, wheezes)
g. Heart (irregular rhythm, murmur, gallop, or rub)
h. Abdomen (masses, tenderness)
i. Hematocrit test results, if indicated
3. ASSESSMENT
a. Normal tiredness. History of sustained hard work or physical activity
without anxiety, depression, or trouble sleeping. Normal exam.
b. Anxiety state. History of recent stressful situations, difficulty sleeping;
fatigue lessens during day, mild headache may be present. Patient may
appear anxious, exam is otherwise normal.
c. Dysthmia. No set pattern but usually accompanied by difficulty sleeping.
Patient may appear depressed, physical exam otherwise normal.
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FATIGUE continued
ASSESSMENT continued
d. Mononucleosis. Mild sore throat, fever, fatigue relieved by rest. Exam
reveals pharyngitis, cervical adenopathy. Positive mono spot test.
e. Anemia. Patient usually c/o lack of energy with physical activity, relieved
by rest. Exam reveals pale nail beds, skin, or mucosae, increased pulse.
Anemia is seen with a hematocrit less that 43% in males, 38% in females.
f. Chronic illness. Fatigued relieved by rest or decreased activity, muscle
aches or joint pains, low grade fever, weight loss may also be present.
Exam may reveal lymphadenopathy, cardiac, lung, or abdominal
abnormalities.
g. Carbon monoxide poisoning. Usually a normal exam, may see pale or
bluish hue to nails. Will generally have a history of wood/oil/coal burning
stove in a trailer with other people in the household having the same
complaint
4. PLAN
a. Patients with normal fatigue need reassurance that there is no evidence
of underlying disease, and should be counseled to make maximum use of
the sleeping time available to them.
b. Those with mild situational anxiety or dysthymia may only require
reassurance that there is no evidence of underlying organic disease and
that their symptoms are situational in origin. They should be instructed to
return for F/U if there is no improvement within 72 hours.
5. MEDICAL OFFICER CONSULTATION IS INDICATED WHEN:
a. Fever greater than 100F
b. Pulse greater than 100 bpm at rest
c. Worsening symptoms over two weeks
d. History of greater than 5 lb weight loss in past month
e. Marked anxiety or depression
f. Inability to sleep
g. Pale nail beds, skin, or mucosae
h. Adenopathy other than mild cervical adenopathy
i. Persistent joint or extremity pain
j. Abnormal lung, cardiac, or abdominal exam
k. Hematocrit below 42% in males, 38% in females
l. When the medic is in doubt or uncomfortable with the case
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HEADACHES
The majority of headaches are easily managed with simple medications. The onset
of most headaches tends to be associated with stress, hangovers, or heat. The vast
majority of these are "muscle tension" headaches. Vascular (migraine type)
headaches and headaches associated with febrile viral illnesses are also common in
young adults.
1. SUBJECTIVE (ask about a previous history for the same complaint)
a. Onset (gradual, sudden, awakens from sleep)
b. Duration of the headache, are they recurrent
c. Location and character (unilateral, occipital, throbbing, band-like)
d. Associated fever, LOC, nausea, vomiting, stiff neck, eye pain, visual
changes, malaise.
e. Aggravating, mitigating factors
f. Trauma within 72 hours
g. Past treatment or evaluation
2. OBJECTIVE (always include vital signs)
a. Vital signs, especially temperature and blood pressure
b. Able to touch chin to chest without pain
c. HEENT exam (evidence of trauma, pupil size and reaction to light, sinus
tenderness, tympanic membranes)
d. URI signs
e. Mental status (alert, oriented, drowsy, confused)
3. ASSESSMENT
a. Simple headache usually has no specific physical findings
b. Musculoskeletal headache. Usually presents with "squeezing band"
encircling the head, and tightness of the neck muscles. It is usually
bilateral and may continue for days.
c. Migraine headaches are characterized by unilateral throbbing pain.
There is usually nausea, vomiting, visual disturbances, and photophobia.
Migraines generally have a history of recurrence.
d. Pain with the chin to chest maneuver along with fever suggest possibility
of meningitis. Suspected meningitis is always an emergency.
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HEADACHES continued
4. PLAN
a. Simple headaches are treated with analgesics, including Tylenol or
aspirin
b. Musculoskeletal headaches can also be treated with analgesics, but
moderate to severe headaches may require muscle relaxants.
c. Migraine headaches will require specific anti-migraine medications and
probably temporary duty limitations.
5. MEDICAL OFFICER CONSULTATION IS INDICATED WHEN:
a. Headaches associated with trauma, LOC, nausea and vomiting, or visual
disturbances
b. Increased blood pressure, temperature greater than 100F
c. Inability to touch chin to chest without pain
d. Moderate to severe musculoskeletal headaches
e. Migraine-type headaches
f. Inability to perform duty
g. When the medic is in doubt or uncomfortable with the case
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CHEST PAIN
Chest pain offers a diagnostic challenge to the medic as well as to the PA or
physician. Most chest pain among healthy soldiers is non-cardiac in origin, but
care must be taken to rule out heart disease in every case. Gastrointestinal,
pulmonary, musculoskeletal, neurological and psychogenic problems can cause
chest pain. The best way to differentiate these non-cardiac from cardiac problems is
to obtain a good history. A description of the pain is extremely important.
1. SUBJECTIVE (ask about a previous history for the same complaint)
a. Onset of pan
b. Precipitating factor(s) of pain
c. Duration of pain
d. Predictable relief of pain
e. Location of pain
f. Quality of pain
g. Pain intensity changing with respiration
h. Previous episodes of pain
i. Previous heart disease
j. Nausea, vomiting, diaphoresis, shortness of breath (SOB)
k. Fainting spells
l. Trauma to chest wall
m. Cough, fever
n. Family history of heart disease
o. Cardiac risk factors (smoker, hypertension, cholesterolemia, diabetes,
sedentary lifestyle, abnormal ECG)
2. OBJECTIVE (always include vital signs)
a. Elevated B/P
b. Pulse rate - tachycardic or irregular pulse
c. Tenderness with palpation over area of chest pain
d. Cyanosis
e. Wheezing, rales
f. Cardiac or pulmonary friction rub on inspiration
g. Abnormal heart sounds
h. Levine's sign (clutching fist to chest)
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ABDOMINAL PAIN
Abdominal pain is a common complaint, and while the most common causes in
young adults are mild and self-limited, there are many serious considerations which
must be ruled out. Such a large list is beyond the scope of this manual. The medic
must, however, take a thorough history, and make referrals as appropriate. See the
discussions on NAUSEA AND VOMITING and DIARRHEA AND CONSTIPATION
as a cross-reference.
1. SUBJECTIVE (ask about a previous history for the same complaint)
a. General (quality, location, onset, duration, radiation of pain)
b. Aggravating or mitigating factors
c. Associated fever, diarrhea, constipation, nausea, vomiting, chest pain or
back pain
d. History of trauma
e. Appetite and last meal
f. Medications, alcohol ingestion
g. Past treatment or evaluation
2. OBJECTIVE (always include vital signs)
a. Vital signs, including postural B/P and pulse
b. Sclera icterus, jaundice (appearance of mucus membranes)
c. Listen to lungs and heart (abnormal sounds)
d. Appearance of abdomen (flat, protuberant, distended)
e. Bowel sounds (normal, increased, or decreased)
f. Tenderness, masses on abdominal palpation
g. Guarding or rebound tenderness
h. Psoas or obdurator signs
i. Costovertebral angle (CVA) tenderness
j. Hernia (males)
k. Guaiac (+) stool, any pain during rectal examination
3. ASSESSMENT
a. Acute gastroenteritis. Pain usually mild, cramps, poorly-localized, with
nausea, vomiting, and diarrhea. See discussion on NAUSEA and
VOMITING
b. Heartburn or gastroesophageal reflux (GER). Mild epigastric,
substernal buring sensation, usually after meals, relieved by antacids
c. Pain from abdominal muscle stress. Excessive coughing or vomiting
causing diffuse abdominal wall discomfort. Afebrile, may have minimal
diffuse guarding
d. Hepatitis. Malaise, nausea, RUD pain and tenderness, jaundice, dark
urine.
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LIST OF MEDICATION
The following is a list of medications prescribed in the self-care protocols in this
manual. After each medication, there is brief description of the symptoms that the
drug will treat effectively. In addition, any special patient instructions in the use of
the medication and possible side effects are listed to make the medic aware of
problems that could surface. Any questions regarding these or any other medication
should be referred to the medical officer.
ANALGESIC BALM (Ben Gay) Effective for relief of minor muscle aches.
Side Effects: Possible rash
Special Instructions: None
ANTIBIOTIC OINTMENT (Neosporin, Bacitracin) An antibiotic ointment for use
on minor skin sores or lesions to prevent infection.
Side Effect: Localized redness, rash
Special Instructions: Use small amounts 2-5 times daily. If redness or itching occur,
stop use and return for reevaluation.
ANTIFUNGAL AGENTS (Tinactin, Desenex) Available in powder, liquid, or
aerosol, Tinactin is effective in the treatment of many superficial fungal infections of
the skin. Tinactin does not sting; it has been know to causes added irritation in very
few cases.
Side Effects: Localized rash can occur
Special Instructions: If a rash or additional irritation should develop, the patient
should be instructed to discontinue use and return for reevaluation.
ANTIHISTAMINES (Benadryl) Provides relief to the patient suffering from runny
nose or nasal stuffiness resulting from allergies, common cold, or influenza.
Antihistamines also decrease secretions and reduce congestion/inflammation of the
nasal passages
Side Effects: Drowsiness, rash (localized or general), tightness of the chest,
dizziness, headaches.
Special Instructions: If drowsiness should develop, the patient should be instructed
not to drive or work around dangerous machinery while taking the antihistamine.
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ASPIRIN Very effective for relief of minor aches and pains. Aspirin should
not be used by patients with a history of gastrointestinal bleeding or peptic
ulcers.
Side Effects: Skin rash, upset stomach, ringing in the ears if taken in large
doses
Special Instruction: Patients should be instructed to take aspirin either with
meals or with a glass of milk
BETADINE Mild skin cleanser; also provides residual protection against
future bacterial infection
Side Effects: None
Special Instructions: None
BURROWS SOLUTION Solution prepared from either powder or tablets
used as a soothing wet dressing to relieve inflammation of the skin resulting
from insect bites, poison ivy, swelling and athletes foot
Side Effects: Localized rash
Special Instructions: Patient should be instructed to keep solution away from
the eyes. Once in liquid form Burrows solution should be kept at room
temperature for no more than 7 days.
CALAMINE LOTION Used to relieve itching skin resulting from poison ivy
(contact dermatitis) or sunburn.
Side Effects: None
Special Instructions: None
CEPACOL LOZENGES Provides soothing relief from throat irritations.
Side Effects: None
Special Instructions: None
CHAPSTICK A stick of solidified petroleum jelly effective in providing relief
for dry, chapped, or cracked lips.
Side Effects: None
Special Instructions: None
CHLORASEPTIC GARGLE Provides soothing relief from throat irritations.
Side Effects: None
Special Instructions: None
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GLOSSARY OF TERMS
Occasionally the medic may be uncertain of the definition of some of the medical
terms used in this manual. Since medic may not have access to a medical
dictionary, the following glossary of terms is provided.
ABDUCTION - 1. The lateral movement of the limbs away from the median plane of
the body, or the lateral bending of eh heard or trunk. 2. The movement of the digits
away from the axial of a limb. 3. Outward rotation of the eyes.
ACCOMODATION The adjustment of the eye for various distances whereby is
able to focus the image of an object on the retina by changing the curvature of the
lens.
ACNE A common skin condition occurring primarily in the late teens and early
twenties, but many continue into the thirties. Heredity, diet, hygiene, stress, and
general illness can aggravate acne and be extremely upsetting to the young soldier.
Acne is caused by plugged oil glands. The oily material that is secreted develops a
dark color when exposed to air, forming what is knows as a blackhead. These
plugged glands may become inflamed, and pimples develop when bacteria begin
breaking down the oil thereby producing irritating substances as by-products. With
proper treatment acne can be improved, thus avoiding scarring and other life-long
side effects.
ADDUCTION - Movement of a limb or eye toward the median plane of the body, or,
in case of digits, toward axial line of a limb.
ADENOPATHY Enlargement of the glands, especially the lymph glands/nodes
ALIMENTARY CANAL OR TRACT The digestive tube from mouth to anus.
ALOPECIA See Hair Loss
ANOREXIA Loss of appetite
ANTERIOR Before or in front of
ATHLETES FOOT Athletes foot is the result of a fungal infection that usually
starts with scaling and/or fissuring between the toes accompanied by intense itching.
It is not uncommon for the infection to spread to other portions of the foot, especially
around the toenail. The presence of athletes foot fungus can be confirmed by a
potassium hydroxide test.
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DANDRUFF- A condition affecting the epidermal (outer) skin layer of the scalp
characterized by itching and scaling of the scalp. More serious cases of dandruff
can affect the facial areas as well
DERMIS see skin
DIARRHEA Loose or liquid bowel movements of abdominal frequency.
DIASTOLIC PRESSURE A measure of the blood pressure during dilation stage of
the heart while it fills with blood; the low point of a blood pressure reading.
DIPLOPIA Seeing two images of a single object; double vision
DORSAL 1. Pertaining to the back. 2. Indicating a position toward a rear part.
Opposed to ventral.
DRUG REACTION (Rash) An acute widespread temporary reddish eruption on
the skin which can develop in individuals sensitive to a particular drug (prescription
or nonprescription). The rash is characterized by itching that can interfere with sleep
or performance of normal duties/activities. The rash results from the enter body
reacting to the drug itself and usually develops early in treatment rather than after
the drug has been taken for a period of time.
DYSMENNORRHEA Painful menstruation
DYSPEPSIA Excessive acidity of the stomach; epigastric discomfort following
meals.
DYSPNEA Air hunger resulting from labored or difficult breathing, sometimes
accompanied by pain. Normal when due to vigorous work or athletic activity.
DYSPHAGIA Difficulty in swallowing
DYSURIA Pain during urination; difficult with urination
EPIDERMIS see Skin
EPISTAXIS Nosebleed (normally resulting from the rupture of the blood vessels
inside the nose)
ESOTROPIA Marked turning inward of the eye; crossed eyes.
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EUSTACHIAN TUBE Auditory tube, channel extending from the middle ear to the
nasal passages.
EXOTROPIA Abnormal turning of one or both eyes outward.
EXUDATE Material, such as fluid, cells, or cellular debris, which has escaped from
blood vessels and has been deposited in tissues or in tissue surface, usually as the
result of inflammation.
FATIGUE State of increased discomfort and decreased efficiency resulting from
prolonged or excessive exertion.
FISSURE A line-like crack in the skin.
FLATULENCE Excessive gas in the stomach and intestines
FLATUS Gas in the digestive tract. Expelling of gas from any digestive tract..
FROSTBITE The condition that results from the skin being exposed to extremely
cold weather for an extended period of time (usually the toes, fingers, or face are
affected). In severe cases, permanent destruction of tissues may occur from the
crystallization of tissue water in the skin and adjacent tissues.
GASTROENTERITIS Inflammation of the stomach and intestines.
HAIR FOLLICLE see Skin
HAIR LOSS (ALOPECIA)- While most hair loss is natural and hereditary, any hair
loss that is sudden or extreme in nature can result from a severe infection, caustic
chemicals, or drugs. When treated promptly and properly, hair growth can resume.
HEAT INJURY - The result of exposure to excessive temperatures with or without
accompanying strenuous activity. The cause of heat injury is an excessive loss of
water and salt from the body or a breakdown of the bodys cooling mechanism.
HEMATURIA Blood in the urine.
HEMORRHOIDS Expansion of one or more veins in the rectal area resulting from
an increase in venous pressure.
HYP(O) A prefix signifying beneath, under, below normal, or deficient.
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VALSALVAS MANEUVER Attempt to forcibly exhale with the glottis, nose, and
mouth closed. If the Eustachian tubes are not obstructed the pressure on the
tympanic membranes will be increased (bulging outward). It also causes an
increased in intrathoracic pressure, slowing of the pulse, decreased return of blood
to the heart, and increased venous pressure.
VENTRAL Pertaining to the belly. Hence, in quadrupeds, pertaining to the lower
or underneath side of the body; in man, pertaining to the anterior portion or the front
side of the body. Opposite of dorsal
WHEEZE- A whistling or signing sound resulting from narrowing of the lumen of a
respiratory passageway. Often only noted by use of a stethoscope. Occurs in
asthma, croup, hay fever, reactive airway disease.
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MEDICAL ABBREVIATION
A
A
ante, before
ACTH adrenocorticotropic hormone
AD
auris dexter (right ear)
ADA American Diabetes Association
ADH antidiuretic hormone
ADL activities of daily living
ad lib as desired
AFIP Armed Forces Institute of Pathology
A/G albumin/globulin ratio
AK
above knee
AKA Also Known As; Above Knee
Amputation
AMA against medial advice
AMA American Medical Association
AP/LA anterior, posterior, and lateral
APC aspirin, phenacetin, and caffeine
ASA aspirin (acetylsalicylic acid)
AU
both ears
aud auditory
AV
arteriovenous
A/W alive and well
B
BBB bundle branch block
BCP birth control pill
bid
bis in die (twice a day)
BE
barium enema
B/f
black female
BK
below knee
BKA below knee amputation
BM
bowel movement
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g or G gram
GI
gastrointestinal
GTT glucose tolerance test
gtt
guttae (drops)
GU
genitourinary
GYN gynecology
E
ea
E.coli
EDC
EEG
ENT
EKG
ECG
EMG
EOM
ER
ESR
H
HA
headache
Hb.Hgb hemoglobin
Hct
hematocrit
HEENT head, eyes, ears, nose,
throat
HNP herniated nucleus
pulposus
H&P history and physical
HPI history present illness
hs
hora somni (at bedtime)
Hx
history
etiol
each
Escerichia coli
estimated date of confinement
electroenephalogram
ear, nose and throat
electrocardiogram
electocardiogram
electomyogram
external ocular muscles
emergency room
erythrocyte sedimentation
rate
etiology
F
Fb
FB
FBS
FHx
FSH
F/U
FUO
Fx
finger breadth
foreign body
fasting blood sugar
family history
follicle stimulating hormone
follow-up
fever of undetermined origin
fracture
G
GB
GC
GFR
GG
gallbladder
gonococcus
glomerular filtration rate
Gamma globulin
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I
I131
ICF
ICU
ICS
I&D
Infect
IM
IHN
in situ
radioactive iodine
intracellular fluid
intensive care unit
intercostals space
incision and drainage
Infectious
Intramuscular
isoniazid
in natural or normal position
K
K
Kg
KOH
KUB
KVO
potassium (kalium)
kilogram
potassium hydroxide
kidney, ureter, bladder
keep vein open
L
L
lat
LBBB
LCM
LDH
lig
LKS
LMP
LLL
LLQ
LOA
LOC
LOP
LOT
LP
Ls
LSB
Lues
LUL
LUQ
LVH
L&W
left
lateral
left bundle branch block
left costal margin
lactic acid dehydrogenase
ligament
liver, kidney, spleen
last menstrual period
left lower lobe (lung)
left lower quadrant (abdomen)
left occiput anterior
lost of consciousness
left occiput posterior
left occiput temporal
lumbar puncture
lumbosacral
left sternal border
syphilis
left upper lobe
left upper quadrant
Left ventricular hypertrophy
living and well
M
m
MAO
MCA
MCD
MCH
murmur
monoamine osidase
motorcycle accident
minimal cerebral dysfunction
mean corpuscular
MCL
MCV
mEq
mg
MI
ml
MLD
MOM
MSL
MVA
hemoglobin concentration
midcostal line
mean corpuscular volume
milliequivalent
milligram
myocardial infarction
milliliter
minimum lethal dose
milk of magnesia
midsternal line
motor vehicle accident
N
Na
N/A
NB
Neg
NIH
NKA
N2O
NOC
NP
O
OB
obstetrics
O.D. Oculus dexter (right eye)
od
omni die (every day, daily,
once daily)
oint ointment
OPD outpatient department
OR
operating room
O.S. Oculus sinister (left eye)
OT
occupational therapy
Page 83
PV
Px
per vagina
Physical examination
P
p
PA
Q
q
qid
qod
every
four times a day
every other day
R
RNA
ROM
ROS
RVH
Ribonucleic acid
range of motion
review of systems
right ventricular hypertrophy
after
Physician Assistant
pernicious anemia
posterioanterior
PABA
oara-aminobenzoic acid
PaCO2
arterial CO2 tension
PAo2 arterial O2 tension
palp palpation
Pap Papanicolaou smear
PAS para-aminosalicylic acid
PAT Paroxysmal atrial tachycardia
PBI protein bound iodine
p.c. after meals
PCO2 CO2 partial pressure
pd
papillary distance
PDA patent ductus arteriovenous
PE
physical examination
PE
pulmonary embolism
perf perforaton
PERLA
pupils equal reactive to light
And accommodation
PH
past history
PI
present illness
PID pelvic inflammatory disease
PIP proximal interphalangeal (joint)
PKU phenylketonuria
PMH past medical history
PMI pont of maximal impulse
PND paroxysmal nocturnal dyspnea
p.o. Per os (by mouth)
PR
per retum
PSH Past surgical history
Pt
Patient
PT
Physical Therapy
Page 84
S
s
without
SA node
sino atrial node
S1
first heart sound
SBE subacute bacterial
endocarditis
segs segmented neutrophils
Sed Rate
sedimentation rate
SGOT serum glutamic
oxalocacetic transaminase
SGPT serum glutamic-pyruvic
transaminase
SIB sibling
SIG label, let it be imprinted
SLE systemic lupus
erythematosus
SOB shortness of breath
ss
one-half
SSE soap suds enema
SSKI saturated solution of
potassium iodide
STAT immediately
STS serologic test for syphilis
T
T1
first thoracic vertebra
T&A tonsillectomy and adenoidectomy
TAH total abdominal hysterectomy
TB
tuberculosis
Tbc tuberculosis
TID ter in die (three times a day)
TLC total lung capacity,
Tender Loving Care
TM
tympanic membrane
TMJ tempralmandibular joint
TPR temperature, pulse, respiration
TSH thyroid stimulating hormone
tsp
teaspoon
TU
tuberculin unit
TUR transurethral resection (of prostate)
U
U/A
URI
UTI
urinalysis
upper respiratory infection
urinary tract infection
V
vc
vital capacity
VDRL Venereal Disease
Research Laboratories
V.O. Verbal Order
V.S. Vital sign
VSS vital signs stable
W
WBC White blood count
WDWN
Well developed & well
nourished
W/D well-developed
W/f white female
W/m white male
W/N well-nourished
WNL within normal limits
WT weight
XYZ
Y/O
year old
Page 85
NOTES
Page 86
NOTES
Page 87
Page 88
PHONE NUMBER
COMMENTS