Medical Scribe- Final exam review questions and answers 100% pass

Medical Scribe- Final exam review questions and answers 100% pass What are the 5 vital signs? 1. Heart rate 2. Blood pressure 3. Respiratory rate 4. Temperature 5. Oxygen saturation The HPI and the ROS are what type of information? The physical exam is what kind of information? While evaluating a patient complaining of chest pain, your physician tells you that the heart sounds are normal. Would you document this in the HPI, ROS, or PE? Physical exam Would you be contradicting yourself if you wrote, " the patient has abdominal pain", in the HPI, but then later in the physical exam documented, "the abdomen is non-tender", why or why not? No, because the patient stating that they have abdominal pain is a subjective complaint. A non-tender abdomen is an objective finding. What is the difference between the HPI, and the ROS? HPI focuses on the details related to their chief complaint, ROS is a head to toe checklist of symptoms. It includes the chief complaint, associated symptoms, and all other complaints the patient may have. What does disposition (dispo) mean? The patient's destination after they leave the ED. What subcategories are included within the past history section of the template? PMHx: Past medical history- HTN, DM, HLD, CAD, MI PSHx: Past surgical history- appendectomy, cholecystectomy, CABG FHx: Family history- Hx of CAD<55 years old SHx: Social history- ETOH, smoking, drug abuse, occupation What is the abbrieviation for heart attack? MI- myocardial infarction What is the abbreviation for high blood pressure? HTN- hypertension What is the medical term for acid reflux? Gastroesophageal reflux disease What is the medical term for stroke? CVA- cerebral vascular accident What is the term for gallbladder removal? Cholecystectomy What does NKDA stand for? No know drug allergies What is the medical term for redness? Erythema What is the medical term for bruising? Ecchymosis If the doctor says the exam was "benign", what does that mean? Normal- nothing of concern What is CAD? coronary artery disease What other past histories would suggest that a patient has CAD? MI, angina, CABG, stent, angioplasty Does a PMHx of CVA mean the patient has CAD? No Does a surgical history of angioplasty mean the patient has CAD? Yes Explain the difference between CAD and an MI. CAD is a broad term for heart disease. MI is included in CAD. Its an active heart attack If someone has PMHx of A-Fib or CHF, do they also have CAD? No What are the "cardiac risk factors"? HTN, DM, HLD, CAD, Smoking, FHx CAD < 55 yrs old. How is CAD diagnosed? By a cardiologist during a cardiac catherization, NOT done in the ED. Name two ways that an MI can be diagnosed? STEMI-EKG, non-STEMI- troponin What are some associated symptoms of an MI other than CP? N/V, SOB, Diaphoresis What are some associated symptoms for CHF? Pedal edema, SOB What two studies would diagnose CHF? CXR or elevated BNP What is A-fib? Electrical abnormality of the heart causing the top of the heart to quiver. What might someone feel with A-Fib? Palpations, fast, pounding, irregular heart beat. How is A-Fib diagnosed? EKG What could be the CC of someone with a PE? Pleuritic CP, SOB. What are the risk factors of a PE? Known DVT, PMHx of DVT or PE, FHx of DVT or PE, recent surgery, CA, A fib immobility, pregnancy, BCP, smoking What study would diagnose a PE? CTA chest/VQ scan. D-Dimer can only rule it out. What part of the heart does CAD affect? Artery Can a CT chest without IV contrast diagnose a PE? Why or why not? No. You need to be able to see the blood flow. If you can see where the blockage is then you cant determine the flow of blood. You wont see anything with a dry CT. What is an aortic dissection? The separation of the muscular wall from the membrane of the artery, putting the patient at risk for aortic rupture and death. What is PTX? Pneumothorax, collapsed lung What is the most common cause of PTX? Trauma How is the PTX diagnosed? CXR What social