ScribeAmerica Final Exam ED Graded to Pass

What are the 3 types of dispositions? - Discharge, Admit, Transfer What does HPI stand for? - history of present illness What does ROS stand for? - review of systems The HPI and ROS are considered what type of information? - subjective The physical exam is what type of information? - objective If a physician told you a patient's abdomen was non tender, where would you document this? - PE What section focuses directly on the chief complaint? - HPI If someone has a hx of CABG or MI, what is something you can also always document in the PMHx section of the chart? - CAD Name an example of something you may write in the Social Hx portion of the chart. - smokes 1 pack/day Name an example of something you may write in the Family Hx portion of the chart. - Mother had Hx of CAD at age 46 What are the abbreviations for the following past medical history terms? Hypertension Stroke Diabetes Heart Attack High Cholesterol - HTN CVA (cerebrovascular accident) DM MI HLD What are the medical terms for the following past surgical terms? Removal of the appendix Removal of the gallbladder Removal of the uterus Removal of a fallopian tube Removal of the tonsils Removal of the breast - appendectomy cholecystectomy hysterectomy Salpingo-oophorectomy tonsillectomy mastectomy What are the five vital signs? - Blood pressure (BP), heart rate (HR), oxygen saturation (SaO2), respiratory rate (RR), temperature (C or F) What does NKDA stand for? - no known drug allergies What does LNMP stand for? - Last Normal Menstrual Period If the doctor said the exam was "benign", what does this mean? - this means that the exam was normal and of no concern Explain acute vs chronic. - acute: serious, new condition, that could potentially be life-threatening chronic: not of much concern, long-lasting condition, typically not a death threat What are the medical terms for the following pathophysiology abbreviations? CAD AAA COPD PNA URI - coronary artery disease abdominal aortic aneurysm chronic obstructive pulmonary disease pneumonia upper respiratory disease How are the following diseases diagnosed? -CHF (two answers) -PE (three answers) -Cholecystitis -Pancreatitis -Appendicitis -Hemorrhagic CVA (two answers) -DVT - -chest x-ray, bnp (b-type natriuretic peptide) -CT chest with IV contrast (CTA chest), VQ scan, D-dimer -abdominal ultrasound (US) of RUQ -elevated lipase lab test -CT AP w/ PO -CTA w/ IV contrast, LP (lumbar puncture) -ultrasound (US) What are the two types of heart attacks and how are they diagnosed? - STEMI (ST elevation myocardial infarction) and NSTEMI (non ST elevation myocardial infarction)