Examverse

subjective vs objective feeling vs fact pain vs tenderness patients feeling vs physicians assessment benign normal, nothing of concern acute vs chronic new onset vs long standing baseline an individuals normal state of being ausculation listening to sound with a stethoscope palpation act of pressing on an area (by the physician) inpatient admitted to the hospital overnight outpatient seen and sent home the same day chief com...

Past Medical History PMHx High Blood Pressure Hypertension (HTN) Abbreviation for Hypertension HTN High cholesterol Hyperlipidemia (HLD) Abbreviation for Hyperlipidemia HLD Thyroid Problem Usually Hypothyroidism, sometimes Hyperthyroidism Diabetes Diabetes Mellitus Abbreviation for Diabetes Mellitus DM "I only take pills for my diabetes" Non-Insulin Dependent Diabetes Mellitus Abbreviation for Non-Insulin Dependent Diabe...

general h&p template 1. HPI 2. ROS 3. Past History 4. PE 5. Hospital Course 6. A/P when is H&P completed Day 1 of admission Progress Note Template 1. Subjective Summary 2. PE 3. Hospital Course 4. A/P when is progress note completed documented daily starting with day 2 RT respiratory therapist (patient says) thyroid problem hypothyroidism, or sometimes hyperthyroidism (patient says) i only take pills for my diabetes NIDDM (patient...

4 actions of typical PE 1) assessing pt's external appearance and mental status 2) auscultating the pt's heart and lungs 3) palpating the abd 4) examining the pt's legs Extra exam: Examines the throat pharyngeal erythema or exudates Extra exam: examines the inner ear TM erythema or bulging Extra exam: auscultates the abd hyperactive/hypoactive bowel sounds Extra exam: touches the wrists radial pulses Extra exam: squeezes the calf muscles calf tend...

If a physician told you a patient's abdomen was nontender or the patient's skin was pale, where would you document these pieces of information?

associated dz for epigastric region GERD, Mi 5 vital signs HR BP RR temp O2 Sat what is the difference between HPI and ROS ROS-- head to toe checklist of sx (includes chirf complaint, associated sx, and other complaints patient may have HPI--focuses on the details related to the chief complaint what does dispo mean the patients destination after they leave the ED what subcategories are included within the past history section of the template? PMHx- past m...

HTN CC asymptomatic HLD CC asymptomatic DM CC polyuria, polydipsia CAD CC CP or pressure Asthma CC SOB, wheezing How do you diagnose HTN? Check BP How do you diagnose HLD? Check bloodwork How do you diagnose DM? Fasting blood glucose, HA1C How do you diagnose HLD? Check blood work for LDL levels How do you diagnose CAD? Cardiac Catheterization by cardiologist How do you diagnose asthma? Peak Flow Testing How ...

Abrasion Scrape of the skin due to something abrasive Acute New, usually of rapid onset and of concern, opposite of chronic Benign Normal, or no danger to health Bradycardia Slow heart-rate (less than 60bpm) Cardiomegaly Enlarged heart Chronic Long-standing, constant. Opposite of acute. Cerebrovascular Accident (CVA) A Stroke, a lack of blood to the brain Diaphoresis Sweating Deep Vein Thrombosis (DTV) A blood clot in a deep vein ...

Which of the following would belong in a psychiatric exam? Affect Certain words or phrases act as "red flags" to grab your provider's attention to let them know that a patient may require timely and comprehensive medical action. Which of the following words or phrases are NOT considered "red flags"? nocturia in a 65 year old male What does LBBB stand for? Left Bundle Branch Block What does URI stand for? Upper Respiratory Infection What does IDDM stand for?...

Chief Complaint the main reason for the pt's ED visit pain vs tenderness pt's feelings (subjective) vs physician's assessment (objective) distress the doctor's judgement of discomfort baseline an individual's normal state of being What CAN scribes do? -Document Hx, PE, results, procedures, and physician consults -Access and document lab results and radiology findings -Locate and obtains PMHx, previous charts, past results, and recent studies -Record phy...

Abrasion Scrape of the skin due to something abrasive. Abscess Pus underneath the skin Antipyretic Fever reducing medication Acute New,Rapid onset Afebrile W/O a fever (temp less than 100.4) Anterior Front of the body Appendicitis Infection of the appendix Auscultation Listening to sounds w/in organs Benign Normal, no danger Bradycardia Slow Heart Rate Bronchitis Upper airway infection Bronchiolitis Bronch...

pain vs tenderness patient's feeling vs physician's assessment acute vs chronic new onset vs long standing Meaningful Use (MU) a set of government mandated criteria that must be obtained for every patient Medical decision making the physician's thought process Mid-level providers: Nurse Practitioner (LNP) or Physician's Assistant (PA) that works under the supervision of a physician to diagnose and treat patients Nurse or Medical Assistant records me...

What does ROS stand for? Review of symptoms, head to toe checklist of symptoms 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 patients abdomen was nontender or the patients skin was plale, where would you document this information Physical Exam (PE) What section focuses directly on the chief complaint? HPI (History of present illness) What are the 5 vita...

* What medical term describes the surgical removal of the gallbladder? cholecystectomy What does "PHI" stand for? Expand the abbreviation. Protected Health Information T/F. Sharing information about a case with family is allowed, as long as you are scribing with the physician assigned to the case. False ** A patient underwent brain surgery to treat bleeding in the brain from a stroke. What PSHx would you record into the chart? craniotomy A patient's PCP is on v...

What are the 5 vital signs? Heart Rate, Blood Pressure, Respiratory Rate, Temperature, Oxygen Saturation The HPI and ROS are what type of information? subjective The Physical Exam is what type of information? objective What is the difference between the HPI and ROS? HPI focuses on details related to the pt's chief complaint. ROS is a head-to-toe checklist of symptoms, including the chief complaint, associated sx, and all other complaints from the pt What does ...

What does "IDDM" stand for? Do not include any hyphenations for your answer. Insulin Dependent Diabetes Mellitus What does "AMS" stand for? Altered Mental Status A patient states she has had a productive cough for 4 days, and yesterday she developed a fever. Would her fever be considered an associated symptom for her productive cough? Why or why not? Yes, because the fever started soon after the cough Match each critical care dx with it's associated procedure. Res...

What is the standard template for charting? HPI, ROS, Past History, PE, ED Course, Disposition What are some general PMHx? Hypertension (HTN), Hyperlipidemia, Cancer, Diabetes Mellitus (IDDM, NIDDM) What are some cardiac PMHx? Myocardial Infarction, Coronary Artery Disease, Congestive Heart Failure, Atrial Fibrillation What are some pulmonary PMHx? Pulmonary Embolism, Pneumonia, Chronic Obstructive Pulmonary Disease, Asthma What are some abdominal PMx? GERD, AA...

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 s...

A patient is seen in the emergency department complaining of dysuria and tells you that she is 23 weeks pregnant. Your doctor diagnoses her with a UTI. Which of the following would be the best diagnosis? acute urinary tract infection in pregnancy, 2nd trimester A patient cut his left foot on a piece of glass two hours ago and is seen in the emergency department to have sutures placed. The doctor tells you there is no tendon injury and circulatory, sensory and motor is intact. What is the...

AAA Abdominal Aortic Aneurysm A Fib Atrial Fibrillation Abd Abdomen, Abdominal Abx Antibiotics AMA Against Medical Advice AMS Altered Mental Status ASA Acetylsalicylic Acid (Aspirin) BID Twice Daily Bilat LE Bilateral Lower Extremities BM Bowel Movement BP Blood Pressure CA Cancer, Carcinoma CABG Coronary Artery Bypass Graft, "open heart surgery" CAD Coronary Artery Disease, "heart dis...