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Medical Scribe- Final exam review 2022

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What are the 5 vital signs? - ANSWER 1. Heart rate 2. Blood pressure 3. Respiratory rate 4. Temperature 5. Oxygen saturation The HPI and the ROS are what type of information? - ANSWER The p... hysical exam is what kind of information? - ANSWER 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? - ANSWER 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? - ANSWER 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? - ANSWER 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? - ANSWER The patient's destination after they leave the ED. What subcategories are included within the past history section of the template? - ANSWER 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? - ANSWER MI- myocardial infarction What is the abbreviation for high blood pressure? - ANSWER HTN- hypertension What is the medical term for acid reflux? - ANSWER Gastroesophageal reflux disease What is the medical term for stroke? - ANSWER CVA- cerebral vascular accident What is the term for gallbladder removal? - ANSWER Cholecystectomy What does NKDA stand for? - ANSWER No know drug allergies What is the medical term for redness? - ANSWER Erythema What is the medical term for bruising? - ANSWER Ecchymosis If the doctor says the exam was "benign", what does that mean? - ANSWER Normal- nothing of concern What is CAD? - ANSWER coronary artery disease What other past histories would suggest that a patient has CAD? - ANSWER MI, angina, CABG, stent, angioplasty Does a PMHx of CVA mean the patient has CAD? - ANSWER No Does a surgical history of angioplasty mean the patient has CAD? - ANSWER Yes [Show More]

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