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 physical exam is what
...
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 physical 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
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