What are the 3 types of dispositions? ✔✔Discharge, Admit, Transfer
What does HPI stand for? ✔✔history of present illness
What does ROS stand
... [Show More] 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 lifethreatening
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)
STEMI: EKG
NSTEMI: troponin
What are three cardiac risk factors? ✔✔HTN, DM, HLD, CAD, Smoking, FHx CAD < 55 y/o
What are four associated symptoms of an MI other than CP? (Hint: catch phrase) ✔✔Chest
pressure with diaphoresis, N/V (nausea and vomiting), and SOB
What are three symptoms a patient with an Ischemic CVA might present with? ✔✔Unilateral
focal neurological deficits: One-sided weakness, one-sided numbness or changes in
speech/vision
What are the only three symptoms of a true allergic reaction? ✔✔SOB (difficulty breathing),
rash, itching/swelling [Show Less]