*NURSING > QUESTIONS & ANSWERS > Medical Scribe- Final exam review questions and answers 100% pass (All)

Medical Scribe- Final exam review questions and answers 100% pass

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Medical Scribe- Final exam review questions and answers 100% pass What are the 5 vital signs? ✔✔1. Heart rate 2. Blood pressure 3. Respiratory rate 4. Temperature 5. Oxygen saturation The H... PI and the ROS are what type of information? ✔✔ The physical exam is what kind of information? ✔✔ 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? ✔✔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? ✔✔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? ✔✔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? ✔✔The patient's destination after they leave the ED. What subcategories are included within the past history section of the template? ✔✔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? ✔✔MI- myocardial infarction What is the abbreviation for high blood pressure? ✔✔HTN- hypertension What is the medical term for acid reflux? ✔✔Gastroesophageal reflux disease What is the medical term for stroke? ✔✔CVA- cerebral vascular accident What is the term for gallbladder removal? ✔✔Cholecystectomy What does NKDA stand for? ✔✔No know drug allergies What is the medical term for redness? ✔✔Erythema What is the medical term for bruising? ✔✔Ecchymosis If the doctor says the exam was "benign", what does that mean? ✔✔Normal- nothing of concern What is CAD? ✔✔coronary artery disease What other past histories would suggest that a patient has CAD? ✔✔MI, angina, CABG, stent, angioplasty Does a PMHx of CVA mean the patient has CAD? ✔✔No Does a surgical history of angioplasty mean the patient has CAD? ✔✔Yes Explain the difference between CAD and an MI. ✔✔CAD is a broad term for heart disease. MI is included in CAD. Its an active heart attack If someone has PMHx of A-Fib or CHF, do they also have CAD? ✔✔No What are the "cardiac risk factors"? ✔✔HTN, DM, HLD, CAD, Smoking, FHx CAD < 55 yrs old. How is CAD diagnosed? ✔✔By a cardiologist during a cardiac catherization, NOT done in the ED. Name two ways that an MI can be diagnosed? ✔✔STEMI-EKG, non-STEMI- troponin What are some associated symptoms of an MI other than CP? ✔✔N/V, SOB, Diaphoresis [Show More]

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