Medical Scribe- Final exam review 2022 Answered 100% correct

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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 Explain the difference between CAD and an MI. - ANSWER 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? - ANSWER No What are the "cardiac risk factors"? - ANSWER HTN, DM, HLD, CAD, Smoking, FHx CAD < 55 yrs old. How is CAD diagnosed? - ANSWER By a cardiologist during a cardiac catherization, NOT done in the ED. Name two ways that an MI can be diagnosed? - ANSWER STEMI-EKG, non-STEMI- troponin What are some associated symptoms of an MI other than CP? - ANSWER N/V, SOB, Diaphoresis What are some associated symptoms for CHF? - ANSWER Pedal edema, SOB What two studies would diagnose CHF? - ANSWER CXR or elevated BNP What is A-fib? - ANSWER Electrical abnormality of the heart causing the top of the heart to quiver. What might someone feel with A-Fib? - ANSWER Palpations, fast, pounding, irregular heart beat. How is A-Fib diagnosed? - ANSWER EKG What could be the CC of someone with a PE? - ANSWER Pleuritic CP, SOB. What are the risk factors of a PE? - ANSWER Known DVT, PMHx of DVT or PE, FHx of DVT or PE, recent surgery, CA, A fib immobility, pregnancy, BCP, smoking What study would diagnose a PE? - ANSWER CTA chest/VQ scan. D-Dimer can only rule it out. What part of the heart does CAD affect? - ANSWER Artery Can a CT chest without IV contrast diagnose a PE? Why or why not? - ANSWER No. You need to be able to see the blood flow. If you can see where the blockage is then you cant determine the flow of blood. You wont see anything with a dry CT. What is an aortic dissection? - ANSWER The separation of the muscular wall from the membrane of the artery, putting the patient at risk for aortic rupture and death. What is PTX? - ANSWER Pneumothorax, collapsed lung What is the most common cause of PTX? - ANSWER Trauma How is the PTX diagnosed? - ANSWER CXR What social history will most COPD patients also have? - ANSWER Smoking What is the difference between a nebulizer, and an inhaler for asthma? - ANSWER An inhaler is portable and gives a one-time dose and provides a rapid release of medication. A nebulizer is a home machine that delivers continuous treatment over a period of time. What is asthma? - ANSWER Constricting of the airway due to inflammation and muscular contraction of the bronchioles. Also called, reactive airway disease. What physical exam finding also associates with asthma? - ANSWER Wheezing What is PNA? - ANSWER Pneumonia. Bacterial infection and inflammation inside the lung. What might a person with PNA complain of? - ANSWER Productive cough and fever. How is PNA diagnosed? - ANSWER CXR Name all 7 areas of the abdomen? - ANSWER Epigastrium, RUQ, LUQ, RLQ, LLQ, Suprapubic, Periumbilical (right/left flank) What does GERD stand for? - ANSWER Gastro esophageal reflux disease. What is the Layman's name for GERD? - ANSWER Heart burn or acid reflux What might someone with GERD complain of - ANSWER Epigastric pain or "burning". For older patients with GERD symptoms, what life threatening disease may also need to be ruled out? - ANSWER MI What does bile do? Where is it stored? - ANSWER Bile emulsifies the fat in foods. It is produced by the liver, and stored in the gallbladder. What is the difference between cholelithiasis and cholecystitis? - ANSWER Cholelithiasis is gallstones, cholecystitis is acute gallbladder inflammation/infection. What might be the chief complaint of a person with gallstones? - ANSWER RUQ abdominal pain What physical exam finding is closely associated with cholecystitis? - ANSWER Murphy's signs How are gallstones diagnosed? - ANSWER Abdominal ultra sound of the RUQ Name associated symptoms of appendicitis: - ANSWER Fever, N/V, decreased appetite (anorexia). Note: RLQ pain-gradual, constant, worse w/ movements is the CC (not associated symptom. How is appendicitis diagnosed? - ANSWER CT A/P with PO contrast. What would someone with pancreatitis complain of? - ANSWER LUQ abdominal pain, N/V, fever How is pancreatitis diagnosed? - ANSWER Elevated lipase Name for possible CC's for a GI bleed pt: - ANSWER Hematemesis, coffee ground emesis, hematochezia, melena. How is a GI bleed diagnosed in the ED? - ANSWER Guaiac positive or heme+ stool, gastroccult What are we worried about for someone with a GI bleed? - ANSWER Too much blood loss, anemia What is the pre-existing condition you must have before you can get diverticulitis? - ANSWER Diverticulosis What will be the CC for someone with diverticulitis? - ANSWER LLQ abdominal pain What studies would diagnose diverticulitis? - ANSWER CT A/P with PO contrast What might a person with SBO complain of? - ANSWER Abd pain/bloating, vomiting, abdominal distension, no BM's, constipation. How is an SBO diagnosed? - ANSWER CT w/ PO contrast or AAS (acute abd series) X-ray. What is pyelo? - ANSWER Pyelonephritis, kidney infection (different and worse than a UTI), usually spread from a UTI What will be the chief complaint from someone with a UTI? - ANSWER Painful urination (dysuria), frequency, burning, hesitancy, malodourous urine. Where would a patient feel pain if they had pyelo? - ANSWER Flank pain, fever and dysuria. How is a UTI diagnosed? - ANSWER Urine drip or urinalysis (UA), showing white blood cells. What might a person with kidney stones complain of? - ANSWER Flank pain, sudden onset, radiating pain How are kidney stones diagnosed? - ANSWER CT, A/P, or RBC in UA. What is an ectopic pregnancy? - ANSWER Tubal pregnancy, when a fertilized egg develops outside of the uterus (usually in the fallopian tube). High risk for rupture and death. How is an ectopic pregnancy diagnosed? - ANSWER US of the pelvis What is an ovarian torsion? - ANSWER Twisting of the ovarian artery, which reduces the blood flow to the ovary. Could result in infarct of the artery How is ovarian torsion diagnosed? - ANSWER US pelvis Name the two types of CVA's(strokes): - ANSWER Hemmorhagic CVA, Ischemic CVA. (TIA is not a type of stroke) What symptoms might a person with a brain bleed complain of? - ANSWER Thunder clap onset, Worst headache of their life, changes speech, vision, motor (weakness), sensation (numbness), AMS [Show More]

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