Chapter two - Medical Histories

Question 1

CC: Chief Complaint

Answer 1

Reason why the patient is seeing you

Question 2

HPI: Hx of Present Illness

Answer 2

Amplifies the Chief Complaint, describes how each symptom developed, gives the seven attributes of every symptom.

Question 3

PMHx: Past Medical History

Answer 3

Surgical, past medical, psychiatric, childhood illnesses.

Question 4

SHx: Social History

Answer 4

Family of origin, current household, personal interests, and lifestyle. Illicit drug use and alcohol should also be noted. Religion and marital status

Question 5

ROS: Review of Systems

Answer 5

Documents presence or absence of common symptoms related to each major body system. Ask closed ended questions about major body systems.

Question 6

Alg: Allergies

Answer 6

Allergies and reactions

Question 7

Immune: Immunizations

Answer 7

vaccines and dates. Tetanus included.

Question 8

PE: Physical Exam

Answer 8

vitals, ROM, eyes, nose, ears, heart, stomach. MA can do this.

Question 9

Labs

Answer 9

Blood work, x-rays, EKG,

Question 10

Meds: Medications

Answer 10

Current Meds patient is taking

Question 11

A/P: Assessment and plan

Answer 11

Plan for treatment

Question 12

c with line above

Answer 12

With

Question 13

B/O

Answer 13

Because of

Question 14

CA

Answer 14

Cancer

Question 15

etOH

Answer 15

Ethyl alcohol

Question 16

H/O or h/o

Answer 16

History of

Question 17

hs

Answer 17

Bedtime, at bedtime (hour of sleep)

Question 18

I and O

Answer 18

Intake and output

Question 19

LMP

Answer 19

Last menstrual period

Question 20

N/A

Answer 20

Not available or applicable

Question 21

NKDA

Answer 21

No known drug allergies

Question 22

N and V

Answer 22

Nausea and vomiting

Question 23

OB

Answer 23

Obstetrics

Question 24

p with line above

Answer 24

Post or after

Question 25

P

Answer 25

Pulse

Question 26

p.c.

Answer 26

After meals (post cebum)

Question 27

pt

Answer 27

Patient

Question 28

PTA

Answer 28

Prior to admission or arrival at site

Question 29

Post-op

Answer 29

Post-operative

Question 30

PP

Answer 30

Postpartum or post-prandial (after eating)

Question 31

PRN (prn)

Answer 31

As necessary (pro re nata)

Question 32

P/Y or PY

Answer 32

Pack year (packs per day x years smoking)

Question 33

q

Answer 33

every

Question 34

qd

Answer 34

Every day

Question 35

qh

Answer 35

Every hour

Question 36

q2h

Answer 36

Every two hours

Question 37

qod

Answer 37

Every other day

Question 38

R/O

Answer 38

Rule out

Question 39

s with line above

Answer 39

Without

Question 40

S/P or s/p

Answer 40

Status post

Question 41

Si/Sx

Answer 41

Signs and symptoms

Question 42

tid

Answer 42

three times per day

Question 43

V/D

Answer 43

Vomiting and diarrhea

Question 44

SOMR

Answer 44

Source-Oriented Medical Record

Question 45

POMR

Answer 45

Problem-Oriented Medical Record. Most Common

Question 46

SOAP or SOAPER

Answer 46

S - Subjective information
O - Objective information
A - Assessment and/or diagnosis
P - Plan for treatment
E - Educating the patient
R - Response of the patient to the education and care provided

Question 47

CHEDDAR

Answer 47

C - Chief Complaint
H - History of all relevant information
E - Examination of relevant systems
D - Details of complaint and observed problems
D - Drugs, with dosages, currently being taken
A - Assessment based on diagnostics
R - Returning visit for follow up

Question 48

A typical asthma medication would be:

Answer 48

Bronchodilator

Question 49

A patient is being tested for color vision deficiency. Which of the following tests should the CCMA perform? Snellen, Jaeger, Ishihara, or Pelli-Robson?

Answer 49

Ishihara

Question 50

Generally, upon conclusion of a patient’s history, you should:

Answer 50

Take and record vital signs