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Scribing > Day 4 Review > Flashcards

Day 4 Review Flashcards

1
Q

Icterus

A

Yellowing also known as jaundice

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2
Q

Purulent

A

Pus-like

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3
Q

Redness

A

Erythema

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4
Q

Organomegaly

A

Organ enlargement

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5
Q

Perfusion

A

Flow of blood through body’s blood vessels

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6
Q

Affect

A

Feeling and emotion

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7
Q

Consolable

A

Able to be comforted

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8
Q

GCS

A

Glasgow Coma Scale, used to assess level of consciousness in trauma Pt’s

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9
Q

Do any Pt complaints belong in the PE

A

No

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10
Q

PERRL

A

Pupils are equal, round, and reactive to light

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11
Q

What does AT/NT mean

A

Atraumatic / Normocephalic (head and head organs normal)

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12
Q

NAD

A

No acute distress

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13
Q

What does pale conjunctiva indicate

A

Anemia

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14
Q

What is scleral icterus, and what does it indicate

A

Yellowing of eyes; liver failure

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15
Q

Name an instrument the Physician may use to closely investigate the eyes

A

Slit lamp, woods lamp, ophthalmoscope (aka fundoscopic Exam)

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16
Q

Medical term for nostril

A

Naris (plural form: nares)

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17
Q

Medical term for runny nose

A

Rhinorrhea

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18
Q

Medical term for epistaxis

A

Nose bleed

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19
Q

What would dry mucous membranes indicate

A

Dehydration

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20
Q

Why is midline body tenderness worse than paraspinal tenderness

A

Bony tenderness (vertebral point tenderness) points toward spinal fracture and therefore concern for spinal cord injury

Paraspinal tenderness = muscle sprain or strain

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21
Q

RRR

A

Regular Rate and Rhythm (normal cardiac finding)

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22
Q

Name the rhythm the physician would hear if the Pt was in AFib

A

Irregularly irregular rhythm

23
Q

Edema

A

Swelling

24
Q

Medical term for Wrist pulse

A

Radial pulse

25
Q

Medical term for Neck pulse

A

Carotid pulse

26
Q

Medical term for Groin pulse

A

Femoral pulse

27
Q

Medical term for Top of foot pulse

A

Dorsalis pedis (DP) pulse

28
Q

Medical term for Side of foot pulse

A

Posterior Tibialis pulse (PT)

29
Q

If physician checks pulse on the right wrist and says “pulses are fine” what would you document

A

Right radial pulse is 2+

30
Q

Name and describe the paritoneal signs (3)

A

Voluntary guarding

Rebound tenderness (tenderness when Dr releases from palpating abd)

Rigidity (involuntary guarding; organs feel stiff and hard)

= G.R.R.

31
Q

Paritoneal signs are signs of a surgical __________

A

Abd

32
Q

What abd exam sign is indicative of cholecystitis

A

Murphy’s sign

33
Q

If a Dr takes one finger and presses in a specific spot in the RLQ, what is the name of the finding they are investigating?

A

McBurney’s point tenderness

34
Q

What would a “Guaiac positive” stool sample diagnose?

A

GI bleed

35
Q

What phrase do you have to doc in the GU exam for every female pelvic exam performed by a male physician?

A

Female chaperone present

36
Q

What is bony tenderness a sign of?

A

Bone deformity, fracture or injury

37
Q

What is CVA tenderness?

A

Costo-vertebral angle tenderness (tenderness over the kidneys)

38
Q

What is fluctuance a sign of?

A

Abscess

39
Q

Laceration vs abrasion

A

Laceration: incision in skin that usually needs sutures

Abrasion: scrape

40
Q

What procedure is associated with lacerations not abrasions

A

Laceration repair, sutures

41
Q

A&Ox3

A

Alert and oriented to person, place, and time

42
Q

What section of the neuro exam would you document “normal finger-nose-finger test” and “normal heel-to-shin”?

A

Cerebellar/coordination

43
Q

DTR

A

Deep tendon reflex

44
Q

What general area of your body does the cranial nerves (CN) control?

A

Face

45
Q

In Neurological exam, what does “normal gait” mean?

A

Waking normally

46
Q

In psych exam, what SI and HI stand for?

A

Suicidal and homicidal ideations

47
Q

Is the Glasgow Coma Scale (GCS) associated with trauma or medical Pt’s? (Score btw 3-15)

A

Trauma

48
Q

Would you doc “RUE strength 3/5” under the neuro or extremities sec of the exam?

A

Neuro

49
Q

TTP

A

Tender to palpation

50
Q

If a mother states that her child has been extremely tired and drowsy recently, can you doc “lethargy” in PE, just based on that?

A

No (subj)

51
Q

Medical term for hives (allergic rxt rash)

A

Urticaria

52
Q

Medical term for “swollen lymph nodes”

A

Lymphadenopathy

53
Q

If doc “there is right pronator drift”, can you also doc “no focal neuro deficits?

A

No, contradiction

54
Q

If doc NAD in constitutional sec, would you be contradicting yourself if you wrote “mild respiratory distress” in pulmonary exam?

A

Yes

Scribing (8 decks)

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