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Medical History IPAP 3-17 > Exam Review Deck > Flashcards

Exam Review Deck Flashcards

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1
Q

In the patient encounter; “What is the Laundry list of questions about each organ system of the body” referred to as?

A

Review of Systems (ROS)

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2
Q

What is the final part of the medical history and demonstrates your responsibility for the Total Patient?

A

Review of Systems (ROS)

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3
Q

What is the goal when inquiring about the patients allergies?

A

All inclusive listing of patient’s historical allergic/adverse reactions

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4
Q

What is included in the allergy history?

A

Medications (Oral, Topical, injection, etc…)
Food Allergies
Environmental Allergies
Radio-contrast dyes

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5
Q

To properly document allergies what must be included?

A
  • Clearly identified/highlighted on chart
  • Allergen
  • Type of Reaction
  • Severity
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6
Q

What information is found in the assessment portion of a SOAP-P note?

A

Diagnosis (Problem list)

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7
Q

When listing multiple diagnoses how should they listed in the assessment?

A

Most concerning first

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8
Q

What format are patient notes documented?

A 
S- Subjective
O- Objective
A- Assessment
P- Plan
p- Prevention
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9
Q

What is included in the Subjective portion of the SOAP-P note?

A 
Chief Complaint
History of Present Illness
Past Medical History
Family Medical History
Social History
Review of Systems
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10
Q

What is included in the Objective portion of the SOAP-p note?

A

Physical Exam

Labs

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11
Q

What portion of the SOAP-P note is the treatment plan documented?

A

Plan

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12
Q

What is a “Pertinent Positive”?

A

Each symptom common to the concerning disease that the patient has

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13
Q

What is a “Pertinent Negative”?

A

Each symptom common to the disease that the patient does not have

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14
Q

What helps establish the diagnosis of the disease?

A

Pertinent Positives

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15
Q

What helps to rule out the disease?

A

Pertinent Negatives

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16
Q

What is included in the Physical Exam in what order should it be listed?

A

General Assessment of the Patient
Vital Signs
Physical Exam Findings
Results: Labs/Diagnostic Tests

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17
Q

The Objective should flow logically from subjective and reflect differential diagnosis and documented in what order?

A

Head to Toe

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18
Q

On a medication prescription the portion that lists the name and strength of the medication is referred to as what?

A

Inscription

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19
Q

What portion of the Medication prescription gives the quantity prescribed?

A

Subscription

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20
Q

What portion of the Prescription provides the directions for use?

A

Sig (Signature)

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21
Q

The medical suffix “-algia” means what?

A

Pain

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22
Q

The medical suffix “-pexy” means what?

A

Surgical Fixation

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23
Q

The medical prefix “Cyto-“ means what?

A

Cell

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24
Q

The medical suffix “-lithiasis” means what?

A

Calculi (nephrolithiasis: kidney Calculi/stone)

25
Q

The medical suffix “-extomy” means what?

A

Surgical removal of a specified part of the body

26
Q

The Medical suffix “-cele” means what?

A

Relating to a hernia or swelling

27
Q

The Medical suffix “-tomy” means what?

A

Surgical incision or excision of an object

28
Q

The Medical prefix “Hypo-“ means what?

A

Low, under, Beneath, Down, or Below Normal

29
Q

The Medical prefix “Tachy-“ means what?

A

Rapid

30
Q

The Medical prefix “Pyro-“ means what?

A

Denoting Fire, Heat, Fever

31
Q

The Medical suffix “-rrhea” means what?

A

Discharge or Flow

32
Q

The Medical suffix “-osis” means what?

A

Denoting a Process or Condition

-Pathological State

33
Q

The Medical suffix “-plasty” means what?

A

Molding, Grafting, or formation of a specified part of the body

34
Q

The Medical suffix “-sclerosis” means what?

A

Abnormal Hardening of Body Tissue

35
Q

The Medical suffix “-tripsy” means what?

A

Surgical Procedure in which a structure is intentionally Crushed

36
Q

The Medical prefix “Melan/o-“ means what?

A

Black

37
Q

The Medical prefix “Pneum/o” means what?

A

Relating to the lungs

Relating to the presence of air or gas

38
Q

What is the medical term for the surgical removal of a testicle?

A

Orchidectomy

39
Q

The Medical root “Stenosis” means what?

A

Abnormal Narrowing of a body channel

40
Q

What is the medial term for “a nosejob”?

A

Rhinoplasty

41
Q

The Medical suffix “-penia” means what?

A

Lack/Deficiency

42
Q

The Medical prefix “Hemat/o-“ means what?

A

Blood

43
Q

The Medical prefix “Chondr/o-“ means what?

A

Relating to Cartilage

44
Q

The Medical suffix “-malacia” means what?

A

Abnormal softening of tissues related to a disease or other abnormal condition

45
Q

The Medical root “oophor” means what?

A

Denoting the Ovary

46
Q

The Medical prefix “chole-“ means what?

A

Bile/ Gallbladder

47
Q

The Medical suffix “-tome” means what?

A

A Cutting Instrument

48
Q

The Medical prefix “Brady-“ means what?

A

Slow/Delayed

49
Q

What medial term is used to denote the “same side as”…?

A

Ipsilateral

50
Q

What medical term is used to denote “both sides”?

A

Bilateral

51
Q

What term is used to denote a slower than normal heart rate?

A

Bradycardia

52
Q

What is a Cystotome?

A
  • Instrument used for Cystotomy (surgical incision into the urinary bladder)
  • Instrument used in opening the capsule of the lens in cataract operations
53
Q

What is the medical term for inflammation of the gallbladder?

A

Cholecystitis

54
Q

What medical term refers to the surgical removal of one or both ovaries?

A

Oophorectomy

55
Q

What is the definition of Chondromalacia?

A

Abnormal softness of cartilage

56
Q

What is the medical term for vomiting blood?

A

hematemesis

57
Q

What does Neutropenia refer to?

A

Abnormally low/few neutrophils in the blood

58
Q

What is the medical term for a kidney stone (calculus) is broken into small particles, typically by ultrasound shock waves?

A

Lithotripsy

59
Q

What is the medical term which refers to a mild mental illness that is not caused by organic disease, involving symptoms of stress (depression, anxiety, etc..)?

A

Neurosis

Medical History IPAP 3-17 (3 decks)

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