Exam Review Deck Flashcards
In the patient encounter; “What is the Laundry list of questions about each organ system of the body” referred to as?
Review of Systems (ROS)
What is the final part of the medical history and demonstrates your responsibility for the Total Patient?
Review of Systems (ROS)
What is the goal when inquiring about the patients allergies?
All inclusive listing of patient’s historical allergic/adverse reactions
What is included in the allergy history?
Medications (Oral, Topical, injection, etc…)
Food Allergies
Environmental Allergies
Radio-contrast dyes
To properly document allergies what must be included?
- Clearly identified/highlighted on chart
- Allergen
- Type of Reaction
- Severity
What information is found in the assessment portion of a SOAP-P note?
Diagnosis (Problem list)
When listing multiple diagnoses how should they listed in the assessment?
Most concerning first
What format are patient notes documented?
S- Subjective O- Objective A- Assessment P- Plan p- Prevention
What is included in the Subjective portion of the SOAP-P note?
Chief Complaint History of Present Illness Past Medical History Family Medical History Social History Review of Systems
What is included in the Objective portion of the SOAP-p note?
Physical Exam
Labs
What portion of the SOAP-P note is the treatment plan documented?
Plan
What is a “Pertinent Positive”?
Each symptom common to the concerning disease that the patient has
What is a “Pertinent Negative”?
Each symptom common to the disease that the patient does not have
What helps establish the diagnosis of the disease?
Pertinent Positives
What helps to rule out the disease?
Pertinent Negatives
What is included in the Physical Exam in what order should it be listed?
General Assessment of the Patient
Vital Signs
Physical Exam Findings
Results: Labs/Diagnostic Tests
The Objective should flow logically from subjective and reflect differential diagnosis and documented in what order?
Head to Toe
On a medication prescription the portion that lists the name and strength of the medication is referred to as what?
Inscription
What portion of the Medication prescription gives the quantity prescribed?
Subscription
What portion of the Prescription provides the directions for use?
Sig (Signature)
The medical suffix “-algia” means what?
Pain
The medical suffix “-pexy” means what?
Surgical Fixation
The medical prefix “Cyto-“ means what?
Cell
The medical suffix “-lithiasis” means what?
Calculi (nephrolithiasis: kidney Calculi/stone)
