Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

FINAL EXAM SCRIBEAMERICA > More > Flashcards

More Flashcards

1
Q

Vital Signs

A 
BP 
HR
RR
Temp
O2 sat.
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Vital signs obtained by?

A

Nurse or MA upon patient check-in

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Objective Info includes

A

Vital signs, Physical Exam, Orders/Results

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

Subjective Info includes

A

HPI, ROS, Chief Complaint

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

What are 4 important things to document for syncopal episodes?

A

1- what happened prior
2- what happened during
3- what happened after syncopal episode
4- how patient currently feels

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Abnormal Neuro

A

1- Somnolent ( not Alert)
2- Disoriented to (person, place, time, situation) ( not Oriented x4)
3- Aphasia ( expressive or receptive) and Dysarthria ( not normal speech)
4-any abnormal findings ( vs non-focal neurological exam)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Radial Pulse

A

Wrist

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

Carotid Pulse

A

Neck

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

Femoral Pulse

A

Pelvis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

Dorsalis Pedis (DP) Pulse

A

front of foot, intersection of ankle

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Posterior Tibilais (PT) pulse

A

Sides of foot- hard bones are

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Pronator Drift

A

PE- Neurological

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Cranial nerves intact

A

PE- Neurological

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

AT/NC

A

Atraumatic, Normocephalic; PE- Head

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

EOMI

A

Extra Ocular Movements Intact- PE: Eyes

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

RBBB

A

Right Bundle Branch Block- PE: Cardiac

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

PVC

A

Premature Ventricular Contraction

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

LAD

A

Left Anterior Descending (branch of coronary artery)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

Comorbidity

A

The simultaneous presence of 2 chronic diseases or conditions in a patient

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

Systole

A

phase of the heartbeat during which the muscle contracts, pumping blood to the body

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

Diastolic

A

phase of the heartbeat during which muscle is relaxed and heart fills with blood

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

Paresthesia

A

Sensation of tingling or numbness

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

Polydipsia

A

Excessive thirst

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

Anticoagulant

A

A drug that prevents blood clotting

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Q

HTN Risk Factors, CC, PE, Dx by

A

RF- Obesity, DM, high sodium diet, smoking, ETOH
CC- asymptomatic, HA, CP
PE- lower extremity edema, carotid bruit, JVD
Dx by- BP check and monitor with sphygmomanometer
Tx- HCTZ

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
26
Q

DM Risk Factors, CC, PE, Dx by

A 
RF- Obesity, HTN, HLD, high carb diet
CC- unusual weight change, polyuria, polydipsia, blurred vision 
PE- distal paresthesias, pedal edema
Dx- fasting blood glucose
Tx-  Humalog (Insulin) or Metformin
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
27
Q

HLD Risk Factors, CC, PE, Dx by

A

RF- Obesity, DM, EtOH use, high lipid diet
CC- asymptomatic
Dx by- lipid panel
Tx- statins

28
Q

Good cholesterol/lipids

A

HDL- High Density Lipoprotein ( removes cholesterol from artery plaques and recycles it back to the liver)

29
Q

**CAD (Heart disease) Risk Factors, CC, PE, Dx by

A

RF-HTN, DM, HLD, smoking, FHx <55 y/o
CC- Chest pain ; worse with exertion; improve with rest or NTG
Dx by: Cardiac catheterization
Assoc. Meds - ASA, NTG ( Anticoagulants)

30
Q

CAD management steps

A

1 - Cardiac catheterization
2- angioplasty
3-coronary stents
4-CABG

31
Q

Asthma Risk Factors, CC, PE, Dx by

A

RF- Obesity, FHx of asthma
CC- SOB, Wheezing ( improved with nebulizer)
PE- Wheezes
Dx- Peak flow testing - peak flow monitor
Tx- Inhaler or Nebulizer - bronchodilators (Advair) and steroids (Flovent)

32
Q

Normal Constitutional

A

Well developed, well nourished. No Acute Distress

33
Q

Normal Eyes

A

PERRL, EOMI

34
Q

Normal ENT

A

Moist mucous membranes

35
Q

Normal Neck

A

Supply, no lymphadenopathy

36
Q

Normal Cardiovascular

A

Regular rate and rhythm, No murmurs, rubs, or gallops. Distal pulses intact ( well perfused)

37
Q

Normal Respiratory

A

No respiratory distress- clear to auscultation bilaterally. No wheezes, rales, or rhonchi

38
Q

Normal Abdominal

A

Soft. Non-tender. No guarding, rebound, or rigidity

39
Q

Normal Extremities

A

No edema, Full ROM

40
Q

Normal Skin

A

Warm, Dry

41
Q

Normal Neurological

A

Alert and Oriented. Normal Speech

42
Q

Normal Psychiatric

A

Normal affect

43
Q

Normal Head

A

Atraumatic, Normocephalic (AT/NC)

44
Q

PE Abdominal- Murphy’s Sign

A

Cholecystitis, RUQ

45
Q

PE Abdominal- McBurney’s Point

A

Appendicitis, RLQ

46
Q

PE Abdominal Rovsing’s

A

Diverticulitis, LLQ

47
Q

Epigastric

A

GERD, MI

48
Q

LUQ

A

Pancreatitis

49
Q

Suprapubic

A

Ovarian Torsion; Ovarian Cyst; UTI

50
Q

Flanks

A

Pyelonephritis

Renal Calculi

51
Q

Assessment- Simple Statement Structure

A

1-Age and sex of patient
2-Past medical history only if relevant
3- Diagnoses

52
Q

MRI

A

Magnetic Resonance Imaging

53
Q

Levels of Service

A 
1- minmial
2-problem-focused visit
3-expanded problem-focused
4-detailed
5-comprehensive
54
Q

Level 4 Numbers- New Patient

A

HPI (4); ROS (10); PMHx (3); PE (9-18); A/P (1)

55
Q

Level 4 Numbers- Established Patient

A

HPI (2); ROS (2); PMHx (1); PE(2-12); A/P(2)

56
Q

E&M Codes Formula

A

Problem/Health Risk + Counseling = E/M Level

57
Q

MU

A

Meaningful Use

58
Q

CMS

A

Center for Medicare & Medicaid Services

59
Q

CPOE

A

Computerized Physician Order Entry

60
Q

EHR/EMR

A

Electronic Health Record/ Electronic Medical Record

61
Q

PHI

A

Protected Health Information - First or last name/DOB/Medical Record number/fact that you saw them

62
Q

HIPAA

A

Health Insurance Portability and Accountability Act- body of laws designed to protect the private health information of patients across the country

63
Q

HITECH

A

The Health Information Technology for Economic and Clinical Health Act

64
Q

HIPAA Rules

A

1- If a patient is not assigned to your doctor, do not touch the chart
2-There’s always someone watching
3-Never share your username or password
4-No cell phones or pictures
5-Your job does not belong on social media
6- Ask yourself, “Do I need to access this for my job?”

65
Q

Elements of HPI

A

Early Onset. Tears Lovers. Quite Sad. Must Attack Cause.

FINAL EXAM SCRIBEAMERICA (9 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions