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Question 1

Vital Signs

Answer 1

BP 
HR
RR
Temp
O2 sat.

Question 2

Vital signs obtained by?

Answer 2

Nurse or MA upon patient check-in

Question 3

Objective Info includes

Answer 3

Vital signs, Physical Exam, Orders/Results

Question 4

Subjective Info includes

Answer 4

HPI, ROS, Chief Complaint

Question 5

What are 4 important things to document for syncopal episodes?

Answer 5

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

Question 6

Abnormal Neuro

Answer 6

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)

Question 7

Radial Pulse

Answer 7

Wrist

Question 8

Carotid Pulse

Answer 8

Neck

Question 9

Femoral Pulse

Answer 9

Pelvis

Question 10

Dorsalis Pedis (DP) Pulse

Answer 10

front of foot, intersection of ankle

Question 11

Posterior Tibilais (PT) pulse

Answer 11

Sides of foot- hard bones are

Question 12

Pronator Drift

Answer 12

PE- Neurological

Question 13

Cranial nerves intact

Answer 13

PE- Neurological

Question 14

AT/NC

Answer 14

Atraumatic, Normocephalic; PE- Head

Question 15

EOMI

Answer 15

Extra Ocular Movements Intact- PE: Eyes

Question 16

RBBB

Answer 16

Right Bundle Branch Block- PE: Cardiac

Question 17

PVC

Answer 17

Premature Ventricular Contraction

Question 18

LAD

Answer 18

Left Anterior Descending (branch of coronary artery)

Question 19

Comorbidity

Answer 19

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

Question 20

Systole

Answer 20

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

Question 21

Diastolic

Answer 21

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

Question 22

Paresthesia

Answer 22

Sensation of tingling or numbness

Question 23

Polydipsia

Answer 23

Excessive thirst

Question 24

Anticoagulant

Answer 24

A drug that prevents blood clotting

Question 25

HTN Risk Factors, CC, PE, Dx by

Answer 25

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

Question 26

DM Risk Factors, CC, PE, Dx by

Answer 26

``` 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 ```

Question 27

HLD Risk Factors, CC, PE, Dx by

Answer 27

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

Question 28

Good cholesterol/lipids

Answer 28

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

Question 29

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

Answer 29

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)

Question 30

CAD management steps

Answer 30

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

Question 31

Asthma Risk Factors, CC, PE, Dx by

Answer 31

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)

Question 32

Normal Constitutional

Answer 32

Well developed, well nourished. No Acute Distress

Question 33

Normal Eyes

Answer 33

PERRL, EOMI

Question 34

Normal ENT

Answer 34

Moist mucous membranes

Question 35

Normal Neck

Answer 35

Supply, no lymphadenopathy

Question 36

Normal Cardiovascular

Answer 36

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

Question 37

Normal Respiratory

Answer 37

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

Question 38

Normal Abdominal

Answer 38

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

Question 39

Normal Extremities

Answer 39

No edema, Full ROM

Question 40

Normal Skin

Answer 40

Warm, Dry

Question 41

Normal Neurological

Answer 41

Alert and Oriented. Normal Speech

Question 42

Normal Psychiatric

Answer 42

Normal affect

Question 43

Normal Head

Answer 43

Atraumatic, Normocephalic (AT/NC)

Question 44

PE Abdominal- Murphy's Sign

Answer 44

Cholecystitis, RUQ

Question 45

PE Abdominal- McBurney's Point

Answer 45

Appendicitis, RLQ

Question 46

PE Abdominal Rovsing's

Answer 46

Diverticulitis, LLQ

Question 47

Epigastric

Answer 47

GERD, MI

Question 48

LUQ

Answer 48

Pancreatitis

Question 49

Suprapubic

Answer 49

Ovarian Torsion; Ovarian Cyst; UTI

Question 50

Flanks

Answer 50

Pyelonephritis | Renal Calculi

Question 51

Assessment- Simple Statement Structure

Answer 51

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

Question 52

MRI

Answer 52

Magnetic Resonance Imaging

Question 53

Levels of Service

Answer 53

``` 1- minmial 2-problem-focused visit 3-expanded problem-focused 4-detailed 5-comprehensive ```

Question 54

Level 4 Numbers- New Patient

Answer 54

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

Question 55

Level 4 Numbers- Established Patient

Answer 55

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

Question 56

E&M Codes Formula

Answer 56

Problem/Health Risk + Counseling = E/M Level

Question 57

MU

Answer 57

Meaningful Use

Question 58

CMS

Answer 58

Center for Medicare & Medicaid Services

Question 59

CPOE

Answer 59

Computerized Physician Order Entry

Question 60

EHR/EMR

Answer 60

Electronic Health Record/ Electronic Medical Record

Question 61

PHI

Answer 61

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

Question 62

HIPAA

Answer 62

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

Question 63

HITECH

Answer 63

The Health Information Technology for Economic and Clinical Health Act

Question 64

HIPAA Rules

Answer 64

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?"

Question 65

Elements of HPI

Answer 65

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