welcome and patient history

Question 1

emphysema or chronic bronchitis

Answer 1

chronic obstructive pulmonary disease (COPD)

Question 2

subjective

Answer 2

feeling, comes from the patient

Question 3

chronic

Answer 3

long-standing, not of direct concern

Question 4

history of present illness

Answer 4

HPI

Question 5

heart failure

Answer 5

congestive heart failure (CHF)

Question 6

patient says: pneumonia

Answer 6

scribe writes: pneumonia

Question 7

kidney infection

Answer 7

pyelonephritis

Question 8

enlarged prostate

Answer 8

benign prostatic hyperplasia (BPH)

Question 9

high cholesterol

Answer 9

hyperlipidemia

Question 10

heart disease

Answer 10

coronary artery disease (CAD)

Question 11

blood clot in lung

Answer 11

pulmonary embolism (PE)

Question 12

stroke

Answer 12

cerebrovascular accident (CVA)

Question 13

tonsils removed

Answer 13

tonsillectomy

Question 14

ear tubes

Answer 14

pressure equalizer (P.E.) tubes

Question 15

part of my colon removed

Answer 15

partial colectomy

Question 16

the physiological process causing the symptoms

Answer 16

pathophysiology

Question 17

the main reason for the patient’s outpatient visit

Answer 17

chief complaint

Question 18

electronic medical record/electronic health record

Answer 18

EMR/EHR

Question 19

factual finding from the provider, comes from the physician

Answer 19

objective

Question 20

patient’s feeling of discomfort

Answer 20

pain

Question 21

doctor’s finding of reproducible pain

Answer 21

tenderness

Question 22

new onset, likely concerning

Answer 22

acute

Question 23

what is the order of emergency department flow?

Answer 23

check in & triage, history & physical, differential diagnosis, orders & treatment, medical decision making, disposition

Question 24

review of systems

Answer 24

ROS

Question 25

what makes up past history?

Answer 25

past medical history, past surgical history, family history, social history

Question 26

DDx

Answer 26

differential diagnosis; a variety diagnostic possibilities are being considered to diagnose the disease presented

Question 27

combination of tests to rule out diseases, as well as medications and procedures to treat the symptoms and/or disease

Answer 27

orders and treatment

Question 28

medical decision making

Answer 28

MDM

Question 29

what is disposition

Answer 29

where the pt ends up; discharged to home, nursing facility, admitted, transferred, etc

Question 30

PMHx

Answer 30

past medical history

Question 31

high blood pressure

Answer 31

hypertension (HTN)

Question 32

diabetes

Answer 32

diabetes mellitus (DM)

Question 33

"I only take pills for my diabetes"

Answer 33

non-insulin dependent diabetes mellitus (NIDDM)

Question 34

"I take shots (insulin) for my diabetes"

Answer 34

insulin dependent diabetes mellitus (IDDM)

Question 35

heart attack

Answer 35

myocardial infarction (MI)

Question 36

irregular heartbeat

Answer 36

arrythmia

Question 37

reflux

Answer 37

gastroesophageal reflux disease (GERD)

Question 38

ulcers

Answer 38

gastric ulcers or peptic ulcer disease (PUD)

Question 39

patient says: pancreatitis

Answer 39

scribe writes: pancreatitis

Question 40

patient says: hepatitis

Answer 40

scribe writes: hepatitis

Question 41

patient says: irritable bowel syndrome

Answer 41

scribe writes: irritable bowel syndrome (IBS)

Question 42

bladder infection

Answer 42

urinary tract infection (UTI)

Question 43

patient says: kidney stones

Answer 43

renal calculi or nephrolithiasis

Question 44

"I'm on dialysis"

Answer 44

chronic kidney disease (CKD) on dialysis

Question 45

what is the total number of times the patient has pregnant?

Answer 45

gravida G

Question 46

the number of pregnancies that resulted in viable births

Answer 46

para P

Question 47

the total number of miscarriages or elective abortions

Answer 47

abortus A

Question 48

blockages in the brain

Answer 48

ischemia CVA

Question 49

brain bleed

Answer 49

hemorrhagic CVA

Question 50

"mini stroke"

Answer 50

transient ischemic attack (TIA)

Question 51

"bad blood flow to my legs"

Answer 51

PVD - peripheral vascular disease

Question 52

past surgical history

Answer 52

PSHx

Question 53

adenoids removed

Answer 53

adenoidectomy

Question 54

surgical repair of a blood vessel; "balloon in my heart"

Answer 54

angioplasty--> PMHx CAD

Question 55

patient says: stents in my heart

Answer 55

coronary stents--> PMHx CAD

Question 56

breast removal

Answer 56

mastectomy

Question 57

part of my lung removed

Answer 57

partial lobectomy

Question 58

appendix removed

Answer 58

appendectomy

Question 59

gallbladder removed

Answer 59

cholecystectomy

Question 60

spleen removed

Answer 60

splenectomy

Question 61

kidney removed

Answer 61

nephrectomy

Question 62

uterus removed

Answer 62

hysterectomy

Question 63

ovary removed

Answer 63

oophorectomy

Question 64

ovary and fallopian tube removed

Answer 64

salpingo-oophorectomy

Question 65

prostate removed

Answer 65

prostatectomy

Question 66

family history

Answer 66

family hx

Question 67

a younger age of onset (under __) means higher genetic risk

Answer 67

55 years

Question 68

social history

Answer 68

social hx

Question 69

what factors describe social hx

Answer 69

tobacco use/vaping, alcohol use, drug use, occupation, living circumstances

Question 70

true allergy

Answer 70

any medication that causes a rash, itching, swelling, or difficulty breathing