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108 Cards in this Set
- Front
- Back
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High blood pressure |
Hypertension HTN |
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High cholesterol |
Hyperlipidemia |
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CAD |
Coronary Artery Disease |
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AAA |
Abdominal Aortic Aneurysm |
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What are the three types of dispositions? |
•Admit •Discharge •Transfer |
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What does HPI stand for? |
History of present illness |
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What does ROS stand for ? |
Review of Systems |
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The HPI and the ROS are considered what type of information? |
subjective |
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The physical exam is what type of information ?
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objective |
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If a physician told you a patient's abdomen was nontender, where would you document this? |
Physical Exam |
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What section focuses directly on the chief complaint? |
Physical Exam |
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Name an example of something you may write in the surgical history portion of the chart? |
Masectomy |
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Name an example of something you may write in the family hx portion of the chart? |
History of Diabetes Mellitus |
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Name an example of something you may write in the Social Hx portion of the chart?
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Smoker
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What is the abbreviation for hypertension?
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HTN |
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What is the abbreviation for stroke? |
CVA |
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What is the abbreviation for diabetes? |
DM |
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What is the abbreviation for heart attack? |
MI |
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What is the abbreviation for high cholesterol? |
HLD |
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What is the medical term for removal of the appendix? |
Appendectomy |
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What is the medical term for removal of the gallbladder? |
Cholecystectomy |
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What is the medical term for removal of the uterus? |
Hysterectomy |
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What is the medical term for removal of the tonsils? |
Tonsillectomy |
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What is the medical term for removal of the breast? |
Mastectomy |
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What are the five vital signs |
blood pressure temperature oxygen saturation heart rate pulse |
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What does NKDA stand for? |
No Known Drug Allergies |
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What does LNMP stand for? |
Last Normal Menstrual Period |
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If the doctor said the exam was "benign", what does this mean? |
Normal, not a concern |
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What is the medical term for CAD?
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Coronary Artery Disease |
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What is the medical term for AAA? |
Abdominal Aortic Aneurysm |
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What is the medical term for COPD? |
Chronic Obstructive Pulmonary Disease |
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What is the medical term for PNA? |
Pneumonia |
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What is the medical term for URI? |
Upper Respiratory Infection |
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How is CHF diagnosed? |
Chest X Ray, elevated BNP |
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How is PE diagnosed? |
CTA chest |
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How is cholecystitis diagnosed? |
Ultrasound of the right upper quadrant |
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How is pancreatitis diagnosed? |
Elevated lipase |
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How is appendicitis diagnosed? |
CT scan abdomen, pelvis with PO contrast |
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How is a Hemorrhagic CVA diagnosed? |
CT head and lumbar puncture |
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How is deep vein thrombosis diagnosed? |
Ultrasound |
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What are two types of heart attacks and how are they diagnosed? |
STEMI diagnosed by EKG NON-STEMI diagnosed by Troponin |
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What are three types of cardiac risk factors? |
Hypertension Diabetes Mellitus Coronary Artery Disease |
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What are four associated symptoms of an MI other than CP?
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Diaphoresis Nausea/Vomitting Radiation SOB |
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What are three symptoms a patient with an ischemic CVA would present with? |
change in motor, changes in speech, changes in sensation |
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What are the only three true symptoms of an allergic reaction? |
Swelling, Itching, Rash |
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What heart rhythm would a physician hear if the patient were in atrial fibrillation and how is this disease diagnosed?
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Irregularly irregular rhythm
Diagnosed by EKG |
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What physical exam finding is associated with asthma? |
wheezing |
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How is altered mental status different from a focal neurological deficit? What is the major cause of AMS in the elderly?
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AMS affects the whole brain, focal neurological deficit cause damage to certain areas of the brain. The major cause of AMS in the elderly is UTI |
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What is "layman's name" for GERD? |
Acid Reflux |
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What is the most common cause for seizures in children?
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fever |
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Write a pathophysiology finding you learned during training and state its significance.
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PERRLA Pupils Equal Round Reactive to Light and Accommodation PERRLA make sure there is no damage to the optic nerve |
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In your own words, describe the significance of an HPI.
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The story of the symptoms and events that led to the patient's ED
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Name three people who will read the HPI other than the physician.
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Nurse, Provider, Insurance Companies |
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Name five elements of the HPI.
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Onset Timing Location Severity Context |
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True or False: The patient's entire ED visit is based on their answers to the questions asked during the HPI.
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True
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True or False: Accurate chronology is not important in an HPI.
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False Everything needs to be in order |
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What is the main difference between an HPI and an ROS? |
The HPI is the chief complaint, the story The ROS is a yes or no checklist of symptoms |
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List five body systems found in the ROS and provide two symptoms for each system.
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Constitutional: Fever, Weight loss
Eyes: changes in vision, double vision Cardiovascular: chest pain, palpitations Neurological: headache, seizure Psychiatric: depression, anxiety |
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True or False: The symptoms listed in the ROS can contradict the symptoms discussed in the HPI.
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False The ROS cannot contradict the HPI |
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How would you document the GPA for a patient who is currently pregnant, has been pregnant two times in the past, and has one child at home? |
G: 3 P: 1 A: 1 |
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What box would you check to communicate that the patient did not mention any other complaints other than those mentioned?
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"All other systems negative except as marked"
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Write an HPI finding you learned during training and state its significance.
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Patient came in today complaining of a cough that started about three weeks ago. PT states CP with cough and describes it as "sharp & painful" on the left side of chest |
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Write the meaning of this physical exam abbreviation: NAD
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No Acute Distress |
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Write the meaning of this physical exam abbreviation: AT/NC |
Atraumatic Normocephalic |
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Write the meaning of this physical exam abbreviation: PERRL
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Pupils Equal Round Reactive to Light |
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Write the meaning of this physical exam abbreviation: EOMI
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Extraoccular Movement Intact |
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Write the meaning of this physical exam abbreviation: TM
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Tempanic Membrane |
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Write the meaning of this physical exam abbreviation: RRR
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Regular Rate and Rhythm
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Write the meaning of this physical exam abbreviation: JVD
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Jugular Venous Distension |
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Write the meaning of this physical exam abbreviation: TTP
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Tenderness To Palpitation |
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Write the meaning of this physical exam abbreviation: FROM
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Full Range Of Motion |
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Write the meaning of this physical exam abbreviation: CVA tenderness |
Cerebrovascular Accident |
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Write the meaning of this physical exam abbreviation: A&O |
Alert & Oriented |
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Write the meaning of this physical exam abbreviation: SI/HI |
Suicidal Ideation/Homocidal Ideation |
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What disease is associated with scleral icterus? |
Liver failure |
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What condition is associated with fluorescein uptake? |
corneal abraision |
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What condition is associated with bulging and erythematous TM?
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Ear Infection |
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What condition is associated with dry mucous membrane?
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dehydration |
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What condition is associated with tonsillar exudate
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Strepp |
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What condition is associated with sinus tenderness? |
sinusitis |
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What condition is associated with irregularly irregular?
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Atrial fibrillation |
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What condition is associated with JVD? |
Congestive Heart Failure |
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What condition is associated with wheezing? |
Asthma |
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What condition is associated with Pale conjunctiva? |
Anemia |
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What condition is associated with rales? |
Pneumonia |
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What condition is associated with McBurney's Point Tenderness? |
Appendicitis
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What condition is associated with Murphy's Sign? |
Cholecystitis |
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What condition is associated with Guaiac Positive (Heme +)? |
GI |
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What condition is associated with CVA tenderness? |
Pyelonephritis |
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What condition is associated with urticaria? |
Hives |
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What condition is associated with fluctuance and Induration? |
Abscess |
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What condition is associated with bilateral pitting pedal edema? |
Heart failure |
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What condition is associated with calf tenderness? |
Deep Vein Thrombosis |
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What condition is associated with facial asymmetry? |
Bell's Palsy |
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What condition is associated with unilateral weakness? |
CVA |
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What do you write on the chart of the doctor states "The pulses are fine" after checking the patient's pulse near the wrists? |
radial pulse regular rhythm
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What do you write on the chart of the doctor states "The pulses are fine" after checking the patient's pulse near the heel? |
posterior tibialis pulse regular rhythm |
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What do you write on the chart of the doctor states "The pulses are fine" after checking the patient's pulse near the top of the foot?
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dorsal pedis pulse regular rhythm |
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What do you write on the chart of the doctor states "The pulses are fine" after checking the patient's pulse near the neck? |
carotid pulse regular rhythm |
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What do you write on the chart of the doctor states "The pulses are fine" after checking the patient's pulse near the pelvic region?
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pelvic pulse regular rhythm |
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Which words do you think are synonyms with the word "red"?
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Erythematous |
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What organ is in the RUQ? |
Gallbladder and liver |
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What organ is in the LUQ? |
Spleen and pancreas |
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What organ is in the RLQ? |
Appendix |
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What organ is in the LLQ? |
Descending colon |
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What is an extrasystole? |
extra heartbeat |
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What is the physician checking for when they hold their stethoscope to both sides of the patient's neck? |
Carotid bruit |
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Write a PE finding you learned during training and state its significance |
Skin: dry, warm, no rashes
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