Physical exams
Name 1 physical exam sign that would be concerning for appendicitis
What is... Rovsing sign, Psoas sign, Obturator sign, Jump test, McBurney's sign
Painful urination
What is.. dysuria
Name 2 components of an HPI
What is... Severity, context, region, associated symptoms, timing, character, history, modifying factors, duration/onset (SCRATCH MD)
Section of the chart that an EKG get documented
What is... Medical decision making
What is... the HPI and ROS
System where you would document "right facial droop"
What is... neurological
Redness of the skin
What is.. erythema
Name at least 2 important medical history diagnoses that would be important to include in your HPI
What is... HTN, DM, HLD, CVA, CAD, CHF, MI
What 2 sections of the chart are subjective?
HPI and ROS
This is diagnostic of pneumonia
What is... a chest x-ray
Name a contradiction of "regular rate and rhythm"
Melena
What is... black tarry stool
True or false: We do not need to include every question asked by the provider in the HPI
False!
Section of a chart that the provider dictates to us that should be typed verbatim
What is... the physical exam
True or false: We can scroll through Instagram between seeing patients
False!
CVA tenderness stands for...
What is costovertebral angle
Cephalgia
What is... headache
What does a G.P.A score stand for
What is Gravida Para Aborta
Section of the chart that diagnoses are documented
What is... Impression and plan
Name 2 of the 4 types of patient histories we are interested in
What are... personal past medical history, surgical history, family history, social history
System that pharyngeal exudates should be documented in
What is... ENT
Medical term for a urinary tract infection
What is... acute cystitis
Name 3 pertinent positives/negatives for a chief complaint of headache
What is nausea, dizziness, vision changes, numbness, tingling, weakness, neck stiffness/pain
Section of the chart that includes all pertinent and negative symptoms
Name a anticoagulant medication