Patient Health History
Primary reason for making the office visit.
What is CC?
One of the most common chief complaints from patients.
What is pain?
Family history is a record of the health problems of the patient's friends only.
What is false?
In a physical exam, the physician's instruments are considered the primary "tool".
What is false?
This is a preliminary presumptive diagnosis made by the physician based on the health history and physical examination as well as any laboratory results or reports.
What is clinical diagnosis?
This sign is observable by others and can be measured, such as weight gain, fever or rash.
What is objective sign?
What is true?
These types of family medical diseases maybe inherited or genetic.
What is seizures, heart disease, hypertension, and certain types of cancer?
An inventory system should contain the following information.
What is list of supplies used in your facility, item numbers for all supply items, each supplier name, address, telephone number and contact person. Amount of each supply used monthly.
Reordering frequency.
Process of listening to sounds within the body made by the hearts, lungs, stomach, and bowel are being assessed for strength and rhythm.
What is auscultation?
These symptoms are something that the patient experiences but cannot be observed by anyone else.
What is subjective?
This involves asking the patient to describe the pain on a scale.
What is 0 to 10?
Social histories include these lifestyle habits or patterns that could affect the health status of the patient which include.
What is smoking, drinking, and the use of recreational drugs. Marital status, sexual preferences, dietary choices, exercise and/or sleep habits?
Common equipment used in a patient examination.
What is ophthalmoscope, otoscope, reflex hammer, stethoscope, sphygmomanometer, tuning fork, & laryngeal mirror?
Before the physician sees the patient, the medical assistant will test the patient's visual acuity using.
What is distance vision or Snellen chart?
History is gathered during the patient's office visit should cover six areas.
What is chief complaint, present illness, past medical history, family medical history, social history and assessment of body systems?
Common terms used to describe pain.
Social history questions.
What is highest level of education?
What is your occupation?
Do you smoke or chew tobacco?
How much alcohol you drink a day?
Have you ever used heroin, cocaine or any recreational drugs?
Typical examination room equipment & supplies.
What is alcohol wipes, betadine, biohazard container, drapes, emesis basin, fixative spray, gauze, gloves, bandages, tape, bp cuff, tongue depressor and cotton swabs?
Guidelines for electronic or paper medical records.
What is entries should be concise and complete; use only accepted medical abbreviations; document all missed appointments; document telephone calls; document every instance of patient education; do not record personal opinion, speculations, or judgements?
What is client's, clarity, completeness, conciseness, chronological order and confidentiality?
Pain is also described where it is felt in the body.
What is radiating, phantom, referred and intractable?
This provides a more complete, expansive description of the chief complaint.
Present illness?
Examination methods used by the physician.
What is inspection, palpation, percussion, auscultation, mensuration and manipulation?
These are the nine standard body positions used for medical and surgical procedures.
What is supine, dorsal recumbent, Lithotomy, fowler's, Semi-Fowler's, Prone, Sims, knee-chest, Trendelenburg and proctologic?