Diagnose Me
A patient with chest pain, diaphoresis, nausea, and pain radiating to the left arm.
What is acute coronary syndrome?
A screening test for osteoporosis.
What is dual-energy x-ray absorpiotometry (DEXA) scan
You forgot to chart yesterday' visit. The correct action is to create this type of note.
What is a late entry?
The median nerve passes through this fibro-osseous tunnel at the wrist.
What is the carpal tunnel?
Chest pain (3)
What are acute coronary syndrome (ACS), pulmonary embolism (PE), and aortic dissection
A diabetic patient presents with fever, flank pain, nausea and CVA tenderness.
What is pyelonephritis?
A 52-year-old women presents for annual exam, smokes 1-pack per day for 30 years and quit 8 years ago.
What is annual low-dose CT scanning?
When prescribing a medication with significant adverse effects, documentation should include discussion on these three items.
What is risk, benefits and alternatives?
McBurney's point overlies this abdominal structure.
What is the appendix?
Headache (3)
What are subarachnoid hemorrhage, meningitis, and temporal arteritis (aka Giant cell)?
This diagnosis should always be considered in any woman under the age of 50 presenting with abdominal pain.
What is ectopic pregnancy?
All adults should be screened routinely for this behavioral health concern beginning at age 18.
What is depression?
This section of the chart should explain your thought process for selecting one diagnosis over another.
This muscule separates the anterior and posterior triangles of the neck?
What is the sternocleiodomastoid muscle?
Abdominal pain (3)
What are aortic aneurysm, acute appendicitis, and ectopic pregnancy?
An infant has fever, lethargy, poor feeding and bulging fontanelle.
What is meningitis?
This vitamin and dosage is recommended for women who may become pregnant to reduce neural tube defects.
What is 400 mcg of folic acid?
What is falsification of the medical record?
This retroperitoneal organ lies posterior to the stomach and extends from the duodeum to the spleen.
What is the pancreas?
Unilateral eye pain (4)
What are acute angle glaucoma, temporal arteritis, optic neuritis, and blinding uveitis?
A diabetic patient presents with nausea, vomiting and abdominal pain.
What is diabetic ketoacidosis?
Adults age 65 and older should receive this vaccine to prevent invasive pneumococcal disease.
What is PCV20 or PCV15 followed by PPSV23 when indicated?
Using copy and paste without verifying accuracy increases the risk of this type of documentation.
What is fraudulent documentation?
This is a mixed nerve originating in the medulla oblongta that controls the tongue, throat and parotid glands.
What is cranial nerve 9 (CN IX)
Acute vision loss (5)
What are stroke, acute angle-closed glaucoma, Giant cell arteritis, retinal detachment, and retinal artery occlusion?