Academicmaterials

HPI - history of present illness ROS - Review of Systems PE - Physical Examination A/P - acssessment and planning CC - Chief Complaint Chief Complaint - statement or reason for the patient encounter History of present illness - detailed description of development of the patients present disease presented as a chronological story Factors in a HPI - 1. Location on body 2. Quality 3. Severity 4. Duration and Timing 5. Modifying Factors 6.Associated Symptoms 7. Context 8. Chief Compla...

Medical Decision Making (MDM) - Answer-The physician's thought process Pain vs. Tenderness - Answer-Patient's feeling vs. physician's assessment What does distress mean? - Answer-The doctor's judgment of discomfort Baseline - Answer-An individual's normal state of being What does Auscultation mean? - Answer-Listening with a stethoscope Palpation - Answer-The act of pressing on an area by the doctor Inpatient - Answer-Admitted to the hospital overnight Outpatient - Answer-Seen and sen...

What happens if you do not complete the course in 15 days and/or fail the final exam twice? - AnswerOn the 15th day after passing the initial quiz, my course progress will be reset back to 0%. I will then be able to re-progress through the course. When does my certificate for passing Scribe101 expire? - Answer-My Scribe101 certificate does not expire. True or False: In order to take the final exam, I must complete each lesson quiz in order with a passing score of 100% before I can attempt t...

What medical term describes the surgical removal of the gallbladder? - Answer-Cholecystectomy What does "PHI" stand for? - Answer-Protected Health Information T/F. Sharing information about a case with family is allowed, as long as you are scribing with the physician assigned to the case. - Answer-False A patient underwent brain surgery to treat bleeding in the brain from a stroke. What PSHx would you record into the chart? - Answer-Craniotomy A patient's PCP is on vacation. The patient...

A patient is seen in the emergency department complaining of dysuria and tells you that she is 23 weeks pregnant. Your doctor diagnoses her with a UTI. Which of the following would be the best diagnosis? - Answer-acute urinary tract infection in pregnancy, 2nd trimester A patient cut his left foot on a piece of glass two hours ago and is seen in the emergency department to have sutures placed. The doctor tells you there is no tendon injury and circulatory, sensory and motor is intact. What ...

Plantar - Sole side of foot Plantar flexion - Foot movement when toes flex down (pointing your toes) Supine - Body lying face up (chest up and back down) Afebrile - without fever diaphoresis - excessive sweating dysuria - painful urination emesis - vomiting epistaxis - bleeding from the nose gait - a person's manner of walking hematochezia - Bright red, bloody stools hematuria - blood in the urine hemoptysis - coughing up blood incontinence - inability to control bowel movements or...

Abduction - Movement of a body part away from the midline Adduction - Movement of a body part toward the midline Anatomical Position - The erect position of the body with arms at the side and palms of the hands facing forward. Anterior (Ventral) - Nearer to the front Bilateral - Paired structures having right and left members Contralateral - Occurring on the opposite side of the body Deep - Farther from the surface Depressor - A muscle whose contraction pulls down the part of the body to...

What medical term describes the surgical removal of the gallbladder? Word - Answer-Cholecystectomy What does "PHI" stand for? Expand the abbreviation - Answer-Protected Health Information T/F Sharing information about a case with family is allowed, as long as you are scribing with the physician assigned to the case - Answer-F A patient underwent brain surgery to treat bleeding in the brain from a stroke. What PSHx would you record into the chart? - Answer-***NOT Hemorrhagic CVA Craniotom...

ALOC - Altered Level of Consciousness BM - bowel movement DOE - Dyspnea on exertion EOMI - Extraocular Movement Intact (Appropriate function of the extra ocular muscles, tested with "follow my finger") HA - headache MI - Myocardial infarction NAD - no acute distress NSR - Normal Sinus Rhythm PNA - pneumonia UTI - Urinary Tract Infection ASA - Aspirin CA - CancerPCN - Penicillin DM - Diabetes Mellitus PTX - Pneumothorax SOB - Shortness of breath FB - Foreign Body CVA - Cerebral...

* What medical term describes the surgical removal of the gallbladder? - Answer-cholecystectomy What does "PHI" stand for? Expand the abbreviation. - Answer-Protected Health Information T/F. Sharing information about a case with family is allowed, as long as you are scribing with the physician assigned to the case. - Answer-False ** A patient underwent brain surgery to treat bleeding in the brain from a stroke. What PSHx would you record into the chart? - Answer-craniotomy A patient's P...