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symptoms
skin was plale, where would you document this information: Physical Exam (PE)
present illness)
Non-STEMI - Troponin
< 55 y/o
What study would be ordered?: PNA (Pneumonia) CXR
with?: Unilateral weakness/numbness, slurred speech, vision changes
example of each element: Onset - 3 weeks ago Timing - intermittent Quality - pressure Severity - 9/ location - frontal/forehead Modifying factors - worse with light, better after Excedrin Context - does not take a blood thinner, no recent head injuries, Hx of similar HA
Patients entire ED visit is based on their answers to the questions asked during the interview?: True
Accurate chronology is not important in an HPI: False
ROS - head-to-toe checklist of subjective Sx
Symptoms listed in ROS can contradict the Sx discussed in the HPI: False
has been pregnant 4 time in the past, and has one child at home?: G - 5 P - 1 A - 3
system.: Skin - Rashes, itching, redness General - fever, chills, weight loss Cardio - Chest pain,Palpitations Pulmonary - shortness of breath, dyspnea, cough, wheezing GI - abdominal pain, acid reflux
inhalers prescribed by her pulmonologist (Dr. Aranibar) have not provided relief. She reports dyspnea and a mild dry cough since last night, but no fever, chest pain, leg pain, leg swelling, or recent travel. The patient was unable to walk to her bathroom this afternoon secondary to her dyspnea, prompting the 911 call. When paramedics arrived to the patient's home 30 minutes ago, tight expiratory wheezes in all fields were appreciated and the patient's SpO2 was 90% on RA. The patient received a DuoNeb breathing treatment and Solumedrol 125 mg en route to the ED, with mild symptom relief.: CC: wheezing Onset: 4 days ago Timing: worsening Location: Quality: "cannot take a full breath" Severity: not stated, but the spO2 reported by paramedics allows us to understand the objective severity Modifying factors: albuterol inhalers presrcibed by Dr. Aranibar has not provided relief. EMS provided DuoNeb breathing treatment and solumedrol 125 mg en route to ED with mild symptom relief Associated sx: dyspnea, mild dry cough Pertinent negatives: fever, chest pain, leg pain, leg swelling, recent travel Context: Hx of asthma, similar to asthma, EMS report (VS en route)
after checking the patients pulse near the left groin: +1 left femoral pulse
Epigastrium LUQ LLQ: Epigastrium - Stomach LUQ - Pancreas LLQ - Large intestine, Ovary
Rovsing sign CVA tenderness Rhonchi Uvular shift (Google to find the test ordered, not technically in the work- book!).: Rosvings sign is characterized as RLQ pain with LLQ palpation, DDx is appendicitis, charted in abdomen/GI, and orders for CT A/P (abd/pelvis)
CVA tenderness is characterized as tenderness in the flank (angle between the ribs/spine), DDx is pyelonephritis or pyelolithiasis (kidney stones), charted in the back region, orders for CT A/P and UA Rhonchi is characterized as rattling sounds in the lungs, DDx is PNA, charted in respiratory, orders for CXR Uvular shift is characterized as the uvula moved to one side, DDx is a peritonsillar abscess, charted in ENT section and orders for CT of the neck
perkalemia, renal failure
tube
47, CABG x2 in 2011, and tonsillectomy.: No, this is only medical and surgical history which are considered 1 element Need 1 from FHx and SHx
insurance information
"all systems negative" phrase: 10 systems 2 systems with "all system negative" phrase
The "All systems negative" phrase is used for all chart: False, including the phrase is the physicians preference AND also never used on patients unable to complete the interview (advanced dementia, AMS, unresponsive)
provider walks into the patients room for the intial evaluations
would very commonly occur.: Before a high risk procedure such as the lumbar
puncture, conscious sedation, cardioversion, receiving tPA, starting/stop- ping blood thinners, CTs for children
amputations, G-tubes, trach scars, "zipper" sternotomy scar, birthmarks
Ariana Venti is a 24 y/o female presenting to the ED with sharp chest pain onset suddenly 4 hours ago. The pain is located over the central chest and worse when leaning forward.: 4 (level 5 billing) Quality - sharp Location
History and Physical (H&P) Labs/Radiology/Medications Medical Decision Making (MDM) Disposition
tients?: Second hand smoke exposure, immunization status
Kidney removal: Nephrectomy
patients neck while they are cleared from the blackboard you should:: Politely remind the doctor that is outside your job description, but offer to get a nurse or tech to help
treat patients
with managing a pt's airway
Hypothyroidism
End stage Renal Disease (ESRD) on dialysis
Rheumatoid Arthritis (RA)