Worksheets 2, 4, 6

  • We usually identify the patient with 2 identifiers:

    • Name, Date of Birth

  • Personal information including patient’s name, address, & SS# for the computer record it is called demographic 

  • Records entered by the MA

    • Social history, Family history, past medical history, patient demographics, correspondence, medication/allergies, insurance info, vital signs

  • Records entered by the MA

    • Treatment plan, diagnostic imaging, clinical data, orders/referrals

  • A patient states “I smoke two packs of cigarettes per day.” This finding should be recorded in which of the following sections. 

  1. Social history

  2. Past medical history

  3. Chief complaint

  4. Family history

  • Social history

  • When a patient states “It burns when I urinate” should be recorded in which of the following sections:

  1. Review of systems

  2. Chief complaint

  3. past medical history

  4. Social history

  • Chief complaint

  • What do the letters stand for in the SOAP model?

    • Subjective Data

    • Objective, observable, measurable

    • Assessment

    • Plan for treatment

  • What should you document about pain besides the scale?

    • Location, duration, quality, radiation, what alleviates & aggravates

  • When asking about the last menstrual period, note when it:

    • Started

  • After taking PHQ-2. The patient scores more than 3; what is the next step?

    • Provide full form/ask the rest of the PHQ questions

  • After taking GAD-7. Patient scores 9; what is the next step?

    • Monitor the patient. 


  • The part of the brain that controls temperature is the

    • Hypothalamus

  • The average temperature range for an adult is

    • 97.6°F - 99.7°F

  • Fever reading of 100.4°F of TA, R, Oral, Ax, Tym

    • TA: 99.4°F

    • R: 101.4F

    • Oral: 100.4F

    • Ax: 99.4F

    • Tym: 101.4F

  • The pulse rate is measured by

    • Counting the number of taps/beats per minute

  • Our pulse rate is measured by palpation except the ___ site

    • Apical

  • Pulse rate is palpated with the ____ ____ located on the tips of the _____.

    • Sensitive pads, three middle fingers

  • We should not use the ____ when taking a pulse, as it has a ____ of its own.

    • Thumb, pulse

  • Factors affecting pulse rate

    • Age, activities, sex, general health, emotions, pain, medication

  • Average pulse rate of an infant

    • 140 bpm

  • Average pulse rate of an adult

    • 80 bpm

  • The respiratory rate is the

    • Number of respirations per minute

  • Respirations are measured by

    • Counting breaths for 30 seconds & doubling

  • The physical exam is done

    • Once a year

  • Risk factors

    • Increases the probability that an individual will develop a particular condition

  • Diagnosis

    • The scientific method of determining and identifying a condition

  • Prognosis

    • Course and outcome of a patient’s condition

  • Acute illness

    • Characterized by symptoms that have a rapid onset and subside after a relatively short time

  • The patient should be advised of

    • The exam, procedure, reasons for it, who will be doing it, and when it will be done

  • Patient’s privacy

    • Needs to be protected at all times

  • The health screening that women between ages 45 and 54 undergo every year is called a 

    • Mammogram

  • When performing an eye acuity check, the patient should stand ___ away

    • 6 meters/20 feet

  • What is the name of the chart that is used for the eye acuity check?

    • Snellen 

  • Abbreviation for right eye

    • OD

  • Abbreviation for left eye

    • OS

  • Abbreviation for both eyes

    • OV

  • Abbreviation for right ear

    • AD

  • Abbreviation for left ear

    • AS

  • Abbreviation for both ears

    • AV

  • The ratio of water and peroxide for an ear lavage is 

    • 50/50 or 1:1 ratio

  • 2 types of recommended screening for the prevention of colon cancer

    • Colonoscopy, FIT (stool-based test)