PMHx

Question 1

Pt says they have high blood pressure

Answer 1

Pt has hypertension (HTN)

Question 2

Pt says they have high cholesterol

Answer 2

Pt has hyperlipidemia (HLD)

Question 3

Pt says they have a thyroid problem

Answer 3

Pt has hyperthyroidism or hypothyroidism

Question 4

Pt says they have Diabetes

Answer 4

Pt has DM Diabetes Mellitus

Question 5

Pt says I only take pills for my Diabetes

Answer 5

Pt takes NIDDM

Question 6

Pt says I take shots for my Diabetes

Answer 6

Pt uses IDDM

Question 7

pt says they have heart disease

Answer 7

Pt has Coronary Artery Disease (CAD)

Question 8

Pt says they have had a heart attack

Answer 8

Pt has had MI Myocardial infarction and CAD

Question 9

Pt says they have heart failure

Answer 9

Pt has Congestive Heart failure (CHF)

Question 10

Pt has an irregular heartbeat

Answer 10

Arrhythmia

Question 11

pt has murmur

Answer 11

heart murmur

Question 12

pt has episodes of abnormally fast/racing heartbeat

Answer 12

supraventricular tachycardia (SVT)

Question 13

Pt says they have asthma

Answer 13

asthma

Question 14

Pt says they have emphysema/chronic bronchitis

Answer 14

chronic obstructive pulmonary disease (COPD)

Question 15

Pt says they have a blood clot in the lung

Answer 15

scribe writes Pulmonary embolism (PE)

Question 16

Pt says they Pneumonia

Answer 16

scribe writes PNA (pneumonia)

Question 17

Pt says reflux

Answer 17

scribe writes GERD

Question 18

pt says they have Ulcer

Answer 18

scribe writes gastric ulcer or peptic ulcer disease (PUD)

Question 19

Pt says they have pancreatitis

Answer 19

scribe writes pancreatitis

Question 20

Pt says they have Hepatitis

Answer 20

scribe writes They either have Hepatitis A, B, C

Question 21

Pt says Diverticulitis

Answer 21

scribe writes diverticulitits

Question 22

Pt says Crohn’s / UC

Answer 22

Crohn’s disease or ulcerative Colitits

Question 23

Pt says Irratible Bowel

Answer 23

Irratible Bowel Syndrom (IBS)

Question 24

Pt says they have a bladder infection

Answer 24

UTI

Question 25

Pt says they have kidney infection

Answer 25

pyelonephritis

Question 26

pt says they have kidney stones

Answer 26

renal calculi

Question 27

pt says they are on dialysis

Answer 27

CRF or End state renal disease (ESRD)

Question 28

Pt says enlarged prostate

Answer 28

Benign prostatic Hypertrophy (BPH)

Question 29

Gravida (G) means ? Para (P) means? Abortus (A) mean?

Answer 29

total number of pregancies total number of pregnancies reaching gestational vital stage (23 weeks) total number of miscarriage or abortions

Question 30

Pt says brain bleed (stroke)

Answer 30

hemorrhagic CVA

Question 31

Pt says they have had a stroke

Answer 31

Ischemic cerebrovascular accident (CVA)

Question 32

Pt says they have a mini-stroke

Answer 32

transient ischemic attack (TIA)

Question 33

Pt says they have seizures

Answer 33

history of seizures

Question 34

Pt says they are bipolar

Answer 34

bipolar disorder

Question 35

Pt says they have schizophrenia

Answer 35

Schizophrenia

Question 36

Pt says "they drink alot"

Answer 36

ETOH abuse or alcholoism

Question 37

Pt says they do drugs

Answer 37

substance abuse

Question 38

Pt says they have blood clot in leg

Answer 38

deep vein thrombosis (DVT)

Question 39

"Buldge in my Aorta"

Answer 39

aortic aneurysm

Question 40

"bad flow to my legs"

Answer 40

Peripheral vascular disease (PVD)

Question 41

"numbness in my legs"

Answer 41

Peripheral neuropathy

Question 42

Pt says low back pain

Answer 42

chronic low back pain

Question 43

Pt says they bulding/ herniated disk

Answer 43

Degenerative Disk Disease (DDD)

Question 44

Pt says they have Arthritis

Answer 44

Osteoarthritis (OA) or Rhuematoid Arthritis (RA)

Question 45

Pt has weak/ fragile bones

Answer 45

Osteoporosis

Question 46

Pt has cancer

Answer 46

CA or carcinoma of breast, lung, stomach...

Question 47

"spread to my.."

Answer 47

with metastasis to the...

Question 48

pt says they have had Chemo

Answer 48

pt has had chemotherapy

Question 49

pt has had/has radiation

Answer 49

pt has/had radiation therapy

Question 50

pt says they cut it out

Answer 50

s/p surgical resection

Question 51

pt says its gone

Answer 51

pt is in remission