Cardiac System Assessment and Diagnosis
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Questions and Answers

What is the primary purpose of a comprehensive physical exam?

  • To focus on a specific body system
  • To provide primary prevention
  • To diagnose a specific chief complaint
  • To establish a baseline for future visits and assessments (correct)

    • In which section of the history would a cardiac stent be documented?

  • Review of Systems
  • Chief Complaint
  • History of Present Illness
  • History of Subjective (correct)

    • What is included in the assessment section of a patient's documentation?

  • Chief complaint and history of present illness
  • Physical exam and images
  • Prescription and follow-up plans
  • Diagnosis and differential diagnoses (correct)

    • What is the main difference between a comprehensive and focused exam?

    <p>The purpose of the exam</p> Signup and view all the answers

    What type of patient would typically receive a focused exam?

    <p>An established patient with a specific chief complaint</p> Signup and view all the answers

    What is included in the plan section of a patient's documentation?

    <p>Prescription and follow-up plans</p> Signup and view all the answers

    What type of documentation is used in an emergency room setting?

    <p>Focused emergency documentation</p> Signup and view all the answers

    What is the primary goal of a focused exam?

    <p>To diagnose a specific chief complaint</p> Signup and view all the answers

    What is the main difference between a comprehensive and focused follow-up?

    <p>The purpose of the exam</p> Signup and view all the answers

    What is the primary purpose of a comprehensive H&P?

    <p>To establish a baseline for future visits and assessments</p> Signup and view all the answers

    Study Notes

    Cardiac System and Medical Documentation

    • A patient's denial of cardiac stents is documented in the History - Subjective section, under Chief Complaint and History of Present Illness (HPI).

    Medical Documentation Structure

    • Chief Complaint: patient's primary concern
    • History - Subjective: patient's reported information, including HPI, past medical history, and review of systems (ROS)
    • Objective: exam findings, laboratory results, and available images
    • Assessment: diagnosis, including primary and differential diagnoses
    • Plan: treatment plan, including prescriptions, imaging or diagnostic procedures, and follow-up care

    Types of Medical Encounters

    • Comprehensive History and Physical (H&P): most detailed and comprehensive, used for new patients or baseline assessments
    • Focused Encounter: established patient with a specific chief complaint, tailored exam and documentation
    • Focused Follow-up: established patient with a specific concern, follow-up visit
    • Focused Emergency: urgent visit, prioritizing acute concern over comprehensive assessment

    Comprehensive History and Physical (H&P)

    • Introductory Information: patient demographics, including gender, race, ethnicity, language, and accompaniment
    • Past Medical History: surgical, psychiatric, and developmental history, current medications, and current health conditions
    • Social, Occupational, and Family History: including genetic or hereditary risk factors (e.g., cardiac disease, psychiatric illness, cancer, hypertension, diabetes)

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    Description

    Quiz about evaluating and diagnosing cardiac conditions, including history taking, physical examination, and laboratory results. Test your knowledge of cardiac assessment and diagnosis.

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