questions & Answers
What does HPI stand for? - ANSWER-history of present illness
ROS stands for - ANSWER-review of systems
What section focuses directly on the chief complaint? - ANSWER-HPI
Write the full medical term for the following past medical history term:
High blood pressure - ANSWER-Hypertension
Write the full medical term for the following past medical history term:
Diabetes - ANSWER-Diabetes mellitus
Write the full medical term for the following past medical history term:
heart attack - ANSWER-Myocardial infarction
Removal of the gallbladder - ANSWER-cholecystectomy
Removal of the uterus - ANSWER-hysterectomy
Removal of the breast - ANSWER-mastectomy
Removal of the tonsils - ANSWER-tonsillectomy
Removal of the appendix - ANSWER-appendectomy
Which of the following are not considered vital signs? - ANSWER-I&O
Height and weight
HPI and ROS are considered what type of information? - ANSWER-subjective
If a physician told you "the patient has no respiratory distress", where would you
document this? - ANSWER-PE
Which of the following are considered cardiac risk factors? Select all that apply. -
ANSWER-PHX of : Angioplasty with 2 stents
smoking 2 cigars a day
HTN, HLD, DM
MI at 42 years
, CABG
A 70 year old female has a history of a large Aortic Aneurysm and is complaining of a
tearing pain that radiates to her back. What life-threatening diagnosis is at the top of
your DDx? - ANSWER-aortic dissection
Patient was admitted with bilateral pedal edema and also exhibited symptoms such as
dyspnea on exertion (DOE), orthopnea, and paroxysmal nocturnal dyspnea (PND). ED
workup included elevated B-type Natriuretic Peptide and CXR showing enlarged cardiac
silhouette.
What DDx are we investigating? - ANSWER-Chf
An 18 year old female on Birth Control Pills (BCP's) complains of LLE pain and swelling
since this morning. During the physical exam, the patient suddenly feels SOB and has
pain when breathing. What is the most likely cause of her new symptoms? - ANSWER-
DVT traveled to the lung causing a PE
A 26 year old male with a history of Paroxysmal Afib presents with constant palpitations
that began 1 hour ago. Select an answer below for both the rhythm your physician is
likely to describe hearing on exam as well as the test/order that would likely follow. -
ANSWER-Irregularly Irregular Rhythm
ECG/EKG
Acute chest pressure with shortness of breath, diaphoresis, nausea, and vomiting.: -
ANSWER-Myocardial infarction
Cough, SOB, and fever: - ANSWER-pneumonia
SOB with a 30-year history of smoking: - ANSWER-chronic obstructive pulmonary
disease
Burning epigastric pain that is often exacerbated with ingestion of more acidic foods: -
ANSWER-gastroesophageal reflux disease
All of the following statements are true regarding your workflow as an Inpatient Scribe
except: - ANSWER-You are able to assist in minor procedures, with the physician and
patient's approval
A 45 year old patient states they had a heart attack in 2015. He mentions his brother
and father were both diagnosed with CAD <55 years old. He does smoke cigarettes
daily (1ppd) and drinks alcohol socially on the weekends. He had his appendix removed
in 2008.
Based on this information, which categories of history are represented? - ANSWER-
Medical
Surgical