Medical Scribe Final Exam Review | 437 Questions With 100% Correct Answers.

In your own words, describe the significance of an HPI - The HPI is the story of the symptoms and events that led to the patient's ED visit. It includes the CC and the associated sx. How is the HPI different from the ROS? - The HPI focus is a story about the chief complaint and its associated symptoms. ROS is a checklist of symptoms. It includes the chief complaint, associated symptoms, and all other complaints the pt may have. Name five "elements" of the HPI - Onset, timing, location, quality, severity, modifying factors, associated symptoms, context Name eight of the body systems included in the ROS. - Constitutional, eyes, ENT, CV, Resp, GI, GU, MS, skin, neuro, psych, endocrine, heme/lymph, immunological Can the symptoms listed in the ROS ever contradict the symptoms described in the HPI? Why or why not? - No. Symptoms that are documented in the HPI also need to be documented in the ROS. What do you need to remember to document in the HPI and ROS for any patient that is unconscious or incapable of providing information? - "HPI/ROS limited by..." Identify the error in this sentence from an example HPI: "Patient states the CP has been intermittent since Thursday." - We do not document days of the week in the HPI. Instead, we would count back the number of days and document this numerically. Why is it important to remember to document if the patient has had similar symptoms in the past? - Because it is less likely that their current symptoms are life threatening if the have survived similar symptoms in the past. Name one detail that is important to document if the patient has been evaluated in the past for a similar complaint. - What symptoms prompted the prior evaluation? How long ago did the prior evaluation occur?Do any patient complaints belong in the physical exam? - No If a patient says their abdomen feels very painful, can you automatically document "abdominal tenderness" in the physical exam? Why or why not? -No. Subjective vs. objective Which of these two physical exam findings could a physician appreciate without auscultating the patient's lungs: A. No respiratory distress B. No rales - A. No respiratory distress What does PERRL stand for? - Pupils are equal, round, and reactive to light What does AT/NC mean? - Atraumatic/Normocephalic What does NAD stand for? - No acute distress/disease If a patient has pale conjunctiva, what does that indicate? - Anemia What is scleral icterus, and what does it indicate? - Yellowing of the eyes, indicates liver failure In which body system would you document "TM erythema and bulging?" - Ears What is the medical term for nostril? - Naris (both nostrils is nares) To describe a "runny nose" would the doctor use the word "epistaxis" or "rhinorrhea"? - Rhinorrhea What would dry mucous membranes indicate? - DehydrationWhy is midline bony tenderness "worse" than paraspinal tenderness? - Bony tenderness (aka vertebral point tenderness) points towards a spinal fracture and therefore concern for spinal cord injury. Paraspinal tenderness points toward a muscle spasm or strain.