ScribeAmerica ED Final Exam Prep. Completely
Solved
What does ROS stand for? - ANSWER-Review of Systems
The HPI and ROS are considered what type of information? - ANSWER-Subjective
The physical exam (PE) is what type of information? - ANSWER-Objective
If a physician told you a patient's abdomen was nontender or the patient's skin was
pale, where would you document these pieces of information? - ANSWER-Physcal
Exam (PE)
What section focuses directly on the chief complaint? - ANSWER-History of Present
Illness (HPI)
What are the five vital signs? - ANSWER-Heart Rate (HR)
Blood Pressure (BP)
Respiratory Rate (RR)
Temperature (T)
Oxygen Saturation (SpO2)
Name an example of something you might write in the Surgical Hx portion of the chart. -
ANSWER-tonsillectomy - removal of tonsills
adenoidectomy - removal of adenoids
pressure equalizer (P.E.) tubes - ear tubes
coronary artery bypass graft (CABG) - heart bypass
mastectomy - removal of breasts
appendectomy - appendix removed
cholecystectomy - gallbladder removed
nephrectomy - kidney removed
hysterectomy - uterus removed
oophorectomy - ovary removed
prostatectomy - prostate removed
, Name an example of something you may write in the Social Hx portion of the chart. -
ANSWER-tobacco use - smokes 1 ppd
alcohol use (ETOH) - occasional use
illicit drug use - heroine
occupation - construction
living circumstances - senior living center
Name an example of something you may write in the Family Hx portion of the chart. -
ANSWER-general - Hypertension (HTN); Diabetes Mellitus (DM); Cancer/Carcinoma
(CA)
cardiac - MI/CAD less than 55 y/o
pulmonary - PE; asthma
gastrointestinal - Crohn's Disease; Irritable Bowel Syndrome (IBS)
neurological - CVA; aneurysm; seizures
miscellaneous - Sickle Cell Anemia; DVT
What are the medical terms for the following PSHx?
removal of the appendix
removal of the gallbladder
removal of the uterus
removal of the tonsils - ANSWER-appendectomy
cholecystectomy
hysterectomy
tonsillectemy
What are the two types of heart attacks and how are they diagnosed? - ANSWER-
STEMI (EKG) and non-STEMI (Troponin)
What are three cardiac risk factors? - ANSWER-HTN, CAD, HLD, DM, Smoking, FHx
Chest pain, dyspnea, cough, and fever correlate to which DDx? And which study would
be ordered? - ANSWER-Pneumonia (PNA) and CXR
What are three symptoms a patient with an Ischemic CVA would present with? -
ANSWER-one sided weakness/numbness, speech changes, vision changes
What heart rhythm would a physician hear if the patient were in atrial fibrillation and how
is this disease diagnosed? - ANSWER-AFib and EKG
Solved
What does ROS stand for? - ANSWER-Review of Systems
The HPI and ROS are considered what type of information? - ANSWER-Subjective
The physical exam (PE) is what type of information? - ANSWER-Objective
If a physician told you a patient's abdomen was nontender or the patient's skin was
pale, where would you document these pieces of information? - ANSWER-Physcal
Exam (PE)
What section focuses directly on the chief complaint? - ANSWER-History of Present
Illness (HPI)
What are the five vital signs? - ANSWER-Heart Rate (HR)
Blood Pressure (BP)
Respiratory Rate (RR)
Temperature (T)
Oxygen Saturation (SpO2)
Name an example of something you might write in the Surgical Hx portion of the chart. -
ANSWER-tonsillectomy - removal of tonsills
adenoidectomy - removal of adenoids
pressure equalizer (P.E.) tubes - ear tubes
coronary artery bypass graft (CABG) - heart bypass
mastectomy - removal of breasts
appendectomy - appendix removed
cholecystectomy - gallbladder removed
nephrectomy - kidney removed
hysterectomy - uterus removed
oophorectomy - ovary removed
prostatectomy - prostate removed
, Name an example of something you may write in the Social Hx portion of the chart. -
ANSWER-tobacco use - smokes 1 ppd
alcohol use (ETOH) - occasional use
illicit drug use - heroine
occupation - construction
living circumstances - senior living center
Name an example of something you may write in the Family Hx portion of the chart. -
ANSWER-general - Hypertension (HTN); Diabetes Mellitus (DM); Cancer/Carcinoma
(CA)
cardiac - MI/CAD less than 55 y/o
pulmonary - PE; asthma
gastrointestinal - Crohn's Disease; Irritable Bowel Syndrome (IBS)
neurological - CVA; aneurysm; seizures
miscellaneous - Sickle Cell Anemia; DVT
What are the medical terms for the following PSHx?
removal of the appendix
removal of the gallbladder
removal of the uterus
removal of the tonsils - ANSWER-appendectomy
cholecystectomy
hysterectomy
tonsillectemy
What are the two types of heart attacks and how are they diagnosed? - ANSWER-
STEMI (EKG) and non-STEMI (Troponin)
What are three cardiac risk factors? - ANSWER-HTN, CAD, HLD, DM, Smoking, FHx
Chest pain, dyspnea, cough, and fever correlate to which DDx? And which study would
be ordered? - ANSWER-Pneumonia (PNA) and CXR
What are three symptoms a patient with an Ischemic CVA would present with? -
ANSWER-one sided weakness/numbness, speech changes, vision changes
What heart rhythm would a physician hear if the patient were in atrial fibrillation and how
is this disease diagnosed? - ANSWER-AFib and EKG
