SCRIBE EXAM QUESTIONS AND
ANSWERS
SOAP - Answer-Subjective-HPI, ROS, Past Med, Fam, and Social Hx (Patient's point of
view)
Objective-Physical exam, Medical Decision Making (labs, x-rays, etc.)
Assessment-Diagnosis (determined by combining subjective/objective info)
Plan-Disposition (Admission, Discharge, Transfer instructions)
7 Parts of the HPI - Answer-1. Context
2. Time/Duration; time = course of symptoms (improving, worsening, constant,
intermittent, etc.); duration = total time symptoms have been present
3. Location
4. Quality
5. Severity
6. Modifying Factors
7. Pertinent positive and negatives
Level 5 Chart - Answer-HPI: 4-7
ROS: 10+
PFSH: 2+
PEx: 8+ systems
Supination - Answer-Turning the hand so that the palm faces upward.
Volar - Answer-Pertaining to the palm of the hand or the sole of the foot.
Inferior - Answer-Situated below or further away from the head.
Midline - Answer-Line that divides the body into right and left halves.
Abduction - Answer-Moving away from the midline.
ACLS - Answer-Advanced cardiac life support.
AMA - Answer-Against medical advice.
DNR - Answer-do not resuscitate
DOA - Answer-Dead on arrival
OSH - Answer-Outside hospital
PCP - Answer-Primary care physician
,PTA - Answer-Prior to arrival
UTD - Answer-Up to date (as in immunizations)
WNL - Answer-within normal limits
yo - Answer-year old
B/L - Answer-bilateral
D/C - Answer-discharge
H&P - Answer-history & physical
nl - Answer-normal
s/p - Answer-status post
TTP - Answer-tenderness to palpation
Proximal - Answer-closer to the body
Lateral - Answer-farther from the midline
Extension - Answer-straightening out
Distal - Answer-farther from the body
Adduction - Answer-Draws toward the midline
Pronation - Answer-turning of the hand so the palm faces downward
Posterior - Answer-situated behind or directed towards the rear
Plantar - Answer-referring to the sole of the foot
Inverted - Answer-turned inward
Deep - Answer-Farther from the surface
Flexion - Answer-bending or angulation
Percussion - Answer-physician taps on a surface to determine the underlying structure
, Auscultation - Answer-Physician listens to the internal sounds of the body using a
stethoscope
Organomegaly - Answer-Enlargement of organs
Palpation - Answer-Physician feels the different parts of the body
Idiopathic - Answer-no known cause
Necrosis - Answer-Premature death of cells in living tissue
Ostomy - Answer-surgically created opening connecting an internal organ to the surface
of the body
Infarct - Answer-Tissue death caused by a local lack of oxygen due to obstruction of the
tissue's blood supply
Stenosis - Answer-narrowing of a body opening or passage
Ischemia - Answer-Decrease in the blood supply to a bodily organ, tissue, or part
caused by constriction or obstruction of the blood vessels
Ambulatory - Answer-Able to walk about, not confined to bed
Febrile - Answer-having a fever
Post-prandial - Answer-after eating
Cachectic - Answer-Malnutritioned, wasting, or in poor health
Orthostatic - Answer-vital signs taken sitting, standing, and supine
Polydipsia - Answer-excessive thirst
A&W - Answer-alive and well
NAD - Answer-no acute distress
WDWN - Answer-well-developed, well-nourished
CA - Answer-cancer
MRSA - Answer-methycillin resistant staphylococcus aureus; one strain of the
staphylococcus bacteria that is resistant to medications conventionally used to treat it
ANSWERS
SOAP - Answer-Subjective-HPI, ROS, Past Med, Fam, and Social Hx (Patient's point of
view)
Objective-Physical exam, Medical Decision Making (labs, x-rays, etc.)
Assessment-Diagnosis (determined by combining subjective/objective info)
Plan-Disposition (Admission, Discharge, Transfer instructions)
7 Parts of the HPI - Answer-1. Context
2. Time/Duration; time = course of symptoms (improving, worsening, constant,
intermittent, etc.); duration = total time symptoms have been present
3. Location
4. Quality
5. Severity
6. Modifying Factors
7. Pertinent positive and negatives
Level 5 Chart - Answer-HPI: 4-7
ROS: 10+
PFSH: 2+
PEx: 8+ systems
Supination - Answer-Turning the hand so that the palm faces upward.
Volar - Answer-Pertaining to the palm of the hand or the sole of the foot.
Inferior - Answer-Situated below or further away from the head.
Midline - Answer-Line that divides the body into right and left halves.
Abduction - Answer-Moving away from the midline.
ACLS - Answer-Advanced cardiac life support.
AMA - Answer-Against medical advice.
DNR - Answer-do not resuscitate
DOA - Answer-Dead on arrival
OSH - Answer-Outside hospital
PCP - Answer-Primary care physician
,PTA - Answer-Prior to arrival
UTD - Answer-Up to date (as in immunizations)
WNL - Answer-within normal limits
yo - Answer-year old
B/L - Answer-bilateral
D/C - Answer-discharge
H&P - Answer-history & physical
nl - Answer-normal
s/p - Answer-status post
TTP - Answer-tenderness to palpation
Proximal - Answer-closer to the body
Lateral - Answer-farther from the midline
Extension - Answer-straightening out
Distal - Answer-farther from the body
Adduction - Answer-Draws toward the midline
Pronation - Answer-turning of the hand so the palm faces downward
Posterior - Answer-situated behind or directed towards the rear
Plantar - Answer-referring to the sole of the foot
Inverted - Answer-turned inward
Deep - Answer-Farther from the surface
Flexion - Answer-bending or angulation
Percussion - Answer-physician taps on a surface to determine the underlying structure
, Auscultation - Answer-Physician listens to the internal sounds of the body using a
stethoscope
Organomegaly - Answer-Enlargement of organs
Palpation - Answer-Physician feels the different parts of the body
Idiopathic - Answer-no known cause
Necrosis - Answer-Premature death of cells in living tissue
Ostomy - Answer-surgically created opening connecting an internal organ to the surface
of the body
Infarct - Answer-Tissue death caused by a local lack of oxygen due to obstruction of the
tissue's blood supply
Stenosis - Answer-narrowing of a body opening or passage
Ischemia - Answer-Decrease in the blood supply to a bodily organ, tissue, or part
caused by constriction or obstruction of the blood vessels
Ambulatory - Answer-Able to walk about, not confined to bed
Febrile - Answer-having a fever
Post-prandial - Answer-after eating
Cachectic - Answer-Malnutritioned, wasting, or in poor health
Orthostatic - Answer-vital signs taken sitting, standing, and supine
Polydipsia - Answer-excessive thirst
A&W - Answer-alive and well
NAD - Answer-no acute distress
WDWN - Answer-well-developed, well-nourished
CA - Answer-cancer
MRSA - Answer-methycillin resistant staphylococcus aureus; one strain of the
staphylococcus bacteria that is resistant to medications conventionally used to treat it
