THE MEDICAL SCRIBE CERTIFICATE
EXAMINATION QUESTIONS AND
ANSWERS
HPI - Answer-history of present illness
ROS - Answer-Review of Systems
PE - Answer-Physical Examination
A/P - Answer-assessment and planning
CC - Answer-Chief Complaint
Chief Complaint - Answer-statement or reason for the patient encounter
History of present illness - Answer-detailed description of development of the patients
present disease presented as a chronological story
Factors in a HPI - Answer-1. Location on body
2. Quality
3. Severity
4. Duration and Timing
5. Modifying Factors
6.Associated Symptoms
7. Context
8. Chief Complaint
Context - Answer-the situation around the chief complaint
Duration - Answer-how long the main complaint has been going on
Timing - Answer-"constant, coming and going"
Location - Answer-where on the body is the complaint
Quality - Answer-what the chief complaint feels like "dull sharp"
Severity - Answer-1-10 Scale
Modifying Factors - Answer-anything that makes the chief complaint better or worse
, Associated Symptoms - Answer-any symptoms described by the patient that are directly
related to the chief complaint
"no" - Answer-record as patient denies
Bowel Sounds - Answer-intestinal sounds heard from auscultating over the abdomen
Diffuse - Answer-generalized not localized
Distention - Answer-enlarged or swollen due to internal pressure
Femoral Pulse Deficit - Answer-pulse is either skipped or absent over the femoral artery
Gaurding - Answer-tensing of the abdominal wall muscles
Hepatomegaly - Answer-enlarged liver
Mass - Answer-any abd enlargement
McBurney’s Point - Answer-1/3 of the way from ASIS to the umbilicus (appendicitis)
Murphys Sign - Answer-Tests for tenderness of the gallbladder (cholecystitis)
Organomegaly - Answer-enlarged organ
Peritoneal Signs - Answer-rebound tenderness, guarding, indicates peritonitis
Prominent aortic pulsation - Answer-a larger than expected mass while palpating the
abd indicates aortic aneurysm
Psoas Sign - Answer-patient feels pain in the abd when rotating the hip indicates
appendicitis
Rebound - Answer-pain elicited by releasing the hand form the abd
Rigidity - Answer-a stiff abd wall discovered during exam
Rovsings Sign - Answer-pain in the RLQ upon palpation on the LLQ
Splenomegaly - Answer-Enlarged Spleen
Paraspinal - Answer-along the sides of the spine
Sciatica - Answer-compression or irritation of the sciatic nerve leading to back pain
straight led raise - Answer-physical exam testing for sciatica
EXAMINATION QUESTIONS AND
ANSWERS
HPI - Answer-history of present illness
ROS - Answer-Review of Systems
PE - Answer-Physical Examination
A/P - Answer-assessment and planning
CC - Answer-Chief Complaint
Chief Complaint - Answer-statement or reason for the patient encounter
History of present illness - Answer-detailed description of development of the patients
present disease presented as a chronological story
Factors in a HPI - Answer-1. Location on body
2. Quality
3. Severity
4. Duration and Timing
5. Modifying Factors
6.Associated Symptoms
7. Context
8. Chief Complaint
Context - Answer-the situation around the chief complaint
Duration - Answer-how long the main complaint has been going on
Timing - Answer-"constant, coming and going"
Location - Answer-where on the body is the complaint
Quality - Answer-what the chief complaint feels like "dull sharp"
Severity - Answer-1-10 Scale
Modifying Factors - Answer-anything that makes the chief complaint better or worse
, Associated Symptoms - Answer-any symptoms described by the patient that are directly
related to the chief complaint
"no" - Answer-record as patient denies
Bowel Sounds - Answer-intestinal sounds heard from auscultating over the abdomen
Diffuse - Answer-generalized not localized
Distention - Answer-enlarged or swollen due to internal pressure
Femoral Pulse Deficit - Answer-pulse is either skipped or absent over the femoral artery
Gaurding - Answer-tensing of the abdominal wall muscles
Hepatomegaly - Answer-enlarged liver
Mass - Answer-any abd enlargement
McBurney’s Point - Answer-1/3 of the way from ASIS to the umbilicus (appendicitis)
Murphys Sign - Answer-Tests for tenderness of the gallbladder (cholecystitis)
Organomegaly - Answer-enlarged organ
Peritoneal Signs - Answer-rebound tenderness, guarding, indicates peritonitis
Prominent aortic pulsation - Answer-a larger than expected mass while palpating the
abd indicates aortic aneurysm
Psoas Sign - Answer-patient feels pain in the abd when rotating the hip indicates
appendicitis
Rebound - Answer-pain elicited by releasing the hand form the abd
Rigidity - Answer-a stiff abd wall discovered during exam
Rovsings Sign - Answer-pain in the RLQ upon palpation on the LLQ
Splenomegaly - Answer-Enlarged Spleen
Paraspinal - Answer-along the sides of the spine
Sciatica - Answer-compression or irritation of the sciatic nerve leading to back pain
straight led raise - Answer-physical exam testing for sciatica
