Medical Scribe Final Exam Review QUESTIONS &
ANSWERS (VERIFIED) __ LATEST UPDATE!!
In your own words, describe the significance of an HPI ✅✅ (Correct)- 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? ✅✅ (Correct)- 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 ✅✅ (Correct)- Onset, timing, location, quality,
severity, modifying factors, associated symptoms, context
Name eight of the body systems included in the ROS. ✅✅ (Correct)-
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? ✅✅ (Correct)- 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? ✅✅ (Correct)- "HPI/ROS
limited by..."
,Identify the error in this sentence from an example HPI: "Patient states the CP has been
intermittent since Thursday." ✅✅ (Correct)- 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? ✅✅ (Correct)- 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. ✅✅ (Correct)- What symptoms prompted the
prior evaluation? How long ago did the prior evaluation occur?
Do any patient complaints belong in the physical exam? ✅✅ (Correct)- No
If a patient says their abdomen feels very painful, can you automatically document
"abdominal tenderness" in the physical exam? Why or why not? ✅✅ (Correct)-
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 ✅✅ (Correct)- A. No respiratory distress
What does PERRL stand for? ✅✅ (Correct)- Pupils are equal, round, and
reactive to light
What does AT/NC mean? ✅✅ (Correct)- Atraumatic/Normocephalic
,What does NAD stand for? ✅✅ (Correct)- No acute distress/disease
If a patient has pale conjunctiva, what does that indicate? ✅✅ (Correct)- Anemia
What is scleral icterus, and what does it indicate? ✅✅ (Correct)- Yellowing of the
eyes, indicates liver failure
In which body system would you document "TM erythema and bulging?" ✅✅
(Correct)- Ears
What is the medical term for nostril? ✅✅ (Correct)- Naris (both nostrils is nares)
To describe a "runny nose" would the doctor use the word "epistaxis" or "rhinorrhea"?
✅✅ (Correct)- Rhinorrhea
What would dry mucous membranes indicate? ✅✅ (Correct)- Dehydration
Why is midline bony tenderness "worse" than paraspinal tenderness? ✅✅ (Correct)-
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.
If you saw "RRR" written in the cardiac exam, what do you think it might mean? ✅✅
(Correct)- Regular Rate and Rhythm
, BBB ✅✅ (Correct)- Bundle Branch Block
AAA ✅✅ (Correct)- Abdominal aortic aneurysm
Distress ✅✅ (Correct)- The doctor's judgement of discomfort
ABG ✅✅ (Correct)- Arterial blood pressure
BiPAP ✅✅ (Correct)- Bilevel Positive Airway Pressure
Acute ✅✅ (Correct)- New onset, likely concerning
ACLS ✅✅ (Correct)- Advanced Cardiac Life Support
AICD ✅✅ (Correct)- Automated Implanted Cardiac Defibrillator
ALS ✅✅ (Correct)- Advanced Life Support
BLS ✅✅ (Correct)- Bilevel positive airway pressure
APGAR ✅✅ (Correct)- Appearance, pulse, grimace, activity, respiration
ARF ✅✅ (Correct)- Acute renal failure
ANSWERS (VERIFIED) __ LATEST UPDATE!!
In your own words, describe the significance of an HPI ✅✅ (Correct)- 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? ✅✅ (Correct)- 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 ✅✅ (Correct)- Onset, timing, location, quality,
severity, modifying factors, associated symptoms, context
Name eight of the body systems included in the ROS. ✅✅ (Correct)-
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? ✅✅ (Correct)- 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? ✅✅ (Correct)- "HPI/ROS
limited by..."
,Identify the error in this sentence from an example HPI: "Patient states the CP has been
intermittent since Thursday." ✅✅ (Correct)- 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? ✅✅ (Correct)- 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. ✅✅ (Correct)- What symptoms prompted the
prior evaluation? How long ago did the prior evaluation occur?
Do any patient complaints belong in the physical exam? ✅✅ (Correct)- No
If a patient says their abdomen feels very painful, can you automatically document
"abdominal tenderness" in the physical exam? Why or why not? ✅✅ (Correct)-
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 ✅✅ (Correct)- A. No respiratory distress
What does PERRL stand for? ✅✅ (Correct)- Pupils are equal, round, and
reactive to light
What does AT/NC mean? ✅✅ (Correct)- Atraumatic/Normocephalic
,What does NAD stand for? ✅✅ (Correct)- No acute distress/disease
If a patient has pale conjunctiva, what does that indicate? ✅✅ (Correct)- Anemia
What is scleral icterus, and what does it indicate? ✅✅ (Correct)- Yellowing of the
eyes, indicates liver failure
In which body system would you document "TM erythema and bulging?" ✅✅
(Correct)- Ears
What is the medical term for nostril? ✅✅ (Correct)- Naris (both nostrils is nares)
To describe a "runny nose" would the doctor use the word "epistaxis" or "rhinorrhea"?
✅✅ (Correct)- Rhinorrhea
What would dry mucous membranes indicate? ✅✅ (Correct)- Dehydration
Why is midline bony tenderness "worse" than paraspinal tenderness? ✅✅ (Correct)-
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.
If you saw "RRR" written in the cardiac exam, what do you think it might mean? ✅✅
(Correct)- Regular Rate and Rhythm
, BBB ✅✅ (Correct)- Bundle Branch Block
AAA ✅✅ (Correct)- Abdominal aortic aneurysm
Distress ✅✅ (Correct)- The doctor's judgement of discomfort
ABG ✅✅ (Correct)- Arterial blood pressure
BiPAP ✅✅ (Correct)- Bilevel Positive Airway Pressure
Acute ✅✅ (Correct)- New onset, likely concerning
ACLS ✅✅ (Correct)- Advanced Cardiac Life Support
AICD ✅✅ (Correct)- Automated Implanted Cardiac Defibrillator
ALS ✅✅ (Correct)- Advanced Life Support
BLS ✅✅ (Correct)- Bilevel positive airway pressure
APGAR ✅✅ (Correct)- Appearance, pulse, grimace, activity, respiration
ARF ✅✅ (Correct)- Acute renal failure
