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