Complete Questions And Correct Detailed Answers
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Variables of HPI (History of Present Illness)
- ans -1. Timing
2. Location
3. Quality (e.g., aching, sharp, dull, heavy)
4. Quantity (Pain scale)
5. Setting
6. Alleviating/Aggravating Factors
7. Associated Manifestations (What effects does the px have on sleep, strength,
work, weight, appetite, and activities of daily living?)
8. Attributions (What does the pt think it's caused by? Afraid of?)
Brief HPI: - ans -o Focuses on a concise summary of the presenting problem and
major symptoms.
o Suitable for straightforward cases or follow-up visits.
Extended HPI - ans -10 or more systems reviewed
o Provides a detailed account of the history, including multiple symptoms, their
context, and impact on the patient's life.
o Appropriate for complex cases or initial evaluations.
4 general principles of Medical Record Documentation
- ans -1. Accuracy: Ensure all entries are correct and factual.
2. Legibility: Documentation should be readable and clear.
3. Relevance: Include information pertinent to patient care and decision-making.
4. Confidentiality: Maintain patient privacy and secure record access.
CAGE questionnaire to assess what? - ans -ETOH consumption
What does CAGE (ETOH) stand for? - ans -C- cut down
A- annoyed
G- guilty
E- eye opener