Medical Scribe- Final exam review questions and answers

Medical Scribe- Final exam review questions and answers 1 / 9 1. What are the 5 vital signs?: 1. Heart rate 2. Blood pressure 3. Respiratory rate 4. Temperature 5. Oxygen saturation 2. The HPI and the ROS are what type of information?: 3. The physical exam is what kind of information?: 4. While evaluating a patient complaining of chest pain, your physician tells you that the heart sounds are normal. Would you document this in the HPI, ROS, or PE?: Physical exam 5. Would you be contradicting yourself if you wrote, " the patient has abdominal pain", in the HPI, but then later in the physical exam documented, "the abdomen is non-tender", why or why not?: No, because the patient stating that they have abdominal pain is a subjective complaint. A non-tender abdomen is an objective finding. 6. What is the difference between the HPI, and the ROS?: HPI focuses on the details related to their chief complaint, ROS is a head to toe checklist of symptoms. It includes the chief complaint, associated symptoms, and all other complaints the patient may have. 7. What does disposition (dispo) mean?: The patient's destination after they leave the ED. 8. What subcategories are included within the past history section of the template?: PMHx: Past medical history- HTN, DM, HLD, CAD, MI PSHx: Past surgical history- appendectomy, cholecystectomy, CABG FHx: Family history- Hx of CAD55 years old SHx: Social history- ETOH, smoking, drug abuse, occupation 9. What is the abbrieviation for heart attack?: MI- myocardial infarction 10. What is the abbreviation for high blood pressure?: HTN- hypertension 11. What is the medical term for acid reflux?: Gastroesophageal reflux disease 12. What is the medical term for stroke?: CVA- cerebral vascular accident 13. What is the term for gallbladder removal?: Cholecystectomy 14. What does NKDA stand for?: No know drug allergies 15. What is the medical term for redness?: Erythema 16. What is the medical term for bruising?: Ecchymosis