Medical Scribe- Final Exam QUESTIONS
AND WELL VERIFIED ANSWERS
What are the 5 vital signs? - ANSWER>>1. Heart rate
2. Blood pressure
3. Respiratory rate
4. Temperature
5. Oxygen saturation
The HPI and the ROS are what type of information? - ANSWER>>
The physical exam is what kind of information? - ANSWER>>
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? -
ANSWER>>Physical exam
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? - ANSWER>>No, because the patient stating that
they have abdominal pain is a subjective complaint. A non-tender abdomen is an
objective finding.
What is the difference between the HPI, and the ROS? - ANSWER>>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.
What does disposition (dispo) mean? - ANSWER>>The patient's destination after
they leave the ED.
, What subcategories are included within the past history section of the template?
- ANSWER>>PMHx: Past medical history- HTN, DM, HLD, CAD, MI
PSHx: Past surgical history- appendectomy, cholecystectomy, CABG
FHx: Family history- Hx of CAD<55 years old
SHx: Social history- ETOH, smoking, drug abuse, occupation
What is the abbrieviation for heart attack? - ANSWER>>MI- myocardial infarction
What is the abbreviation for high blood pressure? - ANSWER>>HTN- hypertension
What is the medical term for acid reflux? - ANSWER>>Gastroesophageal reflux
disease
What is the medical term for stroke? - ANSWER>>CVA- cerebral vascular accident
What is the term for gallbladder removal? - ANSWER>>Cholecystectomy
What does NKDA stand for? - ANSWER>>No know drug allergies
What is the medical term for redness? - ANSWER>>Erythema
What is the medical term for bruising? - ANSWER>>Ecchymosis
If the doctor says the exam was "benign", what does that mean? -
ANSWER>>Normal- nothing of concern
What is CAD? - ANSWER>>coronary artery disease
What other past histories would suggest that a patient has CAD? - ANSWER>>MI,
angina, CABG, stent, angioplasty
Does a PMHx of CVA mean the patient has CAD? - ANSWER>>No
AND WELL VERIFIED ANSWERS
What are the 5 vital signs? - ANSWER>>1. Heart rate
2. Blood pressure
3. Respiratory rate
4. Temperature
5. Oxygen saturation
The HPI and the ROS are what type of information? - ANSWER>>
The physical exam is what kind of information? - ANSWER>>
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? -
ANSWER>>Physical exam
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? - ANSWER>>No, because the patient stating that
they have abdominal pain is a subjective complaint. A non-tender abdomen is an
objective finding.
What is the difference between the HPI, and the ROS? - ANSWER>>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.
What does disposition (dispo) mean? - ANSWER>>The patient's destination after
they leave the ED.
, What subcategories are included within the past history section of the template?
- ANSWER>>PMHx: Past medical history- HTN, DM, HLD, CAD, MI
PSHx: Past surgical history- appendectomy, cholecystectomy, CABG
FHx: Family history- Hx of CAD<55 years old
SHx: Social history- ETOH, smoking, drug abuse, occupation
What is the abbrieviation for heart attack? - ANSWER>>MI- myocardial infarction
What is the abbreviation for high blood pressure? - ANSWER>>HTN- hypertension
What is the medical term for acid reflux? - ANSWER>>Gastroesophageal reflux
disease
What is the medical term for stroke? - ANSWER>>CVA- cerebral vascular accident
What is the term for gallbladder removal? - ANSWER>>Cholecystectomy
What does NKDA stand for? - ANSWER>>No know drug allergies
What is the medical term for redness? - ANSWER>>Erythema
What is the medical term for bruising? - ANSWER>>Ecchymosis
If the doctor says the exam was "benign", what does that mean? -
ANSWER>>Normal- nothing of concern
What is CAD? - ANSWER>>coronary artery disease
What other past histories would suggest that a patient has CAD? - ANSWER>>MI,
angina, CABG, stent, angioplasty
Does a PMHx of CVA mean the patient has CAD? - ANSWER>>No
