SCRIBE FINAL EXAM ED QUESTIONS
AND ANSWERS
What does ROS stand for? - Answer-Review of Systems
The HPI and ROS are considered what type of information? - Answer-Subjective
The physical exam is what type of information? - Answer-Objective
If a physician told you a patient's abdomen was non-tender or the patient's skin was
pale, where would you document these piece of information? - Answer-Physical Exam
(PE)
What section focuses directly on the chief complaint? - Answer-HPI
What are the five vital signs? - Answer-Temperature (T), Blood Pressure (BP), Heart
Rate (HR), Respiratory Rate(RR), Peripheral Capillary Oxygen Saturation (spo2)
Name an example of something you may write in the Surgical Hx portion of the chart. -
Answer-A surgery they've had in the past. Ex: Appendectomy, Knee Repair.
Name an example of something you may write in the Social Hx portion of the chart. -
Answer-A social aspect of their life, Ex: smoker 1 pack per day (PPD), drinks etOH,
their occupation
Name an example of something you may write in the Family Hx portion of the chart. -
Answer-If one of their relatives has had a Dz. Ex: sister has DM was diagnosed at 12,
What are the medical terms for the following past medical surgical terms?
Removal of the appendix - Answer-Appendectomy
What are the medical terms for the following past medical surgical terms?
Removal of the gallbladder - Answer-Cholecystectomy
What are the medical terms for the following past medical surgical terms?
Removal of the uterus - Answer-Hysterectomy
What are the medical terms for the following past medical surgical terms?
Removal of the tonsils - Answer-Tonsillectomy
What are the two types of heart attacks and how are they diagnosed? - Answer-STEMI,
and a Non-STEMI
STEMI is Dx by EKG
Non-STEMI is Dx by Trop (Troponin)
,What are three cardiac risk factors? - Answer-CAD, HTN, HLD, DM, Smoking, FHx
Chest pain, dyspnea, cough, and fever correlate to which DDx? And what study would
be ordered? - Answer-Pneumonia, CXR would be ordered
What are three symptoms a patient with an Ischemic CVA would present with? -
Answer-One sided weakness/numbness, speech changes, vision changes.
What heart rhythm would a physician hear if the patient were in atrial fibrillation and how
is this disease diagnosed? - Answer-Afib, and this Dz is diagnosed with an EKG
What physical exam finding is associated with cholecystitis? - Answer-RUQ tenderness
and/or Murphy's sign
How is altered mental status different from a focal neurological deficit? What is the
major cause of AMS in the elderly? - Answer-AMS consists of confusion, lethargy,
unresponsiveness it occurs when the WHOLE brain is affected. FND consists pf one
sided weakness/numbness, speech changes, vision changes it occurs when a
smaller/localized area in the brain is affected. A UTI is the common cause of AMS in the
elderly.
What is "layman's name" for GERD? - Answer-Heartburn, indigestion, acid reflux.
What is the most common cause for seizures in children? - Answer-Fever
What is one medication that is used as a vasodilator? Bronchodilator? - Answer-NTG
(nitroglycerin), Nebulizers/inhalers
In your own words, describe the significance of an HPI. - Answer-HPI consists of the
CC, and why the pt was brought into the ED. The story according to the pt.
Imagine a patient with the CC of a headache. Name five elements of the HPI and
provide an applicable example of each element. - Answer-CC: Headache
Onset: 3 hrs ago (when it began)
Location: Left temple (where it's located)
Timing: Constant
Severity: 8/10 (how bad the pain is)
extra elements:
Quality: Pressure
Modifying factors: Worse with light, and better with aceteminophen
Context: Doesn't take blood thinners, no recent head injuries, Hx of similar HA
True or False: The patient's entire ED visit is based on their answers to the questions
asked during the interview. - Answer-True
,True or False: Accurate chronology is not important in an HPI. - Answer-False
What is the main difference between an HPI and an ROS? - Answer-HPI focuses on the
CC, its surrounding context, and associated symptoms. The ROS strictly documents the
presence of absence of all symptoms reviewed by the physician.
True or False: The symptoms listed in the ROS can contradict the symptoms discussed
in the HPI. - Answer-False
How would you document the GPA for a patient who is currently pregnant, has been
pregnant 4 times in the past, and has one child at home? - Answer-G:5/P:1/Ab:3
G: # of times she's been pregnant
P: how many kids she has at home
Ab: # of abortions/miscarriages
List five body systems found in the ROS and provide two symptoms for each system. -
Answer-General: fever, chills, weight loss
Cardio: chest pain, palpitations
Resp: cough, SOB, wheezing
Neuro: headache, seizure, numbness
Skin: rashes, itching, redness
Psych: anxiety, hallucinations, depression
Read the paragraph below and determine the following for the HPI:
Gertrud Ramia is an 80 y/o female with history of asthma presenting to the ED with
worsening wheezing that started 4 days. The patient says feels like she cannot take a
full breath similar to her previous asthma exacerbations, but albuterol inhalers have not
provided relief. She reports dyspnea and a mild dry cough since last night, but no fever,
chest pain, leg pain, leg swelling, or recent travel. The patient was unable to walk to her
bathroom this afternoon secondary to her dyspnea, prompting the 911 call. When
paramedics arrived to the patient's home 30 minutes ago, tight expiratory wheezes in all
field were appreciated and the patient's SpO2 was 92% on RA. The patient received a
DuoNeb breathing treatment and Solumedrol 125 mg en route to the ED, with mild
symptom relief.
CC:
Onset:
Timing:
Location:
Quality:
Severity:
Modifying factors: - Answer-CC: Wheezing
Onset: 4 days ago
Timing: worsening
Location: not stated
, Quality: "cannot take a full breath"
Severity: not stated
Modifying factors: no relief with home inhaler, improved with DuoNeb and Solumedrol
Associated sx: dyspnea and dry cough
Pertinent negatives: no fever, chest pain, leg pain/swelling, no recent travel
Context: Hx of asthma, similar to asthma, EMS report (VS en route, medications given,
response to Tx)
What do you write on the chart if the doctor states, "The pulses are weak" after
checking the patient's pulse near the left groin. - Answer-1+ left femoral pulse
What organs are in the following quadrants: epigastrium? LUQ? LLQ? - Answer-
Epigastrium: stomach. LUQ: pancreas. LLQ: large intestine, ovary.
What does EOMI stand for? - Answer-Extra-ocular Movements Intact
Where would you document stridor? - Answer-ENT (Throat finding) or Respiratory
Is it normal for the toes to fan up or curl down when the adult Babinski reflex is
assessed? - Answer-Curl down
Can the scribe document "Regular heart rate", "tachypnea", and "lungs CTAB" in the
same patient's exam simultaneously? - Answer-YES! Nothing contradicts here.
The opposite of nuchal rigidity is...? - Answer-Supple
Cyanotic skin correlates to ...? - Answer-Hypoxia: low O2 in the blood stream
The patient reports dyspnea on exertion, leg swelling, and inability to lay flat at night
due to increased shortness of breath. The MD while likely examine for _____, _____,
and _____. - Answer-Pedal edema, rales, and JVD
Multi-part application question! Directions: Answer the following questions by 1)
describing the PE finding in layman's terms. 2) list the DDx considered when the
abnormality is present. 3) providing the appropriate body system you would chart the
PE finding AND 4) studies you predict the MD to order
Rovsing sign
CVA tenderness
Rhonchi
JVD
Uvular shift (Google to find the test ordered, not technically in the workbook!) - Answer-
Application question
RLQ pain with LLQ palpation, appendicitis, abdomen/GI, and CT abd/pelvis
Tenderness in the flank (angle between the ribs/spine), kidney stones or kidney
infection aka pyelo, back, CT abd pelvis and UA.
Rattling sound, PNA, respiratory, CXR.
AND ANSWERS
What does ROS stand for? - Answer-Review of Systems
The HPI and ROS are considered what type of information? - Answer-Subjective
The physical exam is what type of information? - Answer-Objective
If a physician told you a patient's abdomen was non-tender or the patient's skin was
pale, where would you document these piece of information? - Answer-Physical Exam
(PE)
What section focuses directly on the chief complaint? - Answer-HPI
What are the five vital signs? - Answer-Temperature (T), Blood Pressure (BP), Heart
Rate (HR), Respiratory Rate(RR), Peripheral Capillary Oxygen Saturation (spo2)
Name an example of something you may write in the Surgical Hx portion of the chart. -
Answer-A surgery they've had in the past. Ex: Appendectomy, Knee Repair.
Name an example of something you may write in the Social Hx portion of the chart. -
Answer-A social aspect of their life, Ex: smoker 1 pack per day (PPD), drinks etOH,
their occupation
Name an example of something you may write in the Family Hx portion of the chart. -
Answer-If one of their relatives has had a Dz. Ex: sister has DM was diagnosed at 12,
What are the medical terms for the following past medical surgical terms?
Removal of the appendix - Answer-Appendectomy
What are the medical terms for the following past medical surgical terms?
Removal of the gallbladder - Answer-Cholecystectomy
What are the medical terms for the following past medical surgical terms?
Removal of the uterus - Answer-Hysterectomy
What are the medical terms for the following past medical surgical terms?
Removal of the tonsils - Answer-Tonsillectomy
What are the two types of heart attacks and how are they diagnosed? - Answer-STEMI,
and a Non-STEMI
STEMI is Dx by EKG
Non-STEMI is Dx by Trop (Troponin)
,What are three cardiac risk factors? - Answer-CAD, HTN, HLD, DM, Smoking, FHx
Chest pain, dyspnea, cough, and fever correlate to which DDx? And what study would
be ordered? - Answer-Pneumonia, CXR would be ordered
What are three symptoms a patient with an Ischemic CVA would present with? -
Answer-One sided weakness/numbness, speech changes, vision changes.
What heart rhythm would a physician hear if the patient were in atrial fibrillation and how
is this disease diagnosed? - Answer-Afib, and this Dz is diagnosed with an EKG
What physical exam finding is associated with cholecystitis? - Answer-RUQ tenderness
and/or Murphy's sign
How is altered mental status different from a focal neurological deficit? What is the
major cause of AMS in the elderly? - Answer-AMS consists of confusion, lethargy,
unresponsiveness it occurs when the WHOLE brain is affected. FND consists pf one
sided weakness/numbness, speech changes, vision changes it occurs when a
smaller/localized area in the brain is affected. A UTI is the common cause of AMS in the
elderly.
What is "layman's name" for GERD? - Answer-Heartburn, indigestion, acid reflux.
What is the most common cause for seizures in children? - Answer-Fever
What is one medication that is used as a vasodilator? Bronchodilator? - Answer-NTG
(nitroglycerin), Nebulizers/inhalers
In your own words, describe the significance of an HPI. - Answer-HPI consists of the
CC, and why the pt was brought into the ED. The story according to the pt.
Imagine a patient with the CC of a headache. Name five elements of the HPI and
provide an applicable example of each element. - Answer-CC: Headache
Onset: 3 hrs ago (when it began)
Location: Left temple (where it's located)
Timing: Constant
Severity: 8/10 (how bad the pain is)
extra elements:
Quality: Pressure
Modifying factors: Worse with light, and better with aceteminophen
Context: Doesn't take blood thinners, no recent head injuries, Hx of similar HA
True or False: The patient's entire ED visit is based on their answers to the questions
asked during the interview. - Answer-True
,True or False: Accurate chronology is not important in an HPI. - Answer-False
What is the main difference between an HPI and an ROS? - Answer-HPI focuses on the
CC, its surrounding context, and associated symptoms. The ROS strictly documents the
presence of absence of all symptoms reviewed by the physician.
True or False: The symptoms listed in the ROS can contradict the symptoms discussed
in the HPI. - Answer-False
How would you document the GPA for a patient who is currently pregnant, has been
pregnant 4 times in the past, and has one child at home? - Answer-G:5/P:1/Ab:3
G: # of times she's been pregnant
P: how many kids she has at home
Ab: # of abortions/miscarriages
List five body systems found in the ROS and provide two symptoms for each system. -
Answer-General: fever, chills, weight loss
Cardio: chest pain, palpitations
Resp: cough, SOB, wheezing
Neuro: headache, seizure, numbness
Skin: rashes, itching, redness
Psych: anxiety, hallucinations, depression
Read the paragraph below and determine the following for the HPI:
Gertrud Ramia is an 80 y/o female with history of asthma presenting to the ED with
worsening wheezing that started 4 days. The patient says feels like she cannot take a
full breath similar to her previous asthma exacerbations, but albuterol inhalers have not
provided relief. She reports dyspnea and a mild dry cough since last night, but no fever,
chest pain, leg pain, leg swelling, or recent travel. The patient was unable to walk to her
bathroom this afternoon secondary to her dyspnea, prompting the 911 call. When
paramedics arrived to the patient's home 30 minutes ago, tight expiratory wheezes in all
field were appreciated and the patient's SpO2 was 92% on RA. The patient received a
DuoNeb breathing treatment and Solumedrol 125 mg en route to the ED, with mild
symptom relief.
CC:
Onset:
Timing:
Location:
Quality:
Severity:
Modifying factors: - Answer-CC: Wheezing
Onset: 4 days ago
Timing: worsening
Location: not stated
, Quality: "cannot take a full breath"
Severity: not stated
Modifying factors: no relief with home inhaler, improved with DuoNeb and Solumedrol
Associated sx: dyspnea and dry cough
Pertinent negatives: no fever, chest pain, leg pain/swelling, no recent travel
Context: Hx of asthma, similar to asthma, EMS report (VS en route, medications given,
response to Tx)
What do you write on the chart if the doctor states, "The pulses are weak" after
checking the patient's pulse near the left groin. - Answer-1+ left femoral pulse
What organs are in the following quadrants: epigastrium? LUQ? LLQ? - Answer-
Epigastrium: stomach. LUQ: pancreas. LLQ: large intestine, ovary.
What does EOMI stand for? - Answer-Extra-ocular Movements Intact
Where would you document stridor? - Answer-ENT (Throat finding) or Respiratory
Is it normal for the toes to fan up or curl down when the adult Babinski reflex is
assessed? - Answer-Curl down
Can the scribe document "Regular heart rate", "tachypnea", and "lungs CTAB" in the
same patient's exam simultaneously? - Answer-YES! Nothing contradicts here.
The opposite of nuchal rigidity is...? - Answer-Supple
Cyanotic skin correlates to ...? - Answer-Hypoxia: low O2 in the blood stream
The patient reports dyspnea on exertion, leg swelling, and inability to lay flat at night
due to increased shortness of breath. The MD while likely examine for _____, _____,
and _____. - Answer-Pedal edema, rales, and JVD
Multi-part application question! Directions: Answer the following questions by 1)
describing the PE finding in layman's terms. 2) list the DDx considered when the
abnormality is present. 3) providing the appropriate body system you would chart the
PE finding AND 4) studies you predict the MD to order
Rovsing sign
CVA tenderness
Rhonchi
JVD
Uvular shift (Google to find the test ordered, not technically in the workbook!) - Answer-
Application question
RLQ pain with LLQ palpation, appendicitis, abdomen/GI, and CT abd/pelvis
Tenderness in the flank (angle between the ribs/spine), kidney stones or kidney
infection aka pyelo, back, CT abd pelvis and UA.
Rattling sound, PNA, respiratory, CXR.
