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Exam (elaborations)

ScribeAmerica ED Final Exam Prep. Completely Solved

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What does ROS stand for? - ANSWER-Review of Systems The HPI and ROS are considered what type of information? - ANSWER-Subjective The physical exam (PE) is what type of information? - ANSWER-Objective If a physician told you a patient's abdomen was nontender or the patient's skin was pale, ...

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  • August 8, 2024
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  • 2024/2025
  • Exam (elaborations)
  • Questions & answers
  • ScribeAmerica ED
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ScribeAmerica ED Final Exam Prep. Completely
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What does ROS stand for? - ANSWER-Review of Systems

The HPI and ROS are considered what type of information? - ANSWER-Subjective

The physical exam (PE) is what type of information? - ANSWER-Objective

If a physician told you a patient's abdomen was nontender or the patient's skin was
pale, where would you document these pieces of information? - ANSWER-Physcal
Exam (PE)

What section focuses directly on the chief complaint? - ANSWER-History of Present
Illness (HPI)

What are the five vital signs? - ANSWER-Heart Rate (HR)
Blood Pressure (BP)
Respiratory Rate (RR)
Temperature (T)
Oxygen Saturation (SpO2)

Name an example of something you might write in the Surgical Hx portion of the chart. -
ANSWER-tonsillectomy - removal of tonsills

adenoidectomy - removal of adenoids

pressure equalizer (P.E.) tubes - ear tubes

coronary artery bypass graft (CABG) - heart bypass

mastectomy - removal of breasts

appendectomy - appendix removed

cholecystectomy - gallbladder removed

nephrectomy - kidney removed

hysterectomy - uterus removed

oophorectomy - ovary removed

prostatectomy - prostate removed

, Name an example of something you may write in the Social Hx portion of the chart. -
ANSWER-tobacco use - smokes 1 ppd
alcohol use (ETOH) - occasional use
illicit drug use - heroine
occupation - construction
living circumstances - senior living center

Name an example of something you may write in the Family Hx portion of the chart. -
ANSWER-general - Hypertension (HTN); Diabetes Mellitus (DM); Cancer/Carcinoma
(CA)

cardiac - MI/CAD less than 55 y/o

pulmonary - PE; asthma

gastrointestinal - Crohn's Disease; Irritable Bowel Syndrome (IBS)

neurological - CVA; aneurysm; seizures

miscellaneous - Sickle Cell Anemia; DVT

What are the medical terms for the following PSHx?

removal of the appendix
removal of the gallbladder
removal of the uterus
removal of the tonsils - ANSWER-appendectomy
cholecystectomy
hysterectomy
tonsillectemy

What are the two types of heart attacks and how are they diagnosed? - ANSWER-
STEMI (EKG) and non-STEMI (Troponin)

What are three cardiac risk factors? - ANSWER-HTN, CAD, HLD, DM, Smoking, FHx

Chest pain, dyspnea, cough, and fever correlate to which DDx? And which study would
be ordered? - ANSWER-Pneumonia (PNA) and CXR

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 EKG

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