10/18/24, 11:33 AM
Scribe America Scribe U Final Exam Study 2022 (DETAILED
ANSWERS) 2024 - DISTINCTION GUARANTEED
Terms in this set (126)
Define SOAP subjective, objective, assessment, plan
CC chief complaint
what terms are important to have to make discuss, management, evaluation
sure the provider is reimbursed
HPI history of present illness (the story of the symptoms)
Onset, Timing, Location, Quality, Severity, Modifying Factors, Associated Symptoms,
What are the 8 elements of the HPI?
Context
when the symptoms began , never write days of the week, use 3 days ago, weeks
Onset
ago, months ago
What makes it better? What makes it worse? (ex. sleeping on my right side makes it
Modifying Factors
better)
Timing the frequency of the reported symptoms, constant, intermittent, waxing and waning
Location where the discomfort is coming from
quality describing the pain, sharp, dull, aching, cramping
severity how bad is the pain, mild, moderate, severe, on a scale of 1-10
associated symptoms (sx) any other symptoms that accompany the complaint
NAD no acute distress
Define term and name body system it is General , Constitutional malnourished
under:
Cachectic , Emaciated
Define term and name body system it is General,
under: spaced out, in a stupor
obtunded
Define term and name body system it is Head,
under: Atraumatic / Normocephalic
AT/NC
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Define term and name body system it is Eyes,
under: Extra ocular muscles intact
EOMI Eyes are moving intact
Define term and name body system it is Eyes
under: Without yellowing
Anicteric
Define term and name body system it is Eyes
under: white under eyes
Normal conjunctiva (normal)
Define term and name body system it is Eyes
under: pupils equal round and reactive to light
PERRL
Define term and name body system it is Eyes
under: two different sized pupils
Anisocria
Define term and name body system it is Eyes
under: extra ocular muscle entrapment
EOM entrapment lazy eye
Define term and name body system it is Eyes
under: yellowing in eyes
Sclera Icterus
Define term and name body system it is Eyes
under: paleness of lower part of inner eye,
pale conjunctiva associated w/ anemia
Define term and name body system it is Eyes
under: redness in eyes, pink eye
Conjunctival injection / hyperemia
Define term and name body system it is Ear
under: tympanic membranes normal
TMs normal
Define term and name body system it is Ear
under: inner ear redness
TM erythema
Define term and name body system it is Ear
under: Earwax
cerumen
Define term and name body system it is Ear
under: middle ear infection
TM w/ otitis media
Define term and name body system it is Skin
under: swelling on face, around eyes, typically caused by allergic reaction
Angioedema
Define term and name body system it is Skin
under: blue skin color, caused by low O2 in blood stream
cyanotic
Define term and name body system it is Neck
under: enlarged thyroid gland
Thyromegaly
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