1.
Where would you chart "abdominal pain?"
Correct Answer
A. Review of Systems (ROS)
Explanation
In the context of medical documentation, "abdominal pain" would be charted under the Review of Systems (ROS). The ROS is a systematic approach to gather information about the patient's symptoms and overall health. It includes questions about various body systems, such as cardiovascular, respiratory, gastrointestinal, etc. Since "abdominal pain" is a symptom related to the gastrointestinal system, it would be appropriate to document it under the ROS. The Physical Exam, on the other hand, focuses on the objective findings from the examination of the patient's body, rather than subjective symptoms like pain.
2.
Where would you chart "RUQ tenderness"
Correct Answer
B. pHysical Exam.
Explanation
"RUQ tenderness" refers to tenderness or pain in the right upper quadrant of the abdomen. This is a specific symptom that can be assessed through physical examination by palpating or pressing on the area to check for any discomfort or pain. Review of Systems (ROS) typically focuses on asking questions about various body systems and symptoms experienced by the patient, but it does not involve direct physical examination. Therefore, "RUQ tenderness" would be charted under Physical Exam, where the healthcare provider can assess the specific area for tenderness.
3.
Where would you chart "Palpitations"
Correct Answer
A. Review of Systems (ROS)
Explanation
In medical practice, the Review of Systems (ROS) is a standard part of the patient's medical history and examination. It involves a systematic inquiry about the patient's symptoms, including any concerns or abnormalities they may have experienced. "Palpitations" refers to the sensation of an irregular or rapid heart rate, which is a symptom that would typically be addressed in the ROS. The physical exam, on the other hand, focuses more on the objective assessment of the patient's physical condition rather than their subjective symptoms. Therefore, charting "Palpitations" would be more appropriate in the Review of Systems section.
4.
Where would you chart "Tachycardia"
Correct Answer
B. pHysical Exam.
Explanation
"Tachycardia" refers to a rapid heart rate, which is a physical symptom that can be observed and measured during a physical examination. The physical exam involves a thorough assessment of the patient's body, including vital signs such as heart rate, blood pressure, and respiratory rate. Therefore, charting "Tachycardia" would be appropriate in the physical exam section rather than the review of systems, which typically focuses on the patient's subjective symptoms and concerns.
5.
Where would you chart "Sore Throat"
Correct Answer
A. Review of Systems (ROS)
Explanation
In medical practice, the Review of Systems (ROS) is a systematic approach used by healthcare providers to gather information about a patient's symptoms and medical history. It involves asking specific questions about various body systems, including the respiratory system, which would include symptoms related to a sore throat. Therefore, charting "Sore Throat" would be appropriate under the Review of Systems (ROS) section to document the patient's complaint and aid in diagnosis and treatment.
6.
Where would you chart "Pharyngeal Erythema?"
Correct Answer
B. pHysical Exam.
Explanation
Pharyngeal erythema is a physical finding that can be observed during a physical exam. It refers to redness or inflammation of the pharynx, which is the part of the throat behind the mouth and nasal cavity. This condition can be assessed visually by a healthcare provider during a physical examination. In contrast, the Review of Systems (ROS) is a questionnaire or checklist used to gather information about a patient's symptoms and medical history. Since pharyngeal erythema is a physical finding, it would be charted under the Physical Exam section rather than the ROS.
7.
Where would you chart "Leg Swelling?"
Correct Answer
A. Review of Systems (ROS)
Explanation
In the context of medical documentation, "Leg Swelling" would be charted under the "Review of Systems (ROS)" section. The ROS is a systematic approach to gather information about a patient's symptoms and medical history. It includes a comprehensive list of questions about various body systems, allowing healthcare providers to assess the patient's overall health. Leg swelling is a symptom that falls under the category of musculoskeletal or cardiovascular systems, which are typically included in the ROS. The physical exam, on the other hand, focuses on the direct examination of the patient's body and is more specific to the current physical condition.
8.
Where would you chart "Edema?"
Correct Answer
B. pHysical Exam.
Explanation
Edema refers to the swelling caused by the accumulation of fluid in the body tissues. It is a physical symptom that can be observed and assessed through a physical examination. During a physical exam, a healthcare provider can visually inspect and palpate the body to check for signs of edema, such as puffy or swollen areas. In contrast, the Review of Systems (ROS) is a series of questions asked by healthcare providers to gather information about a patient's symptoms and medical history, which may not directly involve the observation or assessment of physical symptoms like edema.
9.
Where would you chart a "Cut?"
Correct Answer
A. Review of Systems (ROS)
Explanation
In medical documentation, a "cut" would be charted under the Review of Systems (ROS) section. The ROS is a systematic approach used by healthcare professionals to gather information about a patient's symptoms and medical history. It includes questions about various body systems, such as the respiratory, cardiovascular, and musculoskeletal systems. A "cut" would fall under the category of the integumentary system, which focuses on the skin, hair, and nails. Therefore, it would be appropriate to document a "cut" under the ROS section as it pertains to the patient's overall medical history and symptoms.
10.
Where would you chart a "7cm Laceration?"
Correct Answer
B. pHysical Exam.
Explanation
In the context of the question, a "7cm laceration" refers to a physical injury or wound. Therefore, it would be appropriate to chart this information under the "Physical Exam" section, as it is a finding that can be observed and assessed during a physical examination. The Review of Systems (ROS) typically focuses on the patient's subjective symptoms and experiences, rather than objective physical findings.
11.
Where would you chart "Ankle Pain?"
Correct Answer
A. Review of Systems (ROS)
Explanation
Ankle pain would be charted under the "Review of Systems (ROS)" section. The ROS section is used to document the patient's subjective complaints and symptoms, including any pain or discomfort they may be experiencing. The physical exam section, on the other hand, is used to document the objective findings from the healthcare provider's examination of the patient. Since ankle pain is a subjective complaint, it would be appropriate to chart it under the ROS section.
12.
Where would you chart "Tenderness over the L medial malleolus?"
Correct Answer
B. pHysical Exam.
Explanation
The correct answer is Physical Exam because tenderness over the L medial malleolus is a physical finding that can be assessed during a physical examination. The Review of Systems (ROS) is a series of questions asked to gather information about a patient's symptoms, and it does not involve any physical examination. Therefore, the physical exam is the appropriate place to chart the finding of tenderness over the L medial malleolus.
13.
Where would you chart a "Toothache?"
Correct Answer
A. Review of Systems (ROS)
Explanation
A "Toothache" would be charted under the Review of Systems (ROS) section. The ROS is a comprehensive assessment of the patient's symptoms and helps to identify any potential underlying medical conditions. Toothache is a symptom related to dental health, and therefore it would be appropriate to document it under the ROS. The Physical Exam section focuses more on the physical examination findings rather than symptoms reported by the patient.
14.
Where would you chart "Poor dentition?"
Correct Answer
B. pHysical Exam.
Explanation
"Poor dentition" refers to the condition of having bad or unhealthy teeth. This is something that can be observed and assessed through a physical examination of the patient's mouth and teeth. Review of Systems (ROS) typically focuses on the patient's symptoms and general health, whereas physical exam specifically looks at the physical attributes and condition of the body, including the teeth. Therefore, it is more appropriate to chart "Poor dentition" under the Physical Exam category.
15.
Where would you chart a "Rash?"
Correct Answer
A. Review of Systems (ROS)
Explanation
The correct answer is "Review of Systems (ROS)". In medical practice, a "Rash" would typically be charted under the Review of Systems (ROS) section. The ROS is a comprehensive checklist of symptoms or issues that the patient may be experiencing, and it helps the healthcare provider gather information about the patient's overall health. A rash is a common symptom that would be documented in this section as it pertains to the patient's skin condition. The Physical Exam section focuses more on the objective findings during the examination rather than the patient's subjective symptoms like a rash.
16.
Where would you chart "Urticaria?"
Correct Answer
B. pHysical Exam.
Explanation
In the given context, "Urticaria" refers to a skin condition characterized by the appearance of itchy, raised, and red welts on the skin. Since the term "Physical Exam" is mentioned as the answer, it can be inferred that charting "Urticaria" would involve documenting the presence, location, and characteristics of the welts during a physical examination of the patient. This would typically involve visual inspection and palpation of the affected areas to assess the extent and severity of the condition.