AST V3 Lecture 3 Assessment
(65).webp "AST V3 Lecture 3 Assessment - Quiz")
- 1.
25yoMaleAcute ComplaintFacial swellingLeft jawSince 12 hours ago when pain woke him upNo symptoms last nightNo painSome numbnessTongue normalNo dysphagiaNo treatmentQuestions 28-30 are based on the above information.
- 2.
The audio recording is based on a real patient visit. Take notes on the relevant information from the visit. Your notes will not be graded.Questions 18-27 are based on this recording.
- 3.
Type your notes below.
- 4.
Medically relevant information:25yoMaleAcute ComplaintFacial swellingLeft jawSince 12 hours ago when pain woke him upNo symptoms last nightNo painSome numbnessTongue normalNo dysphagiaNo treatmentSelect Phrases from the Phrase Bank below that should be used to convert the facts above into a cohesive HPI.
- A.
… episodes of [COMPLAINT] lasting [DURATION]
- B.
... complains of [COMPLAINT], worse/better with [FACTOR]
- C.
[COMPLAINT] onset during/after/before/when [CONTEXT].
- D.
The patient is a [AGE] year old male/female presenting for follow up of [CHIEF COMPLAINT].
- E.
… also reports/complains of [ASSOCIATED SYMPTOMS]
- F.
… denies [NEGATIVE ASSOCIATED SYMPTOMS]
- G.
The patient is a [AGE] year old male/female presenting with complaint of [CHIEF COMPLAINT].
- H.
… denies any treatment for his/her symptoms.
- I.
… [COMPLAINT] resolved after [DURATION]
- J.
[COMPLAINT] is localized to her/her [LOCATION]
- K.
… , onset [DURATION] ago
- L.
The patient denies recent injury.
Correct Answer(s)
C. [COMPLAINT] onset during/after/before/when [CONTEXT].
E. … also reports/complains of [ASSOCIATED SYMPTOMS]
F. … denies [NEGATIVE ASSOCIATED SYMPTOMS]
G. The patient is a [AGE] year old male/female presenting with complaint of [CHIEF COMPLAINT].
H. … denies any treatment for his/her symptoms.
J. [COMPLAINT] is localized to her/her [LOCATION]
K. … , onset [DURATION] agoExplanation
The given answer correctly uses the phrases from the Phrase Bank to convert the facts into a cohesive HPI. It includes the patient's age, gender, and chief complaint. It also mentions the duration of the complaint, the location of the symptoms, and any associated symptoms. The answer also states that the patient denies any negative associated symptoms and any treatment for the symptoms. Overall, the answer effectively summarizes the relevant information from the given facts.Rate this question:
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- 5.
Medically Relevant Information:25yoMaleAcute ComplaintFacial swellingLeft jawSince 12 hours ago when pain woke him upNo symptoms last nightNo painSome numbnessTongue normalNo dysphagiaNo treatmentFill in the following HPI with the correct information or phrase based on the phrase bank and information above.The patient is a ________ year old ________ presenting with complaint ________ localized to his ________, onset when he woke up 12 hours ago. He also ________ of mild ________. The patient ________ pain, tongue symptoms, and ________. He denies any ________ for his symptoms.
Correct Answer(s)
25
male
of facial swelling
left jaw
complains, reports
numbness
denies
dysphagia
treatment, treatmentsExplanation
The patient is a 25-year-old male presenting with a complaint of facial swelling localized to his left jaw, onset when he woke up 12 hours ago. He also reports mild numbness. The patient complains of pain, denies tongue symptoms, and dysphagia. He denies any treatment for his symptoms.Rate this question:
- 6.
The first sentence of the HPI should ALWAYS contain...
- A.
Chief Complaint, Age, Gender, History
- B.
Age, Gender, Chief Complaint
- C.
Chief Complaint, Gender, Age, and at least 1 HPI element
- D.
Age, Gender, Chief Complaint, Severity
Correct Answer
B. Age, Gender, Chief ComplaintExplanation
The first sentence of the HPI should always contain the patient's age, gender, and chief complaint. This information is crucial for establishing the context of the patient's condition and helps the healthcare provider to prioritize and understand the patient's medical history. Including the chief complaint in the first sentence allows for a concise summary of the patient's reason for seeking medical attention. The order of age, gender, and chief complaint ensures that the most relevant and essential information is provided upfront.Rate this question:
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- 7.
Patient: "I have been having really bad aching pain in my back which goes down into my right leg and crotch."How is the above quote BEST translated into medical language?
- A.
The patient states that he has really bad back pain that aches and radiates into both his right leg and groin.
- B.
The patient complains of back pain. The patient describes his back pain as aching. The patient states that his back pain radiates into his right lower extremity and groin.
- C.
The patient complains of severe back pain that is aching in nature. He states that the pain "goes down into my right leg and crotch".
- D.
The patient complains of severe back pain that radiates to his right lower extremity and groin. He describes the pain as aching.
Correct Answer
D. The patient complains of severe back pain that radiates to his right lower extremity and groin. He describes the pain as aching.Explanation
The answer accurately translates the patient's statement into medical language. It includes the information that the patient has severe back pain that radiates to the right lower extremity and groin, and describes the pain as aching.Rate this question:
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- 8.
Patient: "My stomach symptoms are all gone!"Fill in the blanks. Translate the quote above into proper wording.The patient's ________ symptoms have ________.
Correct Answer
abdominal, GI, gastrointestinal, epigastric
resolved, improvedExplanation
The patient's abdominal, GI, gastrointestinal, and epigastric symptoms have resolved and improved.Rate this question:
- 9.
Which of the following should be included in subsequent sentences (after the first sentence of the HPI)? (Check all that apply.)
- A.
Chief Complaint
- B.
Elements
- C.
Additional Information - medically relevant
- D.
Age
- E.
Additional Information - medically irrelevant
Correct Answer(s)
B. Elements
C. Additional Information - medically relevantExplanation
In subsequent sentences after the first sentence of the HPI, it is important to include the "Elements" which refer to the specific details or components of the patient's medical history or symptoms. Additionally, including "Additional Information - medically relevant" is crucial as it provides any other pertinent details related to the patient's condition that may be important for diagnosis or treatment. Age and Chief Complaint may already be mentioned in the first sentence of the HPI, so they may not necessarily need to be included in subsequent sentences. "Additional Information - medically irrelevant" should not be included as it is not relevant to the medical assessment.Rate this question:
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- 10.
Information from visit:inner ear painmildonset 2 weeks agoWhat is the BEST way to present the information above?
- A.
The patient complains of mild inner ear pain for the last 2 weeks.
- B.
The patient complains of mild pain to the external aspect of the auditory meatus onset 2 weeks ago.
- C.
The patient complains of mild ear pain for the last 2 weeks.
- D.
The patient complains of inner ear pain. The pain is mild. The pain started 2 weeks ago.
Correct Answer
A. The patient complains of mild inner ear pain for the last 2 weeks.Explanation
The answer "The patient complains of mild inner ear pain for the last 2 weeks" is the best way to present the information because it accurately describes the patient's complaint of pain in the inner ear, specifies that the pain is mild, and indicates that it has been present for the past 2 weeks. This presentation provides a clear and concise summary of the patient's condition.Rate this question:
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- 11.
Which of the following facts should be included in an HPI paragraph about an Upper Respiratory Infection (URI)?
- A.
Cough for 2 weeks
- B.
No nasal congestion
- C.
Hypertension under control with medication
- D.
History of seasonal allergies
Correct Answer(s)
A. Cough for 2 weeks
B. No nasal congestion
D. History of seasonal allergiesExplanation
The facts that should be included in an HPI paragraph about an Upper Respiratory Infection (URI) are cough for 2 weeks, no nasal congestion, and history of seasonal allergies. These symptoms are relevant to the diagnosis and provide important information about the patient's condition. The fact that hypertension is under control with medication is not directly related to the URI and does not need to be included in the HPI paragraph.Rate this question:
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- 12.
Which of the following facts from a visit should be grouped together in the same paragraph? (Check all that apply.)
- A.
Upcoming hernia repair surgery
- B.
Headache episodes lasting 1 hour
- C.
Memory impairment for 2 weeks
- D.
Recent colonoscopy was unremarkable
- E.
Fell down stairs 2 weeks ago
- F.
History of brain cancer
Correct Answer(s)
B. Headache episodes lasting 1 hour
C. Memory impairment for 2 weeks
E. Fell down stairs 2 weeks ago
F. History of brain cancerExplanation
The checked boxes all relate to neurological symptoms-- headache, memory impairment, brain cancer, and potential head trauma during a fall. Colonoscopy and hernia repair are unrelated.Rate this question:
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- 13.
How should you organize an HPI with multiple complaints?
- A.
List information in the order it was discussed during the patient visit.
- B.
The entire HPI should be chronological from start to finish.
- C.
There should be a separate paragraph for each element type.
- D.
Separate different complaints into different paragraphs. The paragraphs should be ordered based on severity.
Correct Answer
D. Separate different complaints into different paragraphs. The paragraphs should be ordered based on severity.Explanation
The correct answer suggests that when organizing an HPI (History of Present Illness) with multiple complaints, it is best to separate different complaints into different paragraphs. This allows for clarity and organization in the documentation. Additionally, the paragraphs should be ordered based on severity, which helps prioritize the information and provides a logical flow to the narrative. By following this approach, healthcare professionals can effectively communicate the patient's concerns and ensure that important details are not overlooked.Rate this question:
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- 14.
Based on the information discussed, that type of visit do you think this is?
- A.
Pre-operative
- B.
Acute complaint
- C.
Follow-up
- D.
Annual Physical
Correct Answer
D. Annual PhysicalExplanation
Based on the information discussed, it can be inferred that this visit is an Annual Physical. The options provided suggest different types of visits, and based on the information given, it is most likely that this visit is for a routine check-up or examination that occurs on an annual basis.Rate this question:
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- 15.
Of the information discussed in the visit, which should have it's own paragraph? (Check all that apply.)
- A.
Hypertension
- B.
Hyperlipidemia
- C.
Alcohol consumption
- D.
Sexual history
- E.
Sleep apnea
- F.
Toe nail fungus
Correct Answer(s)
A. Hypertension
B. Hyperlipidemia
E. Sleep apnea
F. Toe nail fungusExplanation
The conditions that should have their own paragraph in the visit are hypertension, hyperlipidemia, sleep apnea, and toe nail fungus. These conditions are all significant health concerns that require separate discussion and attention. Hypertension and hyperlipidemia are both chronic conditions that can have serious implications for cardiovascular health. Sleep apnea is a sleep disorder that can lead to various health issues if left untreated. Toe nail fungus, although less serious than the other conditions, can still cause discomfort and may require treatment. Therefore, it is important to give each of these conditions their own paragraph to ensure thorough discussion and appropriate management.Rate this question:
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- 16.
Which of the following is MOST important that was discussed during the visit.
- A.
Sexual history and STD test
- B.
Hyperlipidemia and statin drugs
- C.
Sister moved to LA and is a teacher
- D.
Sleep apnea
Correct Answer
B. Hyperlipidemia and statin drugsExplanation
The most important topic discussed during the visit is hyperlipidemia and statin drugs. This suggests that the visit likely involved a discussion about high cholesterol levels and the use of medication to manage it.Rate this question:
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- 17.
Doctor: So how is your sleep apnea? Patient: I’ve actually been using the CPAP more. Doctor: Thats fantastic! From the sounds of it you’ve been doing really wellPatient: Well no, I’m not taking my statin. Doctor: But at least you’re eating well, exercising, and using the CPAP. Do you feel more rested and have more energy?Patient: No not really, I’m in a weird turn of life, but it will get better. Things are starting to settle after the divorce. I’m not worried about getting married again. I don’t have a bucket list. I’m good... I feel goodBased on the dialogue above about the patient's sleep apnea, which of the following presents the relevant info BEST?
- A.
The patient has a history of sleep apnea which he treats with CPAP. He denies taking his statin medication.
- B.
The patient has a history of sleep apnea. He states he is using the CPAP more often. He notes that personal issues may be affecting his sleep as well.
- C.
The patient has a history of sleep apnea. He states he is using the CPAP more often with minimal relief. He denies taking his statin medication. He notes that his divorce is settling, that he does not have a bucket list, and that he is not concerned about re-marrying. He is also eating well and exercising.
- D.
The patient has a history of sleep apnea.
Correct Answer
B. The patient has a history of sleep apnea. He states he is using the CPAP more often. He notes that personal issues may be affecting his sleep as well.Explanation
This is the correct answer because it includes information about: history of sleep apnea, frequency of CPAP treatment for sleep apnea, and that personal issues might affect his sleep in addition to the sleep apnea.
Option A - incorrect because statin drugs do not treat sleep apnea.
Option C - incorrect because too much irrelevant detail about the patient's personal life is included. The phrase "personal issues" is sufficient to describe these issues.
Option D - incorrect because it is missing relevant information about treatment and personal issues.Rate this question:
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- 18.
Which of the following standard phrases should you use to convert the dialogue into a proper HPI? (Check all that apply.) Patient: Also a test we mentioned last time- I had a funky toenail. Now it’s 18 months out. Doctor: Oh right, we were going to do a fungal culture. It’s been 16 months so the order is expired. Have you used any over the counter treatments? Patient: Last time I saw you, you suggested I use a spray. I did for quite some time but there have been no results. Doctor: It didn't even make a dent?Patient: Nope, for 18 months it’s been the sameHINT: Relevant information from the dialogue should fit into the [BRACKETS] in the chosen phrase.
- A.
… was previously diagnosed with [CONDITION]
- B.
… for the last [DURATION]
- C.
The patient is a/an [AGE] year old male/female presenting with complaint of [CHIEF COMPLAINT].
- D.
… has tried [TREATMENT] with/with no/with some/with minimal relief.
- E.
… has a history of [CONDITION] for which he/she takes [MEDICATION]
- F.
… also complains of [COMPLAINT]...
Correct Answer(s)
B. … for the last [DURATION]
D. … has tried [TREATMENT] with/with no/with some/with minimal relief.
F. … also complains of [COMPLAINT]...Explanation
The patient also complains of a funky toenail, which has been present for the last 18 months. The doctor asks if the patient has used any over the counter treatments, to which the patient responds that they have used a spray for quite some time but there have been no results. Therefore, the phrases "also complains of [COMPLAINT]...", "for the last [DURATION]", and "has tried [TREATMENT] with no results" are applicable.Rate this question:
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- 19.
Which information should be included in the HPI paragraph about the patient's hypertension? (Check all that apply.)
- A.
Doctor: So your hypertension... how is that doing? Patient: Not as well as you would like.
- B.
Doctor: Last time we measured you at 149/90, which is not optimal.
- C.
Patient: Yeah I’ve gained a couple pounds that I would like to lose again. I went from 205 to 210.
- D.
Patient: Yeah, I’ve actually stopped my statin.
- E.
Doctor: So for your blood pressure, are you measuring at home or just when you come into the office? Patient: No I don’t measure it, but it’s measured when I’m on the mechanical bike
- F.
Doctor: Your sister still lives in London? Patient: No she moved to LA
Correct Answer(s)
A. Doctor: So your hypertension... how is that doing? Patient: Not as well as you would like.
B. Doctor: Last time we measured you at 149/90, which is not optimal.
C. Patient: Yeah I’ve gained a couple pounds that I would like to lose again. I went from 205 to 210.
E. Doctor: So for your blood pressure, are you measuring at home or just when you come into the office? Patient: No I don’t measure it, but it’s measured when I’m on the mechanical bikeExplanation
The information that should be included in the HPI paragraph about the patient's hypertension includes the patient's statement that their hypertension is not doing well, the doctor's comment about the last measured blood pressure being 149/90 which is not optimal, the patient's statement about gaining weight and wanting to lose it, and the doctor's question about how the patient measures their blood pressure (at home or only at the office).Rate this question:
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- 20.
Which of the following is NOT medically relevant?
- A.
Four 60 minute stationary bike exercise sessions per week
- B.
Gained weight, 205lbs to 210lbs.
- C.
Sexually active with a new partner.
- D.
Consumes 14 alcoholic drinks per week.
- E.
All of the choices are medically relevant.
Correct Answer
E. All of the choices are medically relevant.Explanation
All of the choices provided in the question are medically relevant because they involve factors that can potentially impact a person's health. Regular exercise sessions on a stationary bike can have positive effects on cardiovascular health and overall fitness. Gaining weight may be indicative of changes in diet or lifestyle that can have health implications. Engaging in sexual activity with a new partner can increase the risk of sexually transmitted infections. Consuming 14 alcoholic drinks per week can have negative effects on liver function and overall health. Therefore, all of these choices are medically relevant in different ways.Rate this question:
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- 21.
Which of the following information belongs in the HPI?
- A.
Doctor: He had a normal exam. Although there was a fungal infection on his left toe, actually it may be right depending on how he was oriented. Let me see- oh yes, left big toenail I see it on an old exam.
- B.
Doctor: Any fun plans for the summer? Patient: I have to finish a book
- C.
Patient: Well if it’s fungal what should I do? Doctor: Let’s wait for the culture to return. I suspect it will be fine.
- D.
Doctor: Well okay, do you get any swelling in your legs normally? Patient: No
Correct Answer
D. Doctor: Well okay, do you get any swelling in your legs normally? Patient: NoExplanation
The information belongs in the HPI because it is relevant to the patient's medical history and symptoms. The doctor is asking about swelling in the patient's legs, which could be a symptom of an underlying condition. The patient's response of "No" indicates that they do not normally experience swelling in their legs, providing important information for the doctor's evaluation and diagnosis.Rate this question:
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- 22.
Doctor: You look good overall. I’ll give you a summary, you’ll get labs done, I’ll release them to you online, the STD screening won’t be released online so I’ll have it e-mailed to you. I can also send you a hard copy.Does this information belong in the HPI?
- A.
Yes
- B.
No
- C.
Some of this information belongs in the HPI, some does not.
Correct Answer
B. NoExplanation
The information provided by the doctor regarding the patient's overall appearance and the process of getting labs done, releasing them online, and emailing the STD screening does not belong in the History of Present Illness (HPI). The HPI typically focuses on the patient's chief complaint, symptoms, and relevant medical history leading up to the current visit. The information provided by the doctor is more related to the general process and logistics of the visit, rather than specific details about the patient's condition.Rate this question:
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- 23.
Which phrase should be used to present the following information?HypertensionTakes lisinopril 10mgMedication working well
- A.
… [CONDITION] is well managed/under control with his/her current medication regimen.
- B.
… is treating his/her [CONDITION] with [MEDICATION]
- C.
… [CONDITION] is well managed/under control with [MEDICATION]
- D.
… has a history of [CONDITION] diagnosed in [DATE]
Correct Answer
C. … [CONDITION] is well managed/under control with [MEDICATION]Explanation
The correct answer is "… [CONDITION] is well managed/under control with [MEDICATION]." This phrase accurately presents the information given in the question, stating that the condition (hypertension) is well managed with the medication (lisinopril 10mg).Rate this question:
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- 24.
What is the BEST way to translate the common phrase "Comes in with" to proper wording?
- A.
"Would like to talk about"
- B.
"Made an appointment to discuss"
- C.
"Presents to the office this afternoon with"
- D.
"Presents with"
Correct Answer
D. "Presents with"Explanation
The phrase "Comes in with" is commonly used to describe someone arriving at a place while having a particular condition or symptom. The phrase "Presents with" is the best way to translate this common phrase because it accurately conveys the idea of someone presenting or showing up with a specific condition or symptom. It is commonly used in medical or clinical contexts when describing a patient's symptoms or complaints.Rate this question:
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- 25.
What qualities are important to the quality of the medical note?
- A.
Standard Phrasing
- B.
Proper Wording
- C.
Standard Phrasing and Proper Wording
- D.
Neither Standard Phrasing nor Proper Wording
Correct Answer
C. Standard Phrasing and Proper WordingExplanation
Standard phrasing and proper wording are important qualities for the quality of a medical note. Standard phrasing ensures that the note follows established guidelines and protocols, making it easier for other healthcare professionals to understand and interpret. Proper wording ensures that the note is clear, concise, and accurately conveys the necessary information. Together, these qualities help to maintain consistency, accuracy, and effectiveness in medical documentation.Rate this question:
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- 26.
Which of the following are viable ways to start any general sentence in the HPI? (Check all that apply.)
- A.
The patient let me know that....
- B.
Patient reports...
- C.
She admits...
- D.
He denies...
- E.
He finally told us that...
- F.
The patient states...
Correct Answer(s)
B. Patient reports...
C. She admits...
D. He denies...
F. The patient states...Explanation
The given answer choices are all viable ways to start a general sentence in the HPI. These phrases are commonly used to introduce information provided by the patient. They indicate that the following sentence will contain information reported by the patient, whether it is a statement, admission, denial, or report. These phrases help establish the patient's perspective and provide context for the information that follows.Rate this question:
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- 27.
What is wrong with the following HPI?Patient is a 51-year-old male presenting with complaint of severe headache for the last 6 hours. Patient states that he is nauseous and has had 3 episodes of vomiting. Patient states that he has a history of migraines which he treats with Imitrex. Patient states that he took Imitrex today with no relief. Patient states that he is followed by Dr. Wright, neurology.
- A.
Colloquial language used
- B.
Repetitive use of the same phrase
- C.
Irrelevant information included
- D.
Information should be broken up into multiple paragraphs
Correct Answer
B. Repetitive use of the same phraseExplanation
The HPI contains repetitive use of the phrase "Patient states" multiple times. This repetition is unnecessary and makes the documentation less concise and clear. The information can be presented in a more organized and efficient manner by using alternative phrases or structuring the sentences differently.Rate this question:
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- 28.
What standard note style do we use at Augmedix?
- A.
Complaint focused style
- B.
No style preference
- C.
Fact-based style
- D.
Single-paragraph style
Correct Answer
A. Complaint focused styleExplanation
At Augmedix, the standard note style used is the complaint focused style. This means that when documenting notes, the focus is on capturing any complaints or issues raised by the patient. This style helps to ensure that any concerns or problems are accurately recorded and can be addressed effectively.Rate this question:
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- 29.
Which of the following are important to remember when writing an HPI? (Check all that apply.)
- A.
Use proper wording
- B.
Use standard phrases when possible
- C.
Each complaint should have its own paragraph
Correct Answer(s)
A. Use proper wording
B. Use standard phrases when possible
C. Each complaint should have its own paragraphExplanation
When writing an HPI (History of Present Illness), it is important to remember to use proper wording to accurately describe the patient's symptoms and condition. This ensures clear communication and understanding between healthcare professionals. It is also beneficial to use standard phrases when possible, as these are commonly understood and can save time in documentation. Additionally, each complaint should have its own paragraph to organize information and make it easier to read and reference.Rate this question:
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- 30.
The order of paragraphs in the HPI is determined by the significance of the topic, least significant first, most significant last.
- A.
True
- B.
False
Correct Answer
B. FalseExplanation
The order of paragraphs in the HPI is determined by the significance of the topic, with the most significant first and the least significant last. This allows for a logical flow of information and ensures that the most important points are addressed first.Rate this question:
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- 31.
The chief complaint can be a complaint (ie, abdominal pain) or the reason for visit (ie, pre-operative visit).
- A.
True
- B.
False
Correct Answer
A. TrueExplanation
The chief complaint refers to the main reason why a patient seeks medical attention. It can be a specific complaint, such as abdominal pain, or a general reason for the visit, such as a pre-operative visit. This statement is true as it correctly defines the chief complaint as either a complaint or a reason for the visit.Rate this question:
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