The fact that a patient has experienced recent weight loss, fatigue, and joss of appetite would be included in which part of the review of systems (ROSS)? A. Musculoskeletal B. Gastrointestinal C. Neurological D. Constitutional Answer: D. Constitutional Topic: The Review of Systems (ROSS) Feedback: Vital signs, general health, and weight changes are all part of the constitutional findings in the ROSS. Blooms: Understand 29. Of the following, which is not an element of the history of present illness (HIP)? A. Duration B. Severity C. Quantity D. Quality Answer: C. Annuity Feedback: A physical exam includes objective findings of the care provider hill the HIP includes the signs or symptoms that a patient communicates to the provider, such as the duration, severity, and quality of pain. Blooms: Understand CA. PEEP: V. C. 6 SASHIMI I. A. I; l. A. 2; I. B. I 34. Kelly is being seen by her physician today, and he is asking her if she’s had any increase in or unusual headaches since her last visit, whether she has any blurred vision, and whether she has seen her eye doctor in the past year. The answers to these and other questions are documented in what part of the health record?
Answer: Review of Systems (ROSS) Feedback: Patients either fill out a form which asks for current symptoms, or the care provider verbally asks the patient about signs and symptoms for each body system, to complete a comprehensive review of systems (ROSS). Blooms: Understand ABBES: 4. A CHIME: I. A. I; IA. 2; I. B. I; I. B. 3 Estimated Time: 1-2 minutes 35. How a patient is feeling, any current complaints or concerns, weight loss or gain, appetite, sleep patterns or difficulties, and a recap of vital signs. This information is documented in the general part of the ROSS, and is also known s what?
Answer: constitutional (or general) Learning outcome: 05. 03 Feedback: The elements listed in the question are part of the constitutional (or general) portion of the ROSS. Blooms: Understand CHIME: I. A. I; IA. 2; LB. 1; I. B. 3 CHART NOTE Date of service: September 5, 2013 Patti Wolfe is a 49-year-old patient of Dry. Mamba’s. Ms. Wolfe arrives today complaining of a productive cough, heaviness in her chest, chanciness, and a fever of 102. She started one week ago with symptoms of a cold – runny eyes, nasal congestion, cough, and some wheezing.
The cough was non-productive. She has taken over the counter (ETC) medications, but has not seen much improvement, and in fact her cough has become worse. Ms. Wolfe has a history of gastrointestinal reflux disease (GIRD). She has had no recent weight loss or gain, she has been feeling well, though a little fatigued over the past week; she has no frequency or urgency of urination, does not have any blurred or double vision, and has had no night sweats. Dry. Mamba conducts a physical exam (PEP) with the following findings: Head: Morphophonemic. Eyes:
Equal and reactive to light. Ears: Clear. Nose: congestion noted. Throat: Clear. Lungs: Arles and rancho are noted on auscultation. Dry. Mamba writes an order for a chest x-ray which will be done as an outpatient at the local hospital. She instructs Ms. Wolfe to drink plenty of fluids, take Ethylene or ibuprofen for her chanciness and fever, and to use a cool mist humidifier at night. Dry. Mamba diagnoses the patient with Cough, ruling out pneumonia. 43. In the chart note above, what information is considered to be part of the review of systems (ROSS)?
Answer: She has had no recent weight loss or gain, she has been feeling well, though a little fatigued over the past week, she has no frequency or urgency of urination, does not have any blurred or double vision, and has had no night sweats. Learning Outcome: 05. 03 Feedback: She has had no recent weight loss or gain, she has been feeling well, though a little fatigued over the past week, she has no frequency or urgency of urination, does not have any blurred or double vision, and has had no night sweats. Blooms: Apply Difficulty: 2 Medium Estimated Time: 3-5 minutes