Scribe America Final Exam ED 2023/2024 Questions and Answers

Scribe America Final Exam ED What are the 3 types of dispositions? - Discharge, Admit, Transfer What does HPI stand for? - history of present illness What does ROS stand for? - review of systems The HPI and ROS are considered what type of information? - subjective The physical exam is what type of information? - objective If a physician told you a patient's abdomen was non tender, where would you document this? - PE What section focuses directly on the chief complaint? - HPI If someone has a hx of CABG or MI, what is something you can also always document in the PMHx section of the chart? - CAD Name an example of something you may write in the Social Hx portion of the chart. - smokes 1 pack/day Name an example of something you may write in the Family Hx portion of the chart. - Mother had Hx of CAD at age 46 What are the medical terms for the following past surgical terms? Removal of the appendix Removal of the gallbladder Removal of the uterus Removal of a fallopian tube Removal of the tonsils Removal of the breast - appendectomy cholecystectomy hysterectomy Salpingo-oophorectomy tonsillectomy mastectomy What are the five vital signs? - Blood pressure (BP), heart rate (HR), oxygen saturation (SaO2), respiratory rate (RR), temperature (C or F) What does NKDA stand for? - no known drug allergies What does LNMP stand for? - Last Normal Menstrual Period If the doctor said the exam was "benign", what does this mean? - this means that the exam was normal and of no concern Explain acute vs chronic. - acute: serious, new condition, that could potentially be life- threatening chronic: not of much concern, long-lasting condition, typically not a death threat What are the two types of heart attacks and how are they diagnosed? - STEMI (ST elevation myocardial infarction) and NSTEMI (non ST elevation myocardial infarction) STEMI: EKG NSTEMI: troponin What are three cardiac risk factors? - HTN, DM, HLD, CAD, Smoking, FHx CAD < 55 y/o What are four associated symptoms of an MI other than CP? (Hint: catch phrase) - Chest pressure with diaphoresis, N/V (nausea and vomiting), and SOB What are three symptoms a patient with an Ischemic CVA might present with? - Unilateral focal neurological deficits: One-sided weakness, one-sided numbness or changes in speech/vision What are the only three symptoms of a true allergic reaction? - SOB (difficulty breathing), rash, itching/swelling What heart rhythm would a physician hear if the patient were in atrial fibrillation and how is this disease diagnosed? - an irregularly irregular rhythm, this is diagnosed by and EKG What physical exam finding is associated with asthma? - wheezes (while inspiring or expiring) How is altered mental status different from a focal neurological deficit? - AMS is very different than a focal neurological deficit. AMS is generalized and is typically caused by things that affect the whole brain (drugs, low blood sugar). Focal neurological deficits are localized weakness/numbness in one specific area, corresponding with damage at one specific site in the brain. The most common cause of AMS for patients without a Hx of dementia is from infection, most often caused by a UTI. What is the major cause of AMS in the elderly? - UTI Name one medication associated with seizures. - Dilantin, Tegretol, Keppra, Depakote, Neurontin What question is every patient asked who comes in with a chief complaint of syncope? - Document what happened prior, during, and after the syncopal episode, as well as how the patient currently feels What is the medication administered for CVAs and when is it used vs when would it not be indicated? - Ischemic CVA: tPA or another anticoagulant (not used for a hemorrhagic CVA because it breaks down blood clots and if there is a brain bleed, this would not be helpful in this case) Hemorrhagic CVA: anticonvulsants What is "layman's name" for GERD? - Acid Reflux/Heartburn What is the most common cause for seizures in children? - fever In your own words, describe the significance of an HPI. - The HPI is the beginning of every chart summarizing the reason for the visit and this describes the CC *The HPI should ONLY include information directly related to the CHIEF COMPLAINT and IMPORTANT CONTEXT for that patient. Name three people who will read the HPI other than the physician. - Nurses, Coders, and admitting doctors Name six elements of the HPI - quality, location, timing, onset, duration, associated symptoms, severity, modifying factors, context How many elements of the HPI do you need to document for a complete chart? - 4 elements True or False: The patient's entire ED visit is based on their answers to the questions asked during the HPI. - true True or False: Accurate chronology is not important in an HPI. - false- accurate chronology is very important What is the main difference between an HPI and an ROS? - HPI contains the CC and anything directly related to why the patient is there, whereas the ROS is a checklist of symptoms that the patient does or does not have. How many elements of the ROS do you need to document for a complete chart? - 10 elements List five body systems found in the ROS and provide two symptoms for each system. - Genitourinary: dysuria, Frequency, urgency, Hematuria Neurological: HA, Syncope, Seizure, Numbness, Focal weakness Cardiovascular: CP, palpitations, leg swelling (edema) Gastrointestinal: Abdominal pain, N/V/D, Black or bloody stools Constitutional: Fever, weight loss, diaphoresis True or False: The symptoms listed in the ROS can contradict the symptoms discussed in the HPI. - False. Symptoms that are documented in the HPI also need to be documented in the ROS. How would you document the GPA for a patient who is currently pregnant, has been pregnant two times in the past, and has one child at home? - 4/1/1