ED Scribe - Final Exam Questions with 100% Correct Answers

ED Scribe - Final Exam Questions with 100% Correct Answers Medical Decision Making (MDM) - answerThe physician's thought process Pain vs. Tenderness - answerPatient's feeling vs. physician's assessment What does distress mean? - answerThe doctor's judgment of discomfort Baseline - answerAn individual's normal state of being What does Auscultation mean? - answerListening with a stethoscope Palpation - answerThe act of pressing on an area by the doctor Inpatient - answerAdmitted to the hospital overnight Outpatient - answerSeen and sent home the same day What is the ED flow (overview)? - answer1. Check in and Chief Complaint 2. Physician assessment 3. Objective orders and results 4. Medical Decision Making 5. Disposition What is the ED flow before orders are made? - answer1. Arrival 2. Triage 3. Vital Signs / Bed Placement 4. Nurse Assessment 5. HPI, ROS, Hx, PE What is the ED flow after orders are made? - answer1. Differential Dx 2. Physician orders labs, imaging, procedures, medications 3. Results and ED course 4. Final Dx 5. Disposition What is the general documentation template? - answerHPI ROS PHx PE ED course Disposition Thyroid problem means.. - answerUsually Hypothyroidism, sometimes hyperthyroidism "I only take pills for my diabetes" means.. - answerNon-Insulin Dependent Diabetes Mellitus - NIDDM "I take shots (insulin) for my diabetes" means.. - answerInsulin Dependent Diabetes Mellitus - IDDM Heart disease means.. - answerUsually Coronary Artery Disease - CAD Heart attack means.. - answerMyocardial Infarction - MI and CAD Irregular heartbeat means.. - answerAtrial Fibrillation (A-Fib) Murmur means.. - answerHeart murmur Episodes of abnormally fast/racing heartbeat means.. - answerSupraventricular Tachycardia - SVT Emphysema/Chronic Bronchitis means.. - answerChronic Obstructive Pulmonary Disease - COPD Blood clot in lung means.. - answerPulmonary Embolism - PE Reflux means.. - answerGastroesophageal Reflux Disease - GERD Ulcer means.. - answerGastric Ulcer or Peptic Ulcer Disease Hepatitis means.. - answerHepatitis A, Hepatitis B, or Hepatitis C Crohn's/UC means.. - answerCrohn's Disease or Ulcerative Colitis Kidney infection means.. - answerPyelonephritis - Pyelo Kidney stones means.. - answerRenal calculi "I'm on dialysis" means.. - answerChronic Renal Failure - CRF or End Stage Renal Disease - ESRD on dialysis Enlarged prostate means.. - answerBenign Prostate Hypertrophy - BPH What is the convention for documenting gynecological PMHx? - answerG: P: A: Stroke means.. - answerIschemic Cerebrovascular Accident - CVA Mini-stroke means.. - answerTransient Ischemic Attack - TIA Seizures means.. - answerSeizure disorder/Epilepsy Brain bleed means.. - answerHemorrhagic CVA "I drink a lot" means.. - answerETOH abuse or Alcoholism "I do drugs" means.. - answerSubstance abuse "Blood clot in my leg" means.. - answerDVT "Bulge in my aorta" or "Triple A" - answerAbdominal Aortic Aneurysm "Bad blood flow to my legs" means.. - answerPeripheral Vascular Disease - PVD "Numbness in my legs" means.. - answerPeripheral Neuropathy Bulging/Herniated disc means.. - answerDegenerative Disc Disease - DDD What does Arthritis mean? - answerOsteoarthritis, Rheumatoid Arthritis Joint pain (chronic) means.. - answerDegenerative Joint Disease -DJD Weak/fragile bones means.. - answerOsteoporosis Spread to my means.. - answerWith metastases to the.. "They cut it out" (in regards to cancer) means.. - answerStatus-post surgical resection "It's gone" (in regards to cancer) means.. - answerIn remission Tonsils removed means.. - answerTonsillectomy Adenoids removed means.. - answerAdenoidectomy Ear tubes means.. - answerPressure Equalizer Tubes Heart bypass means.. - answerCoronary Artery Bypass Graft - CABG PMHx CAD Stents means.. - answerCoronary Stents Heart Cath means.. - answerCardiac Catheterization Balloon means.. - answerAngioplasty PMHx CAD Valve surgery means.. - answerValve repair or replacement - Bovine vs. Mechanical Pacer means.. - answerPacemaker Defibrillator means.. - answerAutomatic Implanted Cardiac Defibrillator - AICD Surgery for A Fib means.. - answerAfib s/p cardiac ablation Breast removal means.. - answerMastectomy Hole in my neck means.. - answerTracheostomy - commonly called "trach" Part of lung removed means.. - answerPartial lobectomy Gallbladder removed means.. - answerCholecystectomy Hernia repair means.. - answerHerniorrhaphy Part of my colon removed means.. - answerPartial colectomy Bag to collect stool means.. - answerColostomy Spleen removed means.. - answerSplenectomy