Scribe America Final Exam Questions and
Answers 100% Correct
medical decision making -ANSWER- the physician's thought process
distress -ANSWER- the doctor's judgement of discomfort
baseline -ANSWER- an individual's normal state of being
Unit Secretary -ANSWER- places physician's orders, answers calls, pages for other
specialists, organizes pt. paperwork
mid level provider -ANSWER- LNP or PA; works under supervision of physician to
diagnose and treat patients
ED Nurse -ANSWER- records medical histories, symptoms, monitors the pt., starts IVs,
administers meds, assists with procedures
ED Flow -ANSWER- Walk in/EMS, Triage (CC, Vitals, Level of Acuity), Vital Signs (HR,
BP, RR, T, SaO2), Bed Placement, Nurse Assessment, History and Physical, Physician
Orders, Results and ED Course, Final Dx, Disposition
Documentation -ANSWER- HPI, ROS, Past History, PE, ED Course, Disposition
Hyperlipidemia -ANSWER- HLD
Episodes of abnormally fast/ racing heartbeat -ANSWER- Supraventricular Tachycardia
(SVT)
Emphysema/ Chronic Bronchitis -ANSWER- COPD
Ulcer -ANSWER- Gastric Ulcer or Peptic Ulcer Disease
Kidney Infection -ANSWER- Pyelonephritis
I'm on Dialysis -ANSWER- Chronic Renal Failure (CRF) or End Stage Renal Disease
(ESRD)
Pregnancies, births, and abortions -ANSWER- Para is number of live births, Gravida is
total number of times pt has been pregnant, a is the number of miscarriages or elective
abortions
Patient says I had a balloon -ANSWER- Angioplasty, PMHx CAD
, Patient says I have a hole in my neck -ANSWER- tracheostomy
Part of lung removed -ANSWER- partial lobectomy
bag to collect stool -ANSWER- colostomy
hernia repair -ANSWER- herniorrhaphy
kidney removed -ANSWER- nephrectomy
ovary removed -ANSWER- oophorectomy
tubes tied -ANSWER- tubal ligation (female) or Vasectomy (male)
uterus removed -ANSWER- hysterectomy
brain surgery -ANSWER- carniotomy
stents -ANSWER- coronary stents, PMHx CAD
Social History -ANSWER- Drug Use, Alcohol Use, Occupation, Living Circumstances,
Smoking
Differential Diagnoses -ANSWER- Diseases being considered
Coronary Artery Disease (CAD) -ANSWER- Chest pain with physical exertion, improved
by rest or NTG, diagnosed by Cardiac Catheterization or stress test, should be given
324 mg. Aspirin (Single Greatest risk factor for MI)
Atrial Fibrillation -ANSWER- Electrical abnormality. CC is palpitations.
MI -ANSWER- Chest pressure with diaphoresis, N/V, and SOB, diagnosed by EKG
(Stemi) or Troponin (non Stemi) (STEMI pts must get to Cath lab within 90 min of
arrival)
CHF -ANSWER- heart becomes enlarged, inefficient, and congested with excess fluid.
CC is SOB with associated pedal edema and orthopnea. Diagnosed by CXR or
elevated BNP. Rales, JVD and edema seen on PE. Meds are diuretics
Pericarditis -ANSWER- inflammation of the sac surrounding the heart causing CP
Angina -ANSWER- Symptom of CAD. Diagnosed by exertional CP with history of CAD
Pulmonary Embolism -ANSWER- blood clot in pulmonary artery that blocks blood flow
to the lungs. Symptoms are pleuritic chest pain (worse w/ deep breaths), SOB,
tachycardia and hypoxia. diagnosed by CTA Chest (w/ IV Contrast) or VQ Scan. D
Dimer aids in detecting clots but can't diagnose it
