Download MEDICAL SCRIBE- FINAL EXAM REVIEW QUESTIONS & ANSWERS 100% CORRECT and more Exams Medicine in PDF only on Docsity!
MEDICAL SCRIBE- FINAL EXAM REVIEW
QUESTIONS & ANSWERS
1. What are the 5 vital signs?: 1. Heart rate
2. Blood pressure
3. Respiratory rate
4. Temperature
5. Oxygen saturation
2. The HPI and the ROS are what type of information?:
3. The physical exam is what kind of information?:
4. While evaluating a patient complaining of chest pain, your physician tells
you that the heart sounds are normal. Would you document this in the HPI, ROS, or PE?: Physical exam
5. Would you be contradicting yourself if you wrote, " the patient has abdom-
inal pain", in the HPI, but then later in the physical exam documented, "the abdomen is non-tender", why or why not?: No, because the patient stating that they have abdominal pain is a subjective complaint. A non-tender abdomen is an objective finding.
6. What is the difference between the HPI, and the ROS?: HPI focuses on the
details related to their chief complaint, ROS is a head to toe checklist of symptoms. It
includes the chief complaint, associated symptoms, and all other complaints the patient may have.
7. What does disposition (dispo) mean?: The patient's destination after they
leave the ED.
8. What subcategories are included within the past history section of the
template?: PMHx: Past medical history- HTN, DM, HLD, CAD, MI PSHx: Past surgical history- appendectomy, cholecystectomy, CABG FHx: Family history- Hx of CAD<55 years old SHx: Social history- ETOH, smoking, drug abuse, occupation
9. What is the abbrieviation for heart attack?: MI- myocardial infarction
10. What is the abbreviation for high blood pressure?: HTN- hypertension
11. What is the medical term for acid reflux?: Gastroesophageal reflux disease
12. What is the medical term for stroke?: CVA- cerebral vascular accident
13. What is the term for gallbladder removal?: Cholecystectomy
14. What does NKDA stand for?: No know drug allergies
15. What is the medical term for redness?: Erythema
16. What is the medical term for bruising?: Ecchymosis
30. What is A-fib?: Electrical abnormality of the heart causing the top of the heart to
quiver.
31. What might someone feel with A-Fib?: Palpations, fast, pounding, irregular
heart beat.
32. How is A-Fib diagnosed?: EKG
33. What could be the CC of someone with a PE?: Pleuritic CP, SOB.
34. What are the risk factors of a PE?: Known DVT, PMHx of DVT or PE, FHx of
DVT or PE, recent surgery, CA, A fib immobility, pregnancy, BCP, smoking
35. What study would diagnose a PE?: CTA chest/VQ scan. D-Dimer can only rule
it out.
36. What part of the heart does CAD affect?: Artery
37. Can a CT chest without IV contrast diagnose a PE? Why or why not?: No.
You need to be able to see the blood flow. If you can see where the blockage is then you cant determine the flow of blood. You wont see anything with a dry CT.
38. What is an aortic dissection?: The separation of the muscular wall from the
membrane of the artery, putting the patient at risk for aortic rupture and death.
39. What is PTX?: Pneumothorax, collapsed lung
40. What is the most common cause of PTX?: Trauma
41. How is the PTX diagnosed?: CXR
42. What social history will most COPD patients also have?: Smoking
43. What is the difference between a nebulizer, and an inhaler for asthma?: An
inhaler is portable and gives a one-time dose and provides a rapid release of medication. A nebulizer is a home machine that delivers continuous treatment over a period of time.
44. What is asthma?: Constricting of the airway due to inflammation and muscular
contraction of the bronchioles. Also called, reactive airway disease.
45. What physical exam finding also associates with asthma?: Wheezing
46. What is PNA?: Pneumonia. Bacterial infection and inflammation inside the
lung.
47. What might a person with PNA complain of?: Productive cough and fever.
48. How is PNA diagnosed?: CXR
49. Name all 7 areas of the abdomen?: Epigastrium, RUQ, LUQ, RLQ, LLQ,
56. What might be the chief complaint of a person with gallstones?: RUQ
abdominal pain
57. What physical exam finding is closely associated with cholecystitis?: -
Murphy's signs
58. How are gallstones diagnosed?: Abdominal ultra sound of the RUQ
59. Name associated symptoms of appendicitis:: Fever, N/V, decreased ap- petite
(anorexia). Note: RLQ pain-gradual, constant, worse w/ movements is the CC (not associated symptom.
60. How is appendicitis diagnosed?: CT A/P with PO contrast.
61. What would someone with pancreatitis complain of?: LUQ abdominal pain,
N/V, fever
62. How is pancreatitis diagnosed?: Elevated lipase
63. Name for possible CC's for a GI bleed pt:: Hematemesis, coffee ground
emesis, hematochezia, melena.
64. How is a GI bleed diagnosed in the ED?: Guaiac positive or heme+ stool,
gastroccult
65. What are we worried about for someone with a GI bleed?: Too much blood
loss, anemia
66. What is the pre-existing condition you must have before you can get
diverticulitis?: Diverticulosis
67. What will be the CC for someone with diverticulitis?: LLQ abdominal pain
68. What studies would diagnose diverticulitis?: CT A/P with PO contrast
69. What might a person with SBO complain of?: Abd pain/bloating, vomiting,
abdominal distension, no BM's, constipation.
70. How is an SBO diagnosed?: CT w/ PO contrast or AAS (acute abd series) X-ray.
71. What is pyelo?: Pyelonephritis, kidney infection (different and worse than a
UTI), usually spread from a UTI
72. What will be the chief complaint from someone with a UTI?: Painful urina-
tion (dysuria), frequency, burning, hesitancy, malodourous urine.
73. Where would a patient feel pain if they had pyelo?: Flank pain, fever and
dysuria.
86. What is a TIA?: Transient ischemic attack. Mino stroke. Temporary loss of
blood supply to the brain.
87. How does a TIA differ from a CVA?: TIA- mini stroke, symptoms usually
resolve in less than an hour. CVA- stroke, symptoms last longer, and potentially may not go away.
88. What is a common cause for seizures in children?: Fever
89. What is the name of the state after a seizure?: Postical
90. What are the 3 symptoms of meningitis?: Fever, neck pain/stiffness,
headache
91. What study would diagnose meningitis?: LP- Lumbar puncture
92. What are 4 important things to document for syncopal episodes?: How
they felt before, during, after, and how they currently feel
93. Name 4 causes of altered mental status:: Hypoglycemia, infection, intoxica-
tion, neurological
94. How is AMS different from focal neuro-deficit?: AMS is generalized and
typically caused by something that can affect the whole brain (drugs, low blood sugar). FND are localized (weakness/numbness/speech/vision) to one specific area and corresponds to damage of specific part of the brain.
95. What is DVT?: Deep venous thrombis
96. What are the risk factors for DVT?: Known DVT, PMHx of DVT or PE, FHx of
DVT or PE, recent surgery, CA, A-fib, immobility, pregnancy, BCP, smoking.
97. What are the common signs of DVT?: Extremity pain, swelling (atraumatic)
98. What is AAA?: Abdominal aortic aneurysm.
99. What are three symptoms of cellulitis?: Redness, swelling and pain to an area
of the skin.
100. How is an abscess different from cellulitis: Abscess is cellulitis with fluc-
tuation (pus pocket).
101. What procedure will be performed for every abscess?: Incision and
drainage.
102. What is the main concern with an allergic reaction?: Anaphylaxis, or
respiratory failure.
108. How is the HPI different from the ROS?: HPI focus is a story about the chief
complaint and its associated symptoms. ROS is a checklist of symptoms. It includes the CC, its associated sx and all of the other complaints the pt might have.
109. Name 5 elements of the HPI?: Onset, timing, associated symptoms, loca- tion,
quality, severity, modifying factors, associated symptoms, context.
110. Name 8 of the body systems included in the ROS.: Constitutional, eyes, ENT,
CV, resp, GI, GU, MS, skin, neuro, psych, endocrine, heme/lymph, immuno- logical.
111. Can the systems listed in the ROS ever contradict the symptoms de-
scribed in the HPI? Why?: No, symptoms that are documented in the HPI, also need to be documented in the ROS.
112. What do you need to remember to document In the HPI and ROS for any
patient that is unconscious or incapable of providing information?: "HPI, ROS limited by.............."
113. Identify the error in this sentence from an example HPI: "patient states
the CP has been intermittent since Thursday": We do not document days of the week in the HPI. Instead, we would count back the number of days and document this numerically.
114. Why is it important to remember to document if the patient has had sim-
ilar symptoms in the past?: Because it is less likely that their current symptoms are life threatening if they have survived similar symptoms in the past.
115. Name on detail that is important to document if the patient has been
evaluated in the past for a similar complaint. What symptoms prompted the prior evaluation? How long ago did the prior evaluation occur? Who did they
see? (Name and specialty) What treatment did they receive? Did it help what diagnosis was given? Any prior test results?:
116. What should you focus on when writing an HPI? (Choose one): Docu-
menting the answers to every question asked by the doctor.
117. Which is the first item in the formula for an HPI?:
118. What does MOI stand for in a Trauma HPI?: Mechanism of injury.
119. True or false: In the ROS you should document "all other systems
negative except as mark" for every patient::
120. Based on your knowledge from day 2, why should you always pay
special attention to the complaints of chest pain and SOB?: Direct concern for MI
130. Hematuria: blood in the urine
131. Pedal edema: swelling under skin of feet and ankles, related to CHF
132. Bruise: Ecchymosis
133. nose bleed: Epistaxis
134. Guarding and rebound would be positive findings for this region of the
body: abdomen
135. This body part to determine if there is JVD: neck
136. The presence of fluctuance would likely indicate this in the body tissue:
137. Distal lungs: wheezing, coughing etc..
138. This lab test would be high in patients with pancreatitis: Lipase
139. Salpingo oopherectomy: removal of the ovaries and the fallopian tube
140. What is BUN: blood urea nitrogen
141. What is crenanin?:
142. D-Dimer rules out: DVT or blood clots.. cannot diagnose PE
143. What is pitting edema: Edema that leaves an imprint when touched
144. What are the 4 most important symptoms to write for ay trauma patient-
: LOC, head injury, neck pain, back pain
145. exacerbate: to make worse
146. subjective: based on the patients feelings
147. objective: factual info from provider
148. intermittent: comes and goes
149. waxing and waning: always present but changing in intensity
150. modifying factor: something that makes a symptom better or worse
151. EOMI: extra ocular movements intact
152. easily palpable (normal): 2+
153. barely palpable: 1+
154. absent: 0
155. Full: 3+
156. bounding/aneurysmal: 4+
