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SCRIBE AMERICA FINAL EXAM STUDY GUIDE
1. What does ROS stand for?: Review of symptoms, head to toe checklist of
symptoms
2. The HPI and ROS are considered what type of information?: Subjective
3. The physical exam is what type of information?: Objective
4. If a physician told you a patients abdomen was nontender or the patients
skin was plale, where would you document this information: Physical Exam (PE)
5. What section focuses directly on the chief complaint?: HPI (History of
present illness)
6. What are the 5 vital signs?: 1. Heart rate (HR)
2. Respiratory rate (RR)
3. Blood pressure (BP)
4. Temperature (T)
5. Oxygen Saturation (SpO2)
7. Surgical Hx example: CABG (Coronary artery bypass graft)
8. Social Hx example: Smoker 1 ppd
9. Family Hx example: Brother diagnosed with CAD < 55 y/o
10. Removal of appendix: Appendectomy
11. Removal of gallbladder: Cholecystectomy
12. Removal of uterus: Hysterectomy
13. Removal of tonsils: Tonsillectomy
14. What are the 2 types of heart attacks and how are they diagnosed?: STE- MI
- EKG
Non-STEMI - Troponin
15. What are 3 cardiac risk factors?: HTN, HLD, Smoking, CAD, DM, FHx CAD
< 55 y/o
16. Chest pain, dyspnea, cough and fever correlated to which DDx?
What study would be ordered?: PNA (Pneumonia) CXR
17. What are 3 symptoms a patient with an Ischemic CVA would present
with?: Unilateral weakness/numbness, slurred speech, vision changes
example of each element: Onset - 3 weeks ago Timing - intermittent Quality - pressure Severity - 9/ location - frontal/forehead Modifying factors - worse with light, better after Excedrin Context - does not take a blood thinner, no recent head injuries, Hx of similar HA
26. True or False:
Patients entire ED visit is based on their answers to the questions asked during the interview?: True
27. True or False:
Accurate chronology is not important in an HPI: False
28. What is the main different between HPI and ROS?: HPI - story of the CC
ROS - head-to-toe checklist of subjective Sx
29. True or False:
Symptoms listed in ROS can contradict the Sx discussed in the HPI: False
30. How would you document GPA for a patient who is currently pregnant,
has been pregnant 4 time in the past, and has one child at home?: G - 5 P - 1 A - 3
31. List 5 body systems found in the ROS and provide 2 symptoms for each
system.: Skin - Rashes, itching, redness General - fever, chills, weight loss Cardio - Chest pain,Palpitations Pulmonary - shortness of breath, dyspnea, cough, wheezing GI - abdominal pain, acid reflux
inhalers prescribed by her pulmonologist (Dr. Aranibar) have not provided relief. She reports dyspnea and a mild dry cough since last night, but no fever, chest pain, leg pain, leg swelling, or recent travel. The patient was unable to walk to her bathroom this afternoon secondary to her dyspnea, prompting the 911 call. When paramedics arrived to the patient's home 30 minutes ago, tight expiratory wheezes in all fields were appreciated and the patient's SpO2 was 90% on RA. The patient received a DuoNeb breathing treatment and Solumedrol 125 mg en route to the ED, with mild symptom relief.: CC: wheezing Onset: 4 days ago Timing: worsening Location: Quality: "cannot take a full breath" Severity: not stated, but the spO2 reported by paramedics allows us to understand the objective severity Modifying factors: albuterol inhalers presrcibed by Dr. Aranibar has not provided relief. EMS provided DuoNeb breathing treatment and solumedrol 125 mg en route to ED with mild symptom relief Associated sx: dyspnea, mild dry cough Pertinent negatives: fever, chest pain, leg pain, leg swelling, recent travel Context: Hx of asthma, similar to asthma, EMS report (VS en route)
33. What do you write on the chart if the doctor states, "The pulses are weak"
after checking the patients pulse near the left groin: +1 left femoral pulse
34. What organs are in the following quadrants:
Epigastrium LUQ LLQ: Epigastrium - Stomach LUQ - Pancreas LLQ - Large intestine, Ovary
AND
4) studies you predict the MD to order
Rovsing sign CVA tenderness Rhonchi Uvular shift (Google to find the test ordered, not technically in the work- book!).: Rosvings sign is characterized as RLQ pain with LLQ palpation, DDx is appendicitis, charted in abdomen/GI, and orders for CT A/P (abd/pelvis)
CVA tenderness is characterized as tenderness in the flank (angle between the ribs/spine), DDx is pyelonephritis or pyelolithiasis (kidney stones), charted in the back region, orders for CT A/P and UA Rhonchi is characterized as rattling sounds in the lungs, DDx is PNA, charted in respiratory, orders for CXR Uvular shift is characterized as the uvula moved to one side, DDx is a peritonsillar abscess, charted in ENT section and orders for CT of the neck
43. What organ do LFT's investigate?: Liver
44. A high potassium is called and this is commonly due to .: Hy-
perkalemia, renal failure
45. What does a chest tube treat?: PTX (pneumothorax)
46. Name the procedure used to treat an abscess?: I&D (Incision and drainage)
47. Name 2 procedures that follow sterile technique?: LP, Central line, chest
tube
48. What are the 3 reasons to consult another physician?: - admit patient
- contact specialist for advice
- contact PCP for more information
49. What are 4 of the 12 EKG leads: I, II, III, V1, V2, V3, V4, V5, V6, aVL, aVR,
AVF
50. Hyponaturemia is and indicates.: low sodium levels, dehydration
47, CABG x2 in 2011, and tonsillectomy.: No, this is only medical and surgical history which are considered 1 element Need 1 from FHx and SHx
55. Give 5 examples of PHI: Name, Address, DOB, SSN, phone number, email,
insurance information
56. How many elements are required for a level 5 ROS with and without the
"all systems negative" phrase: 10 systems 2 systems with "all system negative" phrase
57. True or False:
The "All systems negative" phrase is used for all chart: False, including the phrase is the physicians preference AND also never used on patients unable to complete the interview (advanced dementia, AMS, unresponsive)
58. Name 4 common events that are time stamped in the chart: - The moment the
provider walks into the patients room for the intial evaluations
- medication orders
- consults
- procedure start/end times
- disposition times
59. Describe a scenario where the R/B/A (risk benefit assessment) discus- sion
would very commonly occur.: Before a high risk procedure such as the lumbar
puncture, conscious sedation, cardioversion, receiving tPA, starting/stop- ping blood thinners, CTs for children
60. List 2 examples of a "unique exam identifier": Tattoos, scars, piercings
amputations, G-tubes, trach scars, "zipper" sternotomy scar, birthmarks
61. How many elements are included in this HPI:
Ariana Venti is a 24 y/o female presenting to the ED with sharp chest pain onset suddenly 4 hours ago. The pain is located over the central chest and worse when leaning forward.: 4 (level 5 billing) Quality - sharp Location
- Central chest Onset - 4 hours ago Mod factor - worse when leaning forward
History and Physical (H&P) Labs/Radiology/Medications Medical Decision Making (MDM) Disposition
70. What FHx/SHx information is commonly asked for most pediatric pa-
tients?: Second hand smoke exposure, immunization status
71. What is the medical term for the following past surgical history?
Kidney removal: Nephrectomy
72. According to your job description, if your doctor asks you to hold the
patients neck while they are cleared from the blackboard you should:: Politely remind the doctor that is outside your job description, but offer to get a nurse or tech to help
73. Auscultation: Listening with a stethoscope
74. Scribes CANNOT: - Touch patients
- Write orders or prescriptions
- Give verbal orders
- Partake in any activity that may affect patient health or outcome
- Sign or authenticate any chart or record
- Handle bodily fluids or specimens
75. Mid-Level Provider: NP, PA (works under supervision of physician to Dx and
treat patients
76. Charge Nurse: Manages ED pt flow
77. Respiratory therapists (RT): administers breathing treatments and assists
with managing a pt's airway
78. Level of Acuity: 5 (low) to 1 (high)
79. High blood pressure: hypertension (HTN)
80. high cholesterol: hyperlidemia (HLD)
81. Thyroid problem: Hyperthyroidism
Hypothyroidism
82. Diabetes: Diabetes Mellitus (DM)
83. "I only take pills for my diabetes": Non-Insulin Dependent Diabetes Mellitus
93. Pneumonia: Pneumonia (PNA)
94. Reflux: Gastroesophageal Reflux Disease (GERD)
95. Ulcer: Gastric Ulcer or Peptic Ulcer Disease
96. Crohn's/UC: Crohn's Disease or Ulcerative Colitis
97. Irritable bowel: Irritable Bowel Syndrome (IBS)
98. Bladder infection: Urinary Tract Infection (UTI)
99. Kidney infection: Pyelonephritis (Pyelo)
100. Kidney Stones: Renal Calculi
101. "I'm on dialysis": Chronic Renal Failure (CRF)
End stage Renal Disease (ESRD) on dialysis
102. Enlarged Prostrate: Benign Prostatic Hypertrophy (BPH)
103. Brain bleed: Hemorrhagic Cerebrovascular Accident (CVA)
104. Stroke: Ischemic Cerebrovascular Accident (CVA)
105. Mini-stroke: Transient Ischemic Attack (TIA)
106. Bipolar: Bipolar Disorder
107. "I drink a lot": ETOH abuse or alcoholism
108. "I do drugs": Substance Abuse
109. Blood clot in my leg: Lower extremity Deep Vein Thrombosis (DVT)
110. Bulge in my aorta: Aortic Aneurysm
111. Bad blood flow to my legs: Peripheral Vascular Disease (PVD)
112. Numbness in my legs: Peripheral Neuropathy
113. Low back pain: Chronic Low Back Pain
114. Bulging/Herniated disc: Degenerative Disc Disease (DDD)
115. Arthritis: Osteoarthritis (OA)
Rheumatoid Arthritis (RA)
116. Weak/Fragile bones: Osteroporosis
117. Cancer: Cancer (CA) or Carcinoma
118. Spread to my...: With metastases to the...
119. They cut it out: Status-post (s/p) surgical resection
120. It's gone: In remission
