Docsity
Docsity

Prepare for your exams
Prepare for your exams

Study with the several resources on Docsity


Earn points to download
Earn points to download

Earn points by helping other students or get them with a premium plan


Guidelines and tips
Guidelines and tips

SCRIBE AMERICA FINAL EXAM STUDY GUIDE 100% CORRECT, Exams of Medicine

SCRIBE AMERICA FINAL EXAM STUDY GUIDE 100% CORRECT 1. ScribeAmerica final exam study guide with 100% accurate answers 2. How to pass ScribeAmerica final exam with perfect score 3. ScribeAmerica certification exam preparation tips and tricks 4. Guaranteed success strategies for ScribeAmerica final test 5. ScribeAmerica exam study materials with verified answers 6. Best resources for acing ScribeAmerica final assessment 7. ScribeAmerica final exam practice questions and solutions 8. Comprehensive review guide for ScribeAmerica certification 9. ScribeAmerica final exam cheat sheet with correct answers 10. Step-by-step preparation for ScribeAmerica final exam success 11. ScribeAmerica final exam study plan for 100% score 12. Top mistakes to avoid on ScribeAmerica final exam 13. ScribeAmerica final exam study group with verified answers 14. Last-minute revision tips for ScribeAmerica final exam 15. ScribeAmerica final exam question bank with explanations ScribeAmerica final exam

Typology: Exams

2024/2025

Available from 06/13/2025

Prof.Steve
Prof.Steve šŸ‡ŗšŸ‡ø

361 documents

1 / 64

Toggle sidebar

This page cannot be seen from the preview

Don't miss anything!

bg1
1 / 32
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
pf3
pf4
pf5
pf8
pf9
pfa
pfd
pfe
pff
pf12
pf13
pf14
pf15
pf16
pf17
pf18
pf19
pf1a
pf1b
pf1c
pf1d
pf1e
pf1f
pf20
pf21
pf22
pf23
pf24
pf25
pf26
pf27
pf28
pf29
pf2a
pf2b
pf2c
pf2d
pf2e
pf2f
pf30
pf31
pf32
pf33
pf34
pf35
pf36
pf37
pf38
pf39
pf3a
pf3b
pf3c
pf3d
pf3e
pf3f
pf40

Partial preview of the text

Download SCRIBE AMERICA FINAL EXAM STUDY GUIDE 100% CORRECT and more Exams Medicine in PDF only on Docsity!

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