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SCRIBE FINAL EXAM QUESTIONS & ANSWERS
1. SOAP: Subjective-HPI, ROS, Past Med, Fam, and Social Hx (Patient's point of
view) Objective-Physical exam, Medical Decision Making (labs, x-rays, etc.) Assessment-Diagnosis (determined by combining subjective/objective info) Plan-Disposition (Admission, Discharge, Transfer instructions)
2. 7 Parts of the HPI: 1. Context
2. Time/Duration; time = course of symptoms (improving, worsening, constant,
intermittent, etc.); duration = total time symptoms have been present
3. Location
4. Quality
5. Severity
6. Modifying Factors
7. Pertinent positive and negatives
3. Level 5 Chart: HPI: 4-
ROS: 10+
PFSH: 2+
PEx: 8+ systems
4. Supination: Turning the hand so that the palm faces upward.
5. Volar: Pertaining to the palm of the hand or the sole of the foot.
6. Inferior: Situated below or further away from the head.
7. Midline: Line that divides the body into right and left halves.
8. Abduction: Moving away from the midline.
9. ACLS: Advanced cardiac life support.
10. AMA: Against medical advice.
11. DNR: do not resuscitate
12. DOA: Dead on arrival
13. OSH: Outside hospital
14. PCP: Primary care physician
15. PTA: Prior to arrival
16. UTD: Up to date (as in immunizations)
17. WNL: within normal limits
18. yo: year old
19. B/L: bilateral
37. Auscultation: Physician listens to the internal sounds of the body using a
stethoscope
38. Organomegaly: Enlargement of organs
39. Palpation: Physician feels the different parts of the body
40. Idiopathic: no known cause
41. Necrosis: Premature death of cells in living tissue
42. Ostomy: surgically created opening connecting an internal organ to the sur-
face of the body
43. Infarct: Tissue death caused by a local lack of oxygen due to obstruction of the
tissue's blood supply
44. Stenosis: narrowing of a body opening or passage
45. Ischemia: Decrease in the blood supply to a bodily organ, tissue, or part
caused by constriction or obstruction of the blood vessels
46. Ambulatory: Able to walk about, not confined to bed
47. Febrile: having a fever
48. Post-prandial: after eating
49. Cachectic: Malnutritioned, wasting, or in poor health
50. Orthostatic: vital signs taken sitting, standing, and supine
51. Polydipsia: excessive thirst
52. A&W: alive and well
53. NAD: no acute distress
54. WDWN: well-developed, well-nourished
55. CA: cancer
56. MRSA: methycillin resistant staphylococcus aureus; one strain of the staphy-
lococcus bacteria that is resistant to medications conventionally used to treat it
57. DKA: diabetic ketoacidosis-occurs when the body cannot use sugar (glucose) as
a fuel sources because there is no insulin or not enough insulin. Fat is used for fuel instead and produces ketones.
58. DM: diabetes mellitues-a condition characterized by high blood glucose due to
inability to produce insulin or to the cells' inability to respond to insulin
59. FSBS: finger stick blood sugar
60. IDDM: insulin-dependent diabetes mellitus
72. Thyroidectomy: Operation that involved the removal of part or all of they
thyroid
73. ABG: Arterial blood gas-determines the pH of the blood, the partial pressures of
CO2 and O2 in the blood, and the bicarbonate level via blood drawn from an artery
74. BMP: basic metabolic panel-measures your glucose level, electrolyte and fluid
balance, and kidney function (creatinine, K+, Na+, Cl-, and glucose)
75. CBC: complete blood count
76. CMP: complete metabolic panel-BMP plus LFTs and calcium level
77. H&H: HGB&HCT (hemoglobin and hematocrit)
78. LFTs: liver function tests-tests the livers ability to get rid of bilirubin from the
blood and to produce albumin
79. T&S: type and screen
80. UA: urine analysis
81. UDS: urine drug screen
82. IM: intramuscular
83. IV: intravenous
84. SQ: subcutaneous
85. NPO: nothing by mouth
86. PR: per rectum
87. BID: twice a day
88. PRN: as needed
89. TID: three times a day
90. NS: normal saline
91. Abx: antibiotics
92. NKDA: no known drug allergies
93. IVF: IV fluid
94. D-Dimer: Measures fibrin split products. Non-specific test used to help rule out
PE or DVT.
95. Advair: Pulmonary
96. Percocet: Pain control/sedation
114. Albuterol: Pulmonary
115. Singulair: Pulmonary
116. Arrhythmia: irregular or loss of cardiac rhythm
117. Palpitations: Rapid heart rate (subjective irregularity)
118. Hypotension: low blood pressure
119. BP: blood pressure
120. CP: chest pain
121. EKG: electrocardiogram-transthoracic interpretation of the electrical activity
of the heart over a period of time, as detected by electrodes attached to the outer surface of the skin and recorded by a device external to the body
122. EF: ejection fraction-volume of blood pumped from the left and right ventricles
with each heart beath
123. HR: heart ratd
124. PND: paroxysmal nocturnal dyspnea-sudden, severe shortness of breath that
usually occurs at night and wakes a person from sleep
125. HTN: hypertension
126. Angina: chest pain or discomfort that occurs when an area of your heart
muscle doesn't get enough oxygen rich blood
127. Arteries: blood vessels that carry blood away from the heart
128. Veins: blood vessels that carry blood to the heart
129. Bradychardia: slow heart rate (<60)
130. Gallop: extra heart sound called S3 or S4 dependent upon where in the cycle
this added sound comes
131. Edema: swelling of tissue due to excess accumulation of fluid
132. Tachycardia: fast heart rate (>100)
133. Reproducible chest pain: Chest pain that is elicited by palpating the chest
134. BPM: beats per minute
135. DP pulse: dorsalis pedis pulse
136. PT: posterior tibia pulse
137. NSR: normal sinus rhythm
138. JVD: jugular vein distension-bulging of veins in the neck
145. MI: myocardial infarction
146. PE: pulmonary embolism-blood clot that forms in a vein, travels through your
bloodstream, and lodges in your lungs
147. STEMI: ST elevated myocardial infarction
148. aneurysm: Widening of a blood vessel due to pressure on weakened tissues
causing formation of a sac of blood
149. Asystole: state of no cardiac activity
150. Cardiomegaly: enlarged heart
151. Cardioversion: Medical procedure by which an abnormally fast heart rate or
cardiac arrhythmia is converted to a normal rhythm, using electricity or drugs
1. synchronized: sends a therapeutic dose of electric current to the heart at a
specific moment in the cardiac cycle; used to treat cardiac arrhythmias when a pulse is present
2. unsynchronized (defibrillation): used when there is no pulse present
3. Chemical: uses antiarrhythmia medication instead of an electric shock such as
lidocain, adenosine, or amiodarone
152. Echocardiogram: sonogram of the heart, also called cardiac ultrasound
153. Pericarditis: inflammation of the pericardium (fluid filled sac that surrounds
the heart)
154. Risk factors for heart disease: 1. HTN
2. high cholesterol
3. tobacco use
4. family history
5. diabetes
6. obesity
7. age (elderly)
155. Apnea: loss of spontaneous respirations
156. Dyspnea: SOB
157. Hemoptysis: coughing up blood
158. Orthopnea: dyspnea upon lying flat
159. Trachea: airway that connects the lungs and the layrnx/pharynx
160. DOE: dyspnea on exertion
161. NC: nasal canula
6. BCP or hormonal replacement therapy
7. family history
173. stridor: harsh, high pitched sound caused by obstruction of air passages
174. wheezing: whistling sound resulting from the narrowing of air passages
175. croup: swelling around the vocal cords leading to a "barking" cough; common
among children
176. hemothorax: collection of blood in the pleural cavity
177. pneumothorax: collection of air in the space around the lungs
178. Cerumen: earwax
179. Nares: nostrils
180. sinusitis: inflammation of the sinuses
181. Chemosis: swelling of the conjuctiva (the thin membrane that covers the
surface of the eyelid and the sclera)
182. Scleral icterus: yellowing of the sclera
183. aphasia: inability to express oneself through speech
184. paresthesias: situation of tingling, numbness, or prickling
185. vertigo: a particular type of dizziness characterized by a spinning sensation
when stationary
186. subdural hematoma: collection of blood on the brain
187. clonus: involuntary contraction and relaxation of the muscle, characteristic of
some neurologic disorders
188. TM: tympanic membrane-cone-shaped membrane that separates the internal
ear from the middle ear; aka the ear drum
189. MMM: moist mucous membranes
190. EOMI: extraocular motion intact
191. PERRL: pupils equal round reactive to light
192. AMS: altered mental status
193. ALOC: altered level of consciousness
194. CVA: cerebral vascular accident-aka stroke; blood flow to a part of the brain
stops; ischemic or hemorrhagic
195. MAE: moving all extremities
196. A&O: alert and oriented
206. dymentia: loss of global cognitive ability in a previously unimpaired person,
beyond what might be expected from normal aging
207. Hydrocephaly: build up of fluid inside the skull
208. Tonic clonic (grand mal): type of seizure that affects the entire brain
209. Sensation: Perception of a stimulus
210. Mandible: lower jaw bone
211. Trismus: inability to normally open the mouth
212. Tonsillectomy: removal of one or both tonsils
213. Conjunctiva: thin membrane that covers the inner surface of the eyelid and
the sclera
214. Hyphema: blood in the front area of the eye
215. Ptosis: drooping of the upper eyelid
216. Dysarthria: speech condition that occurs making it difficult to pronounce
words due to weakness, paralysis or lack of muscle coordination
217. Saddle anesthesia: loss of sensation restricted to the area of the buttocks
and perineum
218. Meningitis: inflammation of the membranes of the spinal cord or brain (viral
or bacterial)
219. Babinski: Reflex elicited when the sole of the foot is stimulated wit ha blunt
instrument based upon what the big toe does when the sole of the foot is stimulated
220. Mentation: mental activity
221. Nuchal rigidity: patient is unable to flex his or her head forward due to an
unnatural rigidity of the neck muscles
222. Visual acuity test: determines the smallest thing a person can see
223. Visual Fields test: determines degree of peripheral vision
224. CN I: olfactory nerve
225. CN II: optic
226. CN III: oculomotor
227. CN IV: trochlear
228. CN V: trigeminal
229. CN VI: Abducens
