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SCRIBEAMERICA FINAL EXAM QUESTIONS &
ANSWERS 100% CORRECT
1. A patient is seen in the emergency department complaining of dysuria and
tells you that she is 23 weeks pregnant. Your doctor diagnoses her with a UTI. Which of the following would be the best diagnosis?: acute urinary tract infection in pregnancy, 2nd trimester
2. A patient cut his left foot on a piece of glass two hours ago and is seen in
the emergency department to have sutures placed. The doctor tells you there is no tendon injury and circulatory, sensory and motor is intact. What is the best diagnosis for his complaint?: Uncomplicated laceration of the left foot - initial encounter
3. What does AMS stand for?: altered mental status
4. What does GCS stand for?: glasgow coma scale
5. What does DNR stand for?: do not resuscitate
6. What does AAA stand for?: abdominal aortic aneurysm
7. What does PE stand for in the diagnosis section of the chart?: pulmonary
embolism
8. What does DP stand for in "DP pulse"?: dorsalis pedis
9. What does DVT stand for?: deep vein thrombosis
10. What does NTG stand for?: nitroglycerin
11. What does URI stand for?: upper respiratory infection
12. What does CHF stand for?: congestive heart failure
13. What does s/p stand for?: status post
14. What does GERD stand for?: gastroesophageal reflux disease
15. What does EOMI stand for?: extraocular movements intact
16. What does DOE stand for?: dyspnea on exertion
17. What does LBBB stand for?: left bundle branch block
18. What does CVA stand for?: costovertebral angle
19. What does CSF stand for?: cerebrospinal fluid
20. What does PTX stand for?: pneumothorax
21. What does COPD stand for?: chronic obstructive pulmonary disease
22. What does PNA stand for?: pneumonia
23. What does CBC stand for?: complete blood count
Unit Secretary, ED tech, Scribe, Mid-level Provider, charge nurse, RT, ED nurse : Documents the patient's visits on behalf of the physician : Answers phone calls, pages other specialists/ doctors, and orga- nizes the patient's paperwork : Records medical histories, symptoms, monitors the patient, starts IVs, administers mediations, and assists with procedures : Helps the nurse and assists with procedures
: Administers "breathing treatments" and assists with managing a patient's airway : NP or PA that works under the supervision of a physician to diagnose and treat patients : Manages the ED patient flow: Scribe: Documents the patient's visits on behalf of the physician Unit Secretary: Answers phone calls, pages other specialists/ doctors, and orga- nizes the patient's paperwork ED Nurse: Records medical histories, symptoms, monitors the patient, starts IVs, administers mediations, and assists with procedures ED Tech: Helps the nurse and assists with procedures RT: Administers "breathing treatments" and assists with managing a patient's airway Mid-Level Provider: NP or PA that works under the supervision of a physician to diagnose and treat patients Charge Nurse: Manages the ED patient flow
28. T/F. It is the middle of the day. Your provider is busy dealing with a
e. FHx
f. PE: PSHx
PE
30. Which of the following would be documented in ED Course?
a. Physical Exam
b. HPI
c. Family History
d. Re-evals
e. Interpretations
f. Orders
g. Treatments
h. Disposition note: Re-evals
Treatments Orders Interpretations
31. An ROS has marked positive for head trauma with accompanying LOC.
What DDx would your provider be concerned about?: Hemorrhagic CVA
32. What condition is correctly describes "A vascular change that temporar-
ily deprives a part of the brain of oxygen but does not result in any long lasting deficits"?: TIA
33. Certain words or phrases act as "red flags" to grab your providers
attention to let them know a patient may require timely and comprehensive
medical action. Which of the following words or phrases are NOT considered "red flags"?: "nocturne" in a 65 y/o male
34. Match the following Dx with it's patient presentation
Asthma, COPD, PE, CHF SOB & wheezing on exam SOB & bilateral pedal edema & CP SOB & wheezing & SHx of 3ppd SOB & unilateral pedal edema & pleuritic CP: COPD: SOB + wheezing +SHx of 3 ppd PE: SOB + unilateral pedal edema + pleuritic CP
c. Migraine
d. Vertigo
e. Bell's palsy
f. Hypertensive HA: Syncope
Bell's palsy Vertigo
40. What FHx/ SHx information is usually asked for pediatric parents?
a. Immunization status
b. History of cardiac disease
c. Second hand smoke exposure
d. Current occupation: Immunization status
Second hand smoke exposure
41. A 45 year old male presents to the ED with a ripping, tearing pain to his
central chest radiating strait to his back with associated nausea and begun 1 hours ago. What emergency conditions from the following list may explain the patients symptoms?
a. AAA and Aortic dissection
b. Aortic Dissection and MI
c. AAA, Aortic Dissection, and MI
d. Mi and AAA: MI and Aortic Dissection
42. A female patient has been pregnant four times in the past, is currently
pregnant, and has two children at home. Calculate the G, P, and A.: 5,2,
43. You are writing an HPI for a very complex patient who has had multiple
recent hospital admissions and several significant complaints; what is the best way to organize the information in your HPI?: Chronological order
44. For chest pain patients, administering this medication can prevent onset
of MI my thinning out the blood and improving blood flow to the heart. Because of this, it is important in the HPI if the patient has received this medication, and if so who gave the medication and what was the dosage of the medication. What medication is important for meeting this core measure?
a. Epi pen
b. ASA
c. NSAIDS
d. Acetaminophen
CAD
Family hx of CAD <55 y/o PSHx of CABG, angioplasty, and stent HTN HLD
46. T/F. All symptoms documented in the HPI are also documented in the
ROS.: True
47. A patient states she has had a productive cough for 4 days, and yesterday
she developed a fever. Would her fever be considered an associates symp- tom for her productive cough? Why or why not?
a. No, because the fever started later and not on the same day
b. Yes, because the fever causes sputum production
c. Yes, because fever started soon after the cough: Yes, because fever started
soon after the cough
48. Match location with the corresponding DDx
Pancreatic disease, gall bladder disease, appendicitis, diverticulitis LUQ - LLQ - RLQ - RUQ -: LLQ: diverticulitis RLQ: appendicitis LUQ: pancreatic disease RUQ: gall bladder disease
49. T/F. All symptoms documented in the ROS are also documented in the
HPI: False
50. Match the following HPI detail with the corresponding DDx
PTX, GERD, CAD/MI
1. Burning chest pain
2. Chest pains when taking in a deep breath
3. Sharp, stabbing pains that alternately becomes a dull heavy pressure like
an elephant sitting on the chest, but regardless of quality, pain is always brought on by exertion: PTX: chest pains when taking in a deep breath CAD/ MI: sharp, stabbing pains that alternately becomes a dull heavy pressure like
b. MRN
c. Email address
d. Home address
e. Cell phone number
f. Fax number
g. Headshot
h. Results of pending studies
i. Diagnosis
j. Drivers license
k. None of the above: None of the above
62. George is employed with SA as a scribe. He was off today and acciden-
tally cut his cheek while practicing his sward swallowing skills. He goes to the emergency department and is seen by a doctor and another scribe. The emergency department is extremely busy, and so George decides to help out the doctor by scribing his own note using the computer in the room.
Has George taken appropriate steps in this situation?: No, because George accessed his own medical record using his EMR login
63. What are the possible consequences of a HIPAA violations?: Monetary
fines to you and the hospital Scribe program cancellation Violator is blacklisted from medical programs Lawsuit against you and the hospital Prison time Termination
64. If a patient signs a waiver giving you permission to capture photo of their
unique rash, would you be committing a HIPAA violation by using your cellphone to capture the photo?
a. No because the phone is not an approved hospital device
b. Yes because the phone is not an approved hospital device And it is not
encrypted
c. No because the phone is not encrypted
d. No because the phone is not an approved hospital device and is not
encrypted
e. Yes because the phone is not an approved hospital device
f. Yes because the phone is not encrypted: Yes because the phone is not an
approved hospital devise and it is not encrypted
65. A patient has the following history: breast CA s/p chemoradiation therapy
and mastectomy. Based on this, does the patient meet level 5 billing criteria
67. Read through the PE and decide if this meets the Level 5 billing criteria...
a. Genera/Constitutional: NC, AT
b. Eyes: PERRL, EOMI
c. ENT: moist oral mucosa
d. Cardiac: irregularly irregular rhythm, tachycardic, no murmurs, no rubs, no
gallops
e. Respiratory: Lungs clear, no respiratory distress, no wheezing, no rales,
no rhonchi
f. Neurological: A&O x 4
g. Psychiatric: normal affect: No, the PE does not meet level 5 billing criteria
68. Fill in the blank: Critical care must be at least a minimum of.
a. 60 minutes
b. 30 minutes
c. 25 minutes
d. 35 minutes: 30 minutes
69. Among the following diseases listed, select the ones that qualify for CCT.
a. Stable angina
b. DKA
c. Sepsis
d. PTX
e. ACS
f. Acute MI
g. Costochondritis
h. A-fib with RVR
i. Pleuritis
j. CVA
k. PE: DKA
Sepsis PTX ACS Acute MI A-fib with RVR CVA PE
