Scribe America Final Exam Prep, 519
Questions and Correct Answers, 100%
Correct, Updated 2024/2025.
Uterine product removed
Dilation and Curettage (D and C)
Hip surgery
Open Reduction with Internal Fixation (ORIF)
Coronary Stents>> PMHx CAD
Brain surgery
Craniotomy (brain bleed vs brain CA)
True allergy
Rash, itching, swelling, or difficulty breathing
Age of Onset that makes it more likely to be environment than genetics?
50 y/o + (also higher genetic risk if more family members have it)
Age of Onset for CAD?
54 and younger would be genetic and 55 and older would be environment.
What are the three common general family histories your physician may ask about?
Hypertension (HTN)
Diabetes Mellitus (DM)
Cancer (CA)
Two pulmonary FHx
PE and Asthma
Two Gastrointestinal FHx
Crohn's and IBS
Three Neurological FHx
CVA, Aneurysm, Seizures
Two Miscellaneous FHx
Sickle Cell Anemia and DVT
,Social History list...
Tobacco use, Drug use, Alcohol use, living circumstances, occupation
Smoking status (Current)
#ppd or #yr
Smoking status (Former)
year quit
Second hand exposure
(pediatrics)
If Chronic alcoholic need..
Number of drinks/day and type of alcohol
Illicit Drug Use need...
Which Drug, Route of Administration, Date of last use
Social History for pediatrics
Need Caretaker, attends daycare, attends school, siblings, second hand smoke exposure, immunizations
Why must smoking status be documented on every patient 13 yrs and older?
Government standard require this
Would PMHx of chronic alcoholism belong in the SHx section as well as the PMHx section?
Yes
Name the three most common routes of administration of illicit drug use
Oral, Intravenous, Inhaled
Living Circumstances
Doc will ask if pt: lives alone, with family/friends, nursing home/assisted living, hospice,
homeless/shelter
Occupation
Employed, Unemployed, On disability, Retired
If physician asks specifically about type of work, be sure to document it
Identify ED flow:
Walk-in > Triage > Bed > Physician Assessment > Lab/Rad/Meds > Results > MDM/ED Course > Diagnosis
> Consults > Disposition
What are the 5 vital signs?
,Blood Pressure, Respiratory Rate, Temperature, Heart Rate, Oxygen Saturation
What does disposition (dispo) mean?
Destination of the patient following the ED evaluation. Admitted to the hospital, discharged or
transferred to another facility.
What subcategories are included in the Past History section of the template?
PMx: Past Medical History
PSHx: Past Surgical History
FHx: Family History
SHx: Social History
What is the term for gallbladder removal?
Cholesystectomy
What is the medical term for redness?
Erythema/Erythematous
That is the medical term for bruising?
Eccymosis
Pertinent Positives
present symptoms that point to a diagnosis
Catch Phase for CAD
Chest pain with physical exertion
Nitroglycerin
NTG
sublingual
put meds under tongue
Chief Complaint of CAD
CP (worse with exertion, better with rest/NTG)
CAD diagnosed by..
Cardiac Catheterization or stress test (not diagnosed in ED)
PMHx signs for a CAD
MI, Angina, CABG, Cardiac stents, or Angioplasty
Single greatest risk for an MI
, CAD
Meds given to patients with CP
324 mg Aspirin PO
.4 mg NTG SL
Stemi patients must...
go to cath lab within 90 minutes of arrival
CHF
heart becomes enlarged, inefficient, and congested with fluid
Catch phrase for CHF
SOB with pedal edema and orthopnea
Orthopnea
SOB when lying flat
Pedal edema
swelling of ankles and feet
PND
Paroxysmal Nocturnal Dyspnea
DOE
Dyspnea on Exertion
How to diagnose CHF
CXR or elevated BNP
BNP
B type natriuretic peptide
PE of CHF
JVD, Rales in lungs, pedal edema
JVD
Jugular Vein Distention
Atrial Fibrillation
top of heart (atria) quivers abnormally
Atrial Fibrillation diagnosed by...
Questions and Correct Answers, 100%
Correct, Updated 2024/2025.
Uterine product removed
Dilation and Curettage (D and C)
Hip surgery
Open Reduction with Internal Fixation (ORIF)
Coronary Stents>> PMHx CAD
Brain surgery
Craniotomy (brain bleed vs brain CA)
True allergy
Rash, itching, swelling, or difficulty breathing
Age of Onset that makes it more likely to be environment than genetics?
50 y/o + (also higher genetic risk if more family members have it)
Age of Onset for CAD?
54 and younger would be genetic and 55 and older would be environment.
What are the three common general family histories your physician may ask about?
Hypertension (HTN)
Diabetes Mellitus (DM)
Cancer (CA)
Two pulmonary FHx
PE and Asthma
Two Gastrointestinal FHx
Crohn's and IBS
Three Neurological FHx
CVA, Aneurysm, Seizures
Two Miscellaneous FHx
Sickle Cell Anemia and DVT
,Social History list...
Tobacco use, Drug use, Alcohol use, living circumstances, occupation
Smoking status (Current)
#ppd or #yr
Smoking status (Former)
year quit
Second hand exposure
(pediatrics)
If Chronic alcoholic need..
Number of drinks/day and type of alcohol
Illicit Drug Use need...
Which Drug, Route of Administration, Date of last use
Social History for pediatrics
Need Caretaker, attends daycare, attends school, siblings, second hand smoke exposure, immunizations
Why must smoking status be documented on every patient 13 yrs and older?
Government standard require this
Would PMHx of chronic alcoholism belong in the SHx section as well as the PMHx section?
Yes
Name the three most common routes of administration of illicit drug use
Oral, Intravenous, Inhaled
Living Circumstances
Doc will ask if pt: lives alone, with family/friends, nursing home/assisted living, hospice,
homeless/shelter
Occupation
Employed, Unemployed, On disability, Retired
If physician asks specifically about type of work, be sure to document it
Identify ED flow:
Walk-in > Triage > Bed > Physician Assessment > Lab/Rad/Meds > Results > MDM/ED Course > Diagnosis
> Consults > Disposition
What are the 5 vital signs?
,Blood Pressure, Respiratory Rate, Temperature, Heart Rate, Oxygen Saturation
What does disposition (dispo) mean?
Destination of the patient following the ED evaluation. Admitted to the hospital, discharged or
transferred to another facility.
What subcategories are included in the Past History section of the template?
PMx: Past Medical History
PSHx: Past Surgical History
FHx: Family History
SHx: Social History
What is the term for gallbladder removal?
Cholesystectomy
What is the medical term for redness?
Erythema/Erythematous
That is the medical term for bruising?
Eccymosis
Pertinent Positives
present symptoms that point to a diagnosis
Catch Phase for CAD
Chest pain with physical exertion
Nitroglycerin
NTG
sublingual
put meds under tongue
Chief Complaint of CAD
CP (worse with exertion, better with rest/NTG)
CAD diagnosed by..
Cardiac Catheterization or stress test (not diagnosed in ED)
PMHx signs for a CAD
MI, Angina, CABG, Cardiac stents, or Angioplasty
Single greatest risk for an MI
, CAD
Meds given to patients with CP
324 mg Aspirin PO
.4 mg NTG SL
Stemi patients must...
go to cath lab within 90 minutes of arrival
CHF
heart becomes enlarged, inefficient, and congested with fluid
Catch phrase for CHF
SOB with pedal edema and orthopnea
Orthopnea
SOB when lying flat
Pedal edema
swelling of ankles and feet
PND
Paroxysmal Nocturnal Dyspnea
DOE
Dyspnea on Exertion
How to diagnose CHF
CXR or elevated BNP
BNP
B type natriuretic peptide
PE of CHF
JVD, Rales in lungs, pedal edema
JVD
Jugular Vein Distention
Atrial Fibrillation
top of heart (atria) quivers abnormally
Atrial Fibrillation diagnosed by...
