SCRIBE U UPDATED EXAM EVALUATION TEST QUESTIONS
AND SOLUTIONS GUARANTEE A+
✔✔gastrointestinal bleed (GI bleed) - ✔✔hemorrhage in the upper or lower GI tract and
can lead to anemia
CC: hematemesis (bright) (upper), coffee ground emesis (dark) (lower), hematochezia
(bright) (lower), melena (dark) (upper)
Assoc Sx: generalized weakness, lightheadedness, SOB, abd pain, rectal pain
P/E: pale conjunctiva, pallor, tachycardia, rectal exam: melena, grossly bloody stool
diagnosed by heme positive stool (Guaiac positive) during a rectal exam
Scribe Alert: ED concern is the need for a possible blood transfusion due to significant
blood loss
✔✔diverticulitis - ✔✔acute inflammation and infection of abnormal pockets of the large
intestine, known as diverticula
risk factor: diverticulitis, advanced age
CC: LLQ pain
Assoc Sx: nausea, fever, diarrhea
diagnosed by: CT A/P with PO contrast
✔✔pancreatitis - ✔✔inflammation of the pancreas (usually due to overproduction of
enzymes by alochol abuse)
CC: LUQ, epigastric pain
Assoc Sx: N/V
P/E: LUQ tenderness, epigastric tenderness
Diagnosed by Elevated Lipase lab test (or sometimes elevated Amylase)
✔✔gastroesophageal reflux disease (GERD) - ✔✔stomach acid regurgitating into the
esophagus
CC: epigastric pain, burning, improved with antacids
P/E: epigastric tenderness
,Assoc Med: GI cocktail (numbs and soothes the esophagus and stomach)
diagnosed by endocopy (not in ED)
Scribe Alert: due to the proximity of the stomack to the heart, patients with cardiac risk
factors and epigastric pain must also get their heart checked
✔✔diabetic ketoacidosis (DKA) - ✔✔Shortage of insulin resulting in hyperglycemia and
production of ketones
risk factors: diabetes mellitus (DM) type I and II (rare in type II)
CC: persistent vomiting with a hx of DM
Assoc Sx: SOB, polydipsia (increased thirst), polyuria (increased urination)
P/E: ketotic odor "fruity", dry mucous membranes, dehydration, tachypnea
diagnosed by arterial blood gas (ABG), or venous blood gas (VBG) showing low pH
(acidosis), positive serum ketones
✔✔trauma (physical injury) - ✔✔depending on the mechanism of injury (MOI) physical
trauma may break bones, sever nerves, rupture blood vessels, or damage internal
organs
CC: motor vehicle accident (MVA), fall, gunshot wound (GSW)
PE: glasgow coma scale (GCS) 3-15
Assoc med: blood thinners? (coumadin, ASA, plavix)
Diagnosed by trauma protocol depending on MOI: CT or XR
Scribe Alert: Trauma DDx - neurological injuries (hemorrhagic stroke, spinal cord injury)
(key: LOC, confusion, numbness, weakness, HA)
Make sure to note exactly how this trauma occured (how did they fall and where, size of
blade or caliber, etc.)
✔✔Subjective - ✔✔Based on the patient's feeling (HPI,ROS)
✔✔ED Chart Flow - ✔✔HPI/ROS: Subjective
PHx: Foundation/background information - risk factor
PE: first portion of the objective section
ED course: second and final portion of the objective section, tests in ER
Dx/Dispo: The final decision and plan
, ✔✔Subjective Information - ✔✔Includes:
Chief Complain: main reason for the visit (WHY?)
History of Present Illness (HPI): The store of the chief complaint (a paragraph of all info
surrounding CC)
Review of Systems (ROS): A checklist of symptoms from all body systems (inventory
list, pertinent +/-) (even if the patient mentions issues not relevant to CC, include it here,
NOT HPI)
✔✔HPI - ✔✔Houses all answers to questions the doctor asks the patient and is the
story of symptoms and events that led to the patient's ED visit
It is the beginning of every chart summarizing the reason for the visit
Only subjective info here, and info directly related to the CC and important context for
the patient.
It is important to document who the historian is for the HPI (the patient, spouse, child,
caretaker): give credit to the historian. ("per the spouse at bedside...")
sometimes a completed history is not available (language barrier, trauma). Document
why the history is limited ("HPI is unobtainable due to the patient's nonverbal status/lack
of translation")
Only write exactly what you know about the patient and specifically how you know it
("Per EMS, this patient was found unresponsive 15 min ago")
✔✔Example documentation flow 1 - ✔✔HPI: Abd pain X1 week (paragraph) -subjective
ROS: Positive abd pain (inventory) - subjective
PE: tenderness in the RUQ (PE)
Orders: US of the RUQ to evaluate abd pain (US
Dx: abd pain, cholelithiasis
✔✔Example documentation flow 2 - ✔✔HPI: Patient c/o of sore throat x 2 days with
intermittent fever reaching 101.2. She denies difficult swallowing (pertinent negative -
lower concern for disease).
[CC: headache, assoc sx: fever + neck pain - raise concern for disease]
ROS: +Sore throat, -difficulty swallowing, +fever
PE: ENT exam: bilateral tonsillar hypertrophy, pharyngeal erythema, cervical
lymphadenopathy, Vital signs: 100.8
AND SOLUTIONS GUARANTEE A+
✔✔gastrointestinal bleed (GI bleed) - ✔✔hemorrhage in the upper or lower GI tract and
can lead to anemia
CC: hematemesis (bright) (upper), coffee ground emesis (dark) (lower), hematochezia
(bright) (lower), melena (dark) (upper)
Assoc Sx: generalized weakness, lightheadedness, SOB, abd pain, rectal pain
P/E: pale conjunctiva, pallor, tachycardia, rectal exam: melena, grossly bloody stool
diagnosed by heme positive stool (Guaiac positive) during a rectal exam
Scribe Alert: ED concern is the need for a possible blood transfusion due to significant
blood loss
✔✔diverticulitis - ✔✔acute inflammation and infection of abnormal pockets of the large
intestine, known as diverticula
risk factor: diverticulitis, advanced age
CC: LLQ pain
Assoc Sx: nausea, fever, diarrhea
diagnosed by: CT A/P with PO contrast
✔✔pancreatitis - ✔✔inflammation of the pancreas (usually due to overproduction of
enzymes by alochol abuse)
CC: LUQ, epigastric pain
Assoc Sx: N/V
P/E: LUQ tenderness, epigastric tenderness
Diagnosed by Elevated Lipase lab test (or sometimes elevated Amylase)
✔✔gastroesophageal reflux disease (GERD) - ✔✔stomach acid regurgitating into the
esophagus
CC: epigastric pain, burning, improved with antacids
P/E: epigastric tenderness
,Assoc Med: GI cocktail (numbs and soothes the esophagus and stomach)
diagnosed by endocopy (not in ED)
Scribe Alert: due to the proximity of the stomack to the heart, patients with cardiac risk
factors and epigastric pain must also get their heart checked
✔✔diabetic ketoacidosis (DKA) - ✔✔Shortage of insulin resulting in hyperglycemia and
production of ketones
risk factors: diabetes mellitus (DM) type I and II (rare in type II)
CC: persistent vomiting with a hx of DM
Assoc Sx: SOB, polydipsia (increased thirst), polyuria (increased urination)
P/E: ketotic odor "fruity", dry mucous membranes, dehydration, tachypnea
diagnosed by arterial blood gas (ABG), or venous blood gas (VBG) showing low pH
(acidosis), positive serum ketones
✔✔trauma (physical injury) - ✔✔depending on the mechanism of injury (MOI) physical
trauma may break bones, sever nerves, rupture blood vessels, or damage internal
organs
CC: motor vehicle accident (MVA), fall, gunshot wound (GSW)
PE: glasgow coma scale (GCS) 3-15
Assoc med: blood thinners? (coumadin, ASA, plavix)
Diagnosed by trauma protocol depending on MOI: CT or XR
Scribe Alert: Trauma DDx - neurological injuries (hemorrhagic stroke, spinal cord injury)
(key: LOC, confusion, numbness, weakness, HA)
Make sure to note exactly how this trauma occured (how did they fall and where, size of
blade or caliber, etc.)
✔✔Subjective - ✔✔Based on the patient's feeling (HPI,ROS)
✔✔ED Chart Flow - ✔✔HPI/ROS: Subjective
PHx: Foundation/background information - risk factor
PE: first portion of the objective section
ED course: second and final portion of the objective section, tests in ER
Dx/Dispo: The final decision and plan
, ✔✔Subjective Information - ✔✔Includes:
Chief Complain: main reason for the visit (WHY?)
History of Present Illness (HPI): The store of the chief complaint (a paragraph of all info
surrounding CC)
Review of Systems (ROS): A checklist of symptoms from all body systems (inventory
list, pertinent +/-) (even if the patient mentions issues not relevant to CC, include it here,
NOT HPI)
✔✔HPI - ✔✔Houses all answers to questions the doctor asks the patient and is the
story of symptoms and events that led to the patient's ED visit
It is the beginning of every chart summarizing the reason for the visit
Only subjective info here, and info directly related to the CC and important context for
the patient.
It is important to document who the historian is for the HPI (the patient, spouse, child,
caretaker): give credit to the historian. ("per the spouse at bedside...")
sometimes a completed history is not available (language barrier, trauma). Document
why the history is limited ("HPI is unobtainable due to the patient's nonverbal status/lack
of translation")
Only write exactly what you know about the patient and specifically how you know it
("Per EMS, this patient was found unresponsive 15 min ago")
✔✔Example documentation flow 1 - ✔✔HPI: Abd pain X1 week (paragraph) -subjective
ROS: Positive abd pain (inventory) - subjective
PE: tenderness in the RUQ (PE)
Orders: US of the RUQ to evaluate abd pain (US
Dx: abd pain, cholelithiasis
✔✔Example documentation flow 2 - ✔✔HPI: Patient c/o of sore throat x 2 days with
intermittent fever reaching 101.2. She denies difficult swallowing (pertinent negative -
lower concern for disease).
[CC: headache, assoc sx: fever + neck pain - raise concern for disease]
ROS: +Sore throat, -difficulty swallowing, +fever
PE: ENT exam: bilateral tonsillar hypertrophy, pharyngeal erythema, cervical
lymphadenopathy, Vital signs: 100.8
