Medical Scribe, America Scribe 101 Quizzes Latest Updated

Vital signs are: - A series of measures that give an overview of a patient's overall health Heart rate is defined as: - The rate that your heart is pumping blood Blood pressure is defined as: - The pressure at which blood is being pumped throughout your body Which of the following is NOT a vital sign: - Body weight Someone who is breathing really fast and short of breath is MOST likely: - Tachypneic Someone who has smoked for many years and is short of breath is MOST likely: - Hypoxic A person who is very stressed while watching a scary movie is MOST likely: - Tachycardic A sick child who has had a fever for 2 hours most likely has which temperature? - 102.5 Oxygen saturation is defined as: - The saturation of oxygen in your blood Vital signs are usually measured in rate of how many times a second is it happening - False Match the following patient complaints to the location the patient will likely be seen at: "I've had a sore and scratchy throat for a few days." - Urgent Care Match the following patient complaints to the location the patient will likely be seen at: "I'm having severe chest pain and shortness of breath." - Emergency Department Match the following patient complaints to the location the patient will likely be seen at: "I'm here for a regular check up for my diabetes." - Outpatient Clinic A 92 year old male presented to the ED without a heart rate and not breathing. He was successfully resuscitated in the Emergency Department, but he required a breathing tube (intubation) and is receiving oxygen through a ventilator. Where do you think he will go next? - Inpatient Using your knowledge about medical terminology and prefixes, what do you think the following medical term means? Appendicitis - Inflammation of the appendix Using your knowledge about medical terminology and prefixes, what do you think the following medical term means? Hyperthyroidism - Overactive thyroid Which of the following would be considered Subjective? - The patient states that he has right ankle pain. Which of the following would be considered Objective? - The physician tells you that the lungs sound clear. The patient tells you that he has been experiencing pain in his right lower abdomen for several days. When your physician presses on the abdomen, however, he reports that there is no tenderness. Which piece of information would be documented in the objective section of the chart? - No abdominal tenderness on exam Under which section of the chart would you document the following information: The patient denies substance abuse. She is a non-smoker, and works as an accountant. - Social history (SHx) Which of the following would be considered part of the patient's family history (FHx)? - The patient's mother has COPD. Which description best matches that of a scribe? - Unlicensed, non-clinical individuals that assist a provider by charting the patient's visit and making sure its accurate. Using your med term knowledge, what does Tonsillitis mean? - Tonsil infection What does -algia stand for? - pain An 8 year old patient comes in for follow up on their Diabetes, what type of Diabetes do they most likely have? - Type I HTN is also known as: - Hypertension The layman's term "High cholesterol" translates to which medical abbreviation? - HLD TRUE or FALSE: If you have Heart disease, that means you've also have had heart attacks? - False "Heart Disease" is also known as: - Coronary Artery Disease The prefix Hepa corresponds to which organ? - Liver A UTI that is unresolved and goes to the kidneys is known as: - Pyelonephritis GPA is a measure we use to document what - A patient's pregnancy history While your provider is discussing the patient's past medical history, the patient reports right knee pain that began 2 years ago. Her orthopedic physician diagnosed her with arthritis. Is this condition considered acute or chronic? - Chronic The patient is here for follow up of their chronic hypertension and Type II DM. What medical term can be used to describe the fact that this patient has multiple chronic conditions? - Comorbidity Your patient presents for a headache. She also complains of blurred vision and nausea, but denies numbness, weakness, or tingling. What are the pertinent negatives in this example? Select all that apply. - numbness weakness tingling Your patient was diagnosed with hypertension after a blood pressure reading of 168/85. What diet change might you include in their plan? - Low sodium diet Label the following blood pressure readings as hypotensive, normal, pre-hypertensive, or hypertensive. 100/70 - Normal Label the following blood pressure readings as hypotensive, normal, pre-hypertensive, or hypertensive. 150/95 - Hypertensive Label the following blood pressure readings as hypotensive, normal, pre-hypertensive, or hypertensive. 130/85 - Pre-Hypertensive Label the following blood pressure readings as hypotensive, normal, pre-hypertensive, or hypertensive. 80/50 - Hypotensive The majority of DM patients have _______. - Type II diabetes Match the patient statements below to their likely diagnosis: "I've had a really sore throat for 3 days. Today, I noticed that I was also running a fever." - Strep Pharyngitis Match the patient statements below to their likely diagnosis: "I was diagnosed with a UTI at my family doctor 3 days ago, but my symptoms didn't improve with the antibiotics he prescribed. Now I have back pain and a fever!" - Pyelonephritis Match the patient statements below to their likely diagnosis: "I have severe left lower abdominal pain that started suddenly an hour ago." - Ovarian Torsion Match the patient statements below to their likely diagnosis: "I developed this itchy rash all over after taking a new medication." - Allergic Reaction Match the patient statements below to their likely diagnosis: "This area of skin on my arm is really red and swollen. It also feels warm to the touch." - Cellulitis Match the patient statements below to their likely diagnosis: "My chest started hurting while I was walking my dog. I was worried, because I have a history of heart disease!" - Myocardial Infarction Sort the following surgical treatments for CAD from least invasive to most invasive: CABG, Angioplasty, Coronary Stent - Least invasive - angioplasty Middle - coronary stent Most Invasive - CABG Match the chronic illness to its Layman's term or description: Hypertension (HTN) - High blood pressure Match the chronic illness to its Layman's term or description: Diabetes Mellitus (DM) - High blood glucose levels Match the chronic illness to its Layman's term or description: Hyperlipidemia (HLD) - High cholesterol - specifically LDL Match the chronic illness to its Layman's term or description: Coronary artery disease (CAD) - Narrowing of the arteries that supply the heart with blood Why might having multiple conditions at once increase a patient's complexity? -The treatment of one disease may affect or contradict the treatment of the second. -If both illnesses affect a specific organ system, the patient is at increased risk of organ failure. - Compounding symptoms and medication interactions may lead to poor compliance with treatment plan - All of the above - All of the above Abdominal tenderness belongs in which part of the chart - PE True or False: IT'S TOTALLY OK TO WRITE IN ALL CAPS IN THE HPI - False True or False: The HPI will have everything from the ROS - False The clues that make up the HPI are what we know as - Elements SOAP stands for: - Subjective Objective Assessment and Plan Who is usually telling us subjective information? - The patient Who is usually telling us objective information? - The provider ROS stands for - Review of Systems True or false, it is ok to frequently put patient statements within quotes - False The most important part about the HPI is that it tells the story of the - Chief complaint Which of the following are considered objective? - Complete blood count reveals elevated white blood cells RUQ Abdominal Tenderness Non-acute CT Head Non-focal neurological exam Match the following terms as being either subjective or objective: Pain - Subjective Match the following terms as being either subjective or objective: Tenderness - Objective Which of the following pieces of information are NOT subjective? - Vital Signs Physical Exam Orders and Results Match the following NORMAL physical exam basics with the appropriate definition: The Patient is in no acute distress (NAD) - The patient doesn't appear to be in discomfort/pain, per the doctor's observation Match the following NORMAL physical exam basics with the appropriate definition: No scleral icterus - There is no yellowing to the whites of the eyes Match the following NORMAL physical exam basics with the appropriate definition: No Jaundice - No yellowing of the skin Match the following NORMAL physical exam basics with the appropriate definition: There is no respiratory distress - The patient seems to be breathing comfortably Match the following NORMAL physical exam basics with the appropriate definition: They are grossly neurologically intact - The patient is able to answer questions appropriately without any foal neurological deficit Match the following terms with their appropriate definition: Auscultation - Listening to the heart, lungs, or even abdomen with a stethoscope Match the following terms with their appropriate definition: Palpation - Act of pressing on areas of the body such as the abdomen, extremities, or back to assess for any abnormality. The physician will use a variety of techniques to perform their exam. Match the exam technique to the appropriate physical exam findings. External inspection - No acute distress. Well developed and well nourished. No respiratory distress. The physician will use a variety of techniques to perform their exam. Match the exam technique to the appropriate physical exam findings. Auscultation of the heart - Regular rate and rhythm. No murmurs, rubs, or gallops. The physician will use a variety of techniques to perform their exam. Match the exam technique to the appropriate physical exam findings. Auscultation of the lungs - Clear to auscultation bilaterally. No wheezes, rales, or rhonchi. The physician will use a variety of techniques to perform their exam. Match the exam technique to the appropriate physical exam findings. Palpation of the abdomen - Soft, non-tender without rebound, guarding, or rigidity. Non-distended. The physician will use a variety of techniques to perform their exam. Match the exam technique to the appropriate physical exam findings. Examination of the legs - No edema. Distal pulses are intact. Which of the following symptoms would warrant a detailed gynecological exam? - Abnormal vaginal bleeding in a 22 y/o female Exposure to STD and vaginal discharge Lower abdominal pain in female Complication with pregnancy Match the following terms with their appropriate definition: Anterior - Toward the front of the body Match the following terms with their appropriate definition: Posterior - Toward the back of the body Match the following terms with their appropriate definition: Medial - Closer to the midline of the body Match the following terms with their appropriate definition: Lateral - Further from the midline of the body Match the following terms with their appropriate definition: Proximal - In proximity to or closer to Match the following terms with their appropriate definition: Distal - Distant or further away from The doctor dictates "5/5 Motor strength to the bilateral upper and lower extremities. Sensation intact. No pronator drift" to you across the room. Which type of exam is being performed? - Detailed Exam Which of the following would be included in a CBC? Select all that apply. - WBC H&H Which of the following would be included in a BMP? (Select all that apply) - Electrolytes Glucose Creatinine (Kidney function) If a patient overdoses on Acetaminophen (Tylenol), it can injure the liver. What test would be ordered to assess the patient's liver function? - CMP An 11 year old patient fell off a trampoline earlier today, and presents with right wrist pain. Which test is your provider likely to order, to evaluate the patient's pain? - X-ray of the right wrist A gastrointestinal perforation (also known as ruptured bowel) is a highly emergent condition that occurs when there is a hole in the wall of part of the GI tract. What test would be best to evaluate this condition? - CT A/P Your patient presented for severe testicular pain, without known trauma. Your provider is concerned about a testicular torsion. What test will he/she most likely order to look for a torsion? - Ultrasound of the testicles EKG documentation can include which of the following elements: - All of the above (Rate/Rhythm, Axis, Intervals, ST segment, Comparison to prior EKG, Clinical context) Which of the following forms of supplement oxygen might qualify the patient for critical care? Select all that apply. - BiPAP Endotracheal Tube (ETT)