Scribe Final Exam Review 2022/2023

How would you diagnose Hemorrhagic CVA? - ANSWER-LP and Head CT Which of the following lab results need to be monitored closely for efficiency? - ANSWER-d-dimer, troponin Which of the following tests would likely be immediately ordered for a Cardiac Workup in the ED? - ANSWER-troponin, EKG, CXR What procedure would be used to diagnose Meningitis? Expand the abbreviation. - ANSWER-lumbar puncture Which of the following would be ordered to investigate thyroid disease? - ANSWER-TSH, T4, T3 How would you diagnose AFIB? Use the abbreviation to answer the question. - ANSWER-EKG Which of the following diseases may be diagnosed using a CXR? - ANSWER-CHF, PTX, PE, Rib fracture, PNA How would you diagnose an AAA? - ANSWER-CT A/P with IV contrast How would you diagnose a pneumothorax? - ANSWER-CXR Consent should be documented any time a procedure is performed, but there maybe certain situations in which consent is unobtainable. In that case, consent is precluded by clinical urgency. During which of the following procedures would consent usually be unobtainable? - ANSWER-CPR Select the EKG interpretation documentation guidelines. - ANSWER-2 positive or negative findings, rate and rhythm Select terms you might find on an x-ray interpretation. - ANSWER-pneumothorax An ED technician informs the provider that they have just finished applying a splint and sling for the patient with the wrist fracture. What PE finding is important for your provider to assess and include in the procedure note before the patient can be discharged home? - ANSWER-CSMT Match the oxygen administration route to the corresponding definition. - ANSWER-nonrebreather mask- a plastic mask fit over the nose and mouth RA- this means the patient is not on oxygen NC- a plastic tube placed into the patient's nostrils BVM- a large facial mask held in place by hand and attached to an Ambu-bag used to manually inflate the patient's lungs Intubation- an EET goes through the patient's mouth and down the trachea FM- a facial mask with a reservoir bag attached A 13 y/o male patient was riding his bike earlier today and accidentally fell off after traveling on an uneven patch of sidewalk. He landed onto his outstretched right hand and subsequently experienced localized pain and swelling to the his right wrist. An x-ray of the right wrist shows a distal radial fracture. Now that the results are back, the physician will be ready to discharge the patient home. Which of the following would need to go into this patient's disposition note? - ANSWER-F/U with specialist or PCP, Specific conditions for return to the ED, Condition at time of disposition, Time period for f/u, Timing of disposition, patient mental capacity What abbreviation describes the scenario in which a patient declines a hospital stay and decides to go home instead? - ANSWER-AMA Which of the following would need to go into a consult note for a patient that will be admitted to the hospital for treatment of bacterial meningitis? - ANSWER-location in the hospital, name of the accepting facility, consultation note, condition at time of admission, name of accepting physician, specific conditions for return to the ED, What term describes "the patient destination is home"? - ANSWER-discharge LBBB - ANSWER-Left bundle branch block CVA - ANSWER-costovertebral angle Match each critical care dx with its associated procedure. - ANSWER-cardiac rest- CPR sepsis- central line placement respiratory failure- Intubation acute exacerbation- CPAP/BiPAP abnormal herat rhythm- Cardioversion PTX- Chest tube Which of these procedures qualify as critical care procedures and would indicate that critical care time must be documented on a patient? - ANSWER-Cardioversion, Central line placement, CPAP/BiPAP, chest tube, CPR, intubation Among the following diseases listed, select the ones that qualify for CCT - ANSWER-ACS, CVA, Afib, acute MI, DKA, PTX, PE, sepsis NOT pleuritis, stable angina, or costochondritis What condition correctly describes "fertilized egg develops outside the uterus? - ANSWER-ectopic pregnancy A patient recently went on a boat trip 2 days ago and developed dizziness which has continued to persist since onset. She describes her dizziness as a room spinning and reports that it is accompanied by tinnitus, nausea, and vomiting. Physical exam is positive for Romberg's and Head CT is negative. Based on this information which is the most likely final diagnosis for the patient? - ANSWER-BPV Which of the following are not valid DDx for a patient with CC of HA? - ANSWER-syncope, vertigo, Bell's palsy Match the following Dx with it's patient presentation - ANSWER-CHF- SOB+wheezing on exam+Shx of 3 ppd Asthma- SOB +wheezing on exam PE- SOB _ unilateral pedal edema +pleuritic CP COPD- SOB+bilateral pedal edema+CP What condition correctly describes "A vascular change that temporarily deprives a part of the brain of oxygen but does not result in any long lasting deficits"? - ANSWER-TIA Certain words or phrases act as "red flags" to grab your provider's attention to let let them know that a patient may require timely and comprehensive medical action. Which of the following words or phrases are NOT considered a "red flag?" - ANSWER-chest pain in a 45 year old female, tearing pain in the central chest going straight through to the back in a 40 year old female Which section of the chart would you find AKA? - ANSWER-PMHx, PSHx, PE Which of the following would be documented in ED Course? - ANSWER-re-evals, disposition What FHx/SHx information is usually asked for pediatric patients? (Select all that apply.) - ANSWER-immunization status, second hand smoke exposure A 45 year old male presents to the ED with a ripping, tearing pain to his central chest radiating straight to his back with associated nausea that began 1 hour ago. What emergency conditions (ideally from what you have learned in CRT) from the following list may explain the patient's symptoms? - ANSWER-AAA, aortic dissection, and MI What ROS system would include Dyspepsia, the medical term for indigestion? - ANSWER-gastrointestinal What is the medical term for "bright red blood in stools"? (Remember, when typing your answer, do not include any spaces before or after the term/phrase. e.g. Correct way "Good luck" vs incorrect " good luck ".) - ANSWER-Hematochezia Which of the following would NOT be considered an example of PHI? - ANSWER-none of the above 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 for this section of the chart? - ANSWER-no Read through the PE and decide if this meets Level 5 billing criteria. Genera/Constitutional: NC, AT Eyes: PERRL, EOMI ENT: moist oral mucosa Cardiac: irregularly irregular rhythm, tachycardic, no murmurs, no rubs, no gallops Respiratory: Lungs clear, no respiratory distress, no wheezing, no rales, no rhonchi Neurological: A&O x 4 Psychiatric: normal affect - ANSWER-no 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. Â The doctor tells you there is no tendon injury and circulatory, sensory and motor is intact. What is the best diagnosis for his complaint? - ANSWER-uncomplicated laceration of the left foot- initial encounter A patient is seen in the emergency department complaining of dysuria and tells you that she is 23 weeks pregnant. Â Your doctor diagnoses her with a UTI. Â Which of the following would be the best diagnosis? - ANSWER-acute urinary tract infection in pregnancy, 2nd trimester AAA - ANSWER-abdominal aortic aneurysm DNR - ANSWER-do not resuscitate DOE - ANSWER-dyspnea on exertion TIA - ANSWER-transient ischemic attack COPD - ANSWER-chronic obstructive pulmonary disease EOMI - ANSWER-extraocular moments intact CSF - ANSWER-cerebrospinal fluid AMS - ANSWER-altered mental status GCS - ANSWER-glasgow coma state NTG - ANSWER-nitroglycerin GERD - ANSWER-gastroesophageal reflux disease DVT - ANSWER-deep vein thrombosis IDDM - ANSWER-Insulin dependent diabetes mellitus CHF - ANSWER-congestive heart failure PNA - ANSWER-pneumonia s/p - ANSWER-status post DP stand for in DP pulse - ANSWER-dorsalis pedis CBC - ANSWER-complete blood count PTX - ANSWER-pneumothorax URI - ANSWER-upper respiratory infection PE - ANSWER-pulmonary embolism Match the following description to the appropriate team member,. - ANSWER-unit secretary- answers phone calls, pages other specialists/doctors, and organizes the patient's paperwork scribe- documents the patients visit on behalf of the physician ed tech- helps the nurse and assists with procedures rt- administers "breathing treatments' and assists with managing a patient's airway ed nurse- records medical histories, symptoms, monitors the patient, starts IVs, administers medications, and assists with procedures midlevel provider- NP or PA that works under the supervision of a physician to diagnose and treat patients charge nurse- manages the ED patient flow A 43-year-old male presents to the ED with vomiting that began 5 hours ago. He has a history of Type II DM and is s/p right BKA. On objective evaluation it is found that he is hyperglycemic and has elevated ketones and so he will be admitted for DKA. Match the details to the correct section of the chart. (28) - ANSWER-PSHx- right BKA Disposition- admit PMHx- Type II DM Onset- 5 hours ago CC- vomiting Diagnosis- DKA ED Course-hyperglycemia and elevated ketones T/F. It's the middle of the day. Your provider is busy dealing with a crtically ill patient and during this time the ED starts to pick up pace as more patients arrive. While your provider is prepping the critical patient for a procedure, she asks you to look up the CBC result on another patient. You quickly look up the information on your laptop and tell the physician that the labs came back normal except for a blood glucose level of 356, so your provider subsequently asks you to tell the nurse to start that patient on an insulin drip. You locate the nurse and relay the message. This scenario is acceptable and within the bounds of your scribe scope. - ANSWER-False What condition correctly describes "An immune response that leads to rash, itching, swelling, or difficulty breathing"? Hint: 2 words. - ANSWER-allergic reaction An ROS has marked positive for head trauma with accompanying LOC. What DDx would your provider be concerned about? - ANSWER-Hemorrhagic CVA T/F. All symptoms documented in the ROS are also documented in the HPI. - ANSWER-True Which of the following are considered to be cardiac risk factors for CP patients? (select all that apply.) - ANSWER-tobacco use, family history of CAD 55 years old, DM, CAD Quality is an important descriptor that can paint a picture for concerning DDx. Match the following HPI detail with the corresponding DDx. - ANSWER-sharp, stabbing pains that alternatly becomes a dull heavy pressure like an elephant sitting on the chest, but regardless of quality, pain is always brought on by exertion- PTX burning chest pain- GERD chest pains when taking in a deep breath- CAD/MI 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, respectively. (Type your answer using the following format: "G,P,A" "#,#,#"; so for example you woud type 0,0,0 with no spaces before or after the answer) - ANSWER-5,2,2 For chest pain patients, administering this medication can prevent onset of MI by thinning out the blood and improving blood flow to the heart. Because of this, it is important to document in the HPI if the patient 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? - ANSWER-coumadin A patient states she has had a productive cough for 4 days, and yesterday she developed a fever. Would her fever be considered an associated symptom for her productive cough? Why or why not? - ANSWER-yes, because fever causes sputum production 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? - ANSWER-chronological order T/F. All symptoms documented in the HPI are also documented in the ROS. - ANSWER-true How would you document GPA for a patient who has previously been pregnant four times in the past, has three children at home, and is NOT currently pregnant? (Type your answer using the following format: "G,P,A" "#,#,#"; so for example you woud type 0,0,0 with no spaces before or after the answer) - ANSWER-4,3,1 Location is an important element that can paint a picture for concerning DDx. Match location with the corresponding DDx. - ANSWER-RUQ- gall bladder disease RLQ- appendicitis LLQ- diverticulitis LUQ- pancreatic disease What medical term describes "blood present in vomit"? (Remember, when typing your answer, do not include any spaces before or after the term/phrase. e.g. Correct way "Good luck" vs incorrect " good luck ".) - ANSWER-Hematemesis What is the medical term for "coughing up blood"? (Remember, when typing your answer, do not include any spaces before or after the term/phrase. e.g. Correct way "Good luck" vs incorrect " good luck ".) - ANSWER-Hemoptysis What is the medical term for "carotid artery cleaning"? (Remember, when typing your answer, do not include any spaces before or after the term/phrase. e.g. Correct way "Good luck" vs incorrect " good luck ".) - ANSWER-Carotid Endarterectomy What is the medical term for painful urination? (Remember, when typing your answer, do not include any spaces before or after the term/phrase. e.g. Correct way "Good luck" vs incorrect " good luck ".) - ANSWER-dysuria What medical term describes "noticeable blood in the urine"? (Remember, when typing your answer, do not include any spaces before or after the term/phrase. e.g. Correct way "Good luck" vs incorrect " good luck ".) - ANSWER-hematuria What is the medical term for infection of the gall bladder? (Remember, when typing your answer, do not include any spaces before or after the term/phrase. e.g. Correct way "Good luck" vs incorrect " good luck ".) - ANSWER-Cholecystitis What is the medical term for stones in the gallbladder? (Remember, when typing your answer, do not include any spaces before or after the term/phrase. e.g. Correct way "Good luck" vs incorrect " good luck ".) - ANSWER-Cholelithiasis 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? (Select the best option.) - ANSWER-yes because the phone is not an approved hospital device George is employed with SA as a scribe. He was off today and accidentally cut his cheek while practicing his sword 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 the appropriate steps in this situation? - ANSWER-no, because George accessed his own medical record using his EMR login What are the possible consequences of a HIPAA violation? (select all that apply) - ANSWER-all A 45 year old male presents to the ED with a constant, ripping, tearing pain to his central chest radiating straight to his back with associated nausea that began 1 hour ago. What element is constant? - ANSWER-timing?? Fill in the blank: Critical care must be at least a minimum of __________. - ANSWER-30 minutes What do you need to make sure to document for every admitted patient? (select the best option.) - ANSWER-A consultation note indicating the admitting physician You've just caught up on all of your charting. What are some things you can do to increase your providers efficiency? (Select all that apply.) - ANSWER-preparing charts for patients that are assigned to your provider, preparing for dispositions, tracking results, accompanying your provider on reveals GI cocktail - ANSWER-liquid consumed by mouth to treat upset stomach (Common Medications & Treatments) You are starting your shift and your physician immediately picks up 3 patients. The first patient is presenting with a productive cough steadily worsening since onset 4 weeks ago. The second patient has had abdominal discomfort slowly localizing into the right lower abdomen with accompanying fever over the last 6 hours and on PE, the patient has RLQ tenderness on palpation. The third patient has urinary sx and urinedip has already resulted and is positive for leukocytes and bacteria. Given the information, what might the most likely diagnoses' end up being for these patients? - ANSWER-PNA, Appendicitis, UTI Match the following results with the corresponding diagnosis. - ANSWER-combination of - EKG and - blood work : no MI combination of - EKG and + blood work : NSTEMI combination of + EKG and + blood work : STEMI Match the normal grading scale with the corresponding PE finding. - ANSWER-strength- 5/5 GCS- 2+ Reflexes- 15 You see the physician check the patient's pulses in four places; the right wrist, the top of the right foot, the back of the right foot and the left neck. The doctor states "The pulses are fine". Match the location with the appropriate pulse that you would document in the physical exam? - ANSWER-wrist- 2+ radial pulse neck- 2+ carotid top of foot- 2+ DDP back of foot- 2+ PTP Which of the following would belong in a psychiatric exam? (Select all that apply.) - ANSWER-cerebellar exam, sensory exam, and Glasgow coma scale Your physician tells you the patient had a wood's lamp exam to look for fluorescein uptake. In which organ system would you document this physical exam finding? - ANSWER-eyes An 23-year-old female is brought in by EMS for a motor vehicle crash. Your physician verbalizes outloud that the patient appears to be on a backboard and her cervical spine is stabilized with a hard collar. The patient also appears to be lethargic with obvious lacerations above her right eyebrow, left hand, and left thigh. Match the following exam findings with the appropriate organ system. - ANSWER-patient lethargic- neurological lacerations to the right eyebrow, left hand and left thigh- integumentary patient backboardered- back patient with a c-colar- neck What condition correctly describes "translocation of a thrombus leading to dyspnea and hypoxia"? Use the abbreviation form of the condition. (Remember, do not include any spaces before or after the term/phrase.) - ANSWER-PE EET - ANSWER-endotracheal tube