Scribe America Final Exam Questions & Answers Latest Updated

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? - Answer acute urinary tract infection in pregnancy, 2nd trimester 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? - Answer Uncomplicated laceration of the left foot - initial encounter What does AMS stand for? - Answer altered mental status What does GCS stand for? - Answer glasgow coma scale What does DNR stand for? - Answer do not resuscitate What does AAA stand for? - Answer abdominal aortic aneurysm What does PE stand for in the diagnosis section of the chart? - Answer pulmonary embolism What does DP stand for in "DP pulse"? - Answer dorsalis pedis What does DVT stand for? - Answer deep vein thrombosis What does NTG stand for? - Answer nitroglycerin What does URI stand for? - Answer upper respiratory infection What does CHF stand for? - Answer congestive heart failure What does s/p stand for? - Answer status post What does GERD stand for? - Answer gastroesophageal reflux disease What does EOMI stand for? - Answer extraocular movements intact What does DOE stand for? - Answer dyspnea on exertion What does LBBB stand for? - Answer left bundle branch block What does CVA stand for? - Answer costovertebral angle What does CSF stand for? - Answer cerebrospinal fluid What does PTX stand for? - Answer pneumothorax What does COPD stand for? - Answer chronic obstructive pulmonary disease What does PNA stand for? - Answer pneumonia What does CBC stand for? - Answer complete blood count What does IDDM stand for? - Answer insulin dependent diabetes mellitus What does TIA stand for? - Answer transient ischemic attack A 43 y/o 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. 5 hours ago, DKA, vomiting, admit, Type II DM, right BKA, hyperglycemia & elevated ketones, Onset: Disposition: ED Course: CC: PMHx: Diagnosis: PSHx: - Answer Onset: 5 hours ago Disposition: admit ED Course: hyperglycemia and elevated ketones CC: vomiting PMHx: Type II DM Diagnosis: DKA PSHx: right BKA Match the following description to the appropriate team member. 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 organizes 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 - Answer Scribe: Documents the patient's visits on behalf of the physician Unit Secretary: Answers phone calls, pages other specialists/ doctors, and organizes 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 T/F. It is the middle of the day. Your provider is busy dealing with a critical ill patient and during this time the ED Strats to pick up tase 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 Which section of the chart would you find AKA? a. PSHx b. PMHx c. SHx d. Disposition e. FHx f. PE - Answer PSHx PE 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 - Answer Re-evals Treatments Orders Interpretations An ROS has marked positive for head trauma with accompanying LOC. What DDx would your provider be concerned about? - Answer Hemorrhagic CVA What condition is 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 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"? - Answer "nocturne" in a 65 y/o male 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 - Answer COPD: SOB + wheezing +SHx of 3 ppd PE: SOB + unilateral pedal edema + pleuritic CP CHF: SOB + bilateral pedal edema + CP asthma: SOB + wheezing on exam What condition correctly describes "Fertilized egg developed 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 Heat CT is negative. Based on this information which is the most likely final diagnosis for the patient? CVA Syncope Bell's Palsy BVP - Answer BPV What condition correctly describes "An immune response that leads to rash, itching, swelling, or difficulty breathing"? - Answer allergic reaction What condition describes "translocation of a thrombus leading to dyspnea and hypoxia"? - Answer PE Which of the following are not valid DDx for a patient with CC of HA? a. Syncope b. Hemorrhagic CVA c. Migraine d. Vertigo e. Bell's palsy f. Hypertensive HA - Answer Syncope Bell's palsy Vertigo 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 - 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 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 - Answer MI and Aortic Dissection 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. - Answer 5,2,2 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