Scribe America Final Exam Review Questions (Courses 1-5)

Scribe America Final Exam Review Questions (Courses 1-5) Fill in the blanks for ED Flow: Walk in > Blank 1 > Bed > Physician Assessment > Lab/Rad/Meds > Results > MDM > Diagnosis > Consults > Blank 2 Triage, Disposition What are the 3 disposition options? Discharge, Admit, Transfer What are the 5 vital signs? Heart Rate, Blood Pressure, Respiratory Rate, Temperature, Oxygen Saturation The HPI and ROS are what type of information (subjective or objective)? subjective The Physical Exam is what type of information (subjective or objective)? objective While evaluating a patient complaining of chest pain, your physician tells you that the heart sounds are normal. Would you document it in the HPI, ROS, or PE? PE Would you be contradicting yourself if you wrote "The patient has abdominal pain" in the HPI, but then later in the physical exam documented "The abdomen is nontender." Why or why not? No, because the patient stating they have abdominal pain is a subjective complaint. A non-tender abdomen is an objective finding. What is the difference between the HPI and ROS? HPI focuses on the details related to their chief complaint. ROS is a head-to-toe checklist of symptoms. It includes the chief complaint, associated symptoms, and all other complaints the patient may have. What does disposition (dispo) mean? The patient's destination after they leave the Emergency Department. What subcategories are included within the Past History section of the template? PMHx (Past Medical History- HTN, DM, HLD, CAD, MI.......), PSHx, (Past Surgical History- Appendectomy, Cholecystectomy, CABG......)FHx, (Family History- Hx of CAD < 55 y/o....)SHx, (Social History- ETOH, Smoking, Drug Abuse, Occupation.....) What is the abbreviation for a heart attack? MI- Myocardial Infarction What is the abbreviation for high blood pressure? HTN- Hypertension What is the medical term for acid reflux? GERD- Gastroesophageal Reflux Disease What is the medical term for stroke? CVA- Cerebrovascular Accident What is the term for gallbladder removal? Cholecystectomy What does NKDA stand for? No Known Drug Allergies What is the medical term for redness? Erythema What is the medical term for bruising? Ecchymosis If the doctor says the exam was "benign", what does that mean? Normal- Nothing of concern What is CAD? Coronary Artery Disease. What other past histories would suggest that a patient has CAD? MI, Angina, CABG, Stent, Angioplasty Does a PMHx of CVA mean the patient has CAD? No Does a surgical history of angioplasty mean the patient has CAD? Yes Explain the difference between CAD and an MI. CAD is a broad term for heart disease. MI is included in CAD. It's an active heart attack. If someone has a PMHx of A Fib or CHF, do they also have CAD?- No What are the "cardiac risk factors?" HTN, DM, HLD, CAD, Smoking, FHx CAD < 55 y/o How is CAD diagnosed? By a cardiologist during a cardiac catheterization. Not done in the ED. Name two ways that an MI can be diagnosed? STEMI- EKG, Non-STEMI- Troponin What are some associated symptoms of an MI other than CP? N/V, SOB, Diaphoresis What are some associated symptoms for CHF? SOB (Orthopnea, PND, DOE), pedal edema What 2 studies would diagnose CHF? CXR or elevated BNP What is A Fib? Electrical abnormality of the heart causing the top of the heart to quiver What might someone feel with A Fib? Palpitations, fast, pounding, irregular heartbeat How is A Fib diagnosed? EKG What could be the CC of someone with a PE? Pleuritic CP or SOB 17. What are risk factors for a PE? Known DVT, PMHx of DVT or PE, FHx of DVT or PE, recent surgery, CA, Afib, immobility, pregnancy, BCP, smoking 18. What study would diagnose a PE? CTA Chest/VQ Scan. D-Dimer can only rule it out 19. What part of the heart does CAD affect; Arteries, Veins, or Nerves? Arteries 20. Can a CT Chest without IV contrast diagnose a PE? Why or why not? No. Contrast in the vessels(IV) helps clearly see a blockage. 21. What is a PTX? Pneumothorax ("collapsed lung") 22. What is the most common cause of a PTX?