ED SCRIBE FINAL EXAM STUDY GUIDE
QUESTIONS WITH CORRECT ANSWERS
What does ROS stand for? - Answer-Review of Systems
The HPI and ROS are considered what type of information? - Answer-Subjective
The physical exam is what type of information? - Answer-Objective
If a physician told you a patient's abdomen was nontender or the patient's skin was
pale, where would you document these pieces of information? - Answer-Physical Exam
What section focuses directly on the chief complaint? - Answer-History of Present
Illness (HPI)
What are the five vital signs? - Answer-Heart rate
Blood pressure
Temperature
Respiratory Rate
Oxygen Saturation
Name an example of something you may write in the surgical Hx portion of the chart. -
Answer-Tonsillectomy
Name an example of something you may write in the social Hx portion of the chart. -
Answer-Non-smoker
Name an example of something you may write in the Family Hx portion of the chart -
Answer-Father has CAD
Removal of appendix - Answer-appendectomy
Removal of gallbladder - Answer-Cholecystectomy
Removal of Uterus - Answer-Hysterectomy
Removal of Tonsils - Answer-Tonsillectomy
What are the two types of heart attacks and how are they diagnosed? - Answer-STEMI
(EKG)
Non-STEMI (Troponin)
What are three cardiac risk factors? - Answer-HTN
HLD
, CAD
Chest pain, Dyspnea, cough, and fever correlate to which DDx? And What study would
be ordered? - Answer-PNA
CXR
What are the three symptoms a patient with an ischemic CVA would present with? -
Answer-Unilateral weakness
Changes in Vision
Changes in speech
What heart rhythm would a physician hear if the patient were in atrial fibrillation and how
is this disease diagnosed? - Answer-Irregularly irregular rhythm
EKG
What physical exam finding is associated with Cholecystitis - Answer-RUQ Tenderness
or Murphey's Sign
How is altered mental status different from focal neurological deficit? What is the major
cause of AMS in the elderly? - Answer-Altered mental status is generalized/affects the
whole brain where as focal neurological deficits are localized.
UTIs commonly cause AMS in elderly patients
What is the "layman's name" for GERD - Answer-Heartburn, Indigestion, acid reflux
What is the most common cause for seizures in children? - Answer-Fevers
What is one medication that is used as a vasodilator? Bronchodilator? - Answer-NTG
(nitroglycerin)
Nebulizers/Inhalers
In your own words, describe the significance of an HPI. - Answer-The HPI is the story
as to why the patient is visiting the ED. It provides the chief complaint and important
details to help the doctor get started on their "medical investigation." The HPI creates
the road map for the whole ED visit.
Imagine a patient with the CC of a headache. Name five elements of the HPI and
provide an applicable example of each element. - Answer-Onset: Two days ago
Quality: Throbbing
Timing: Constant
Severity: 7/10
Modifying factors: Made worse when bending over
T/F: the patient's entire ED visit is based on their answers to the questions asked during
the interview - Answer-True
QUESTIONS WITH CORRECT ANSWERS
What does ROS stand for? - Answer-Review of Systems
The HPI and ROS are considered what type of information? - Answer-Subjective
The physical exam is what type of information? - Answer-Objective
If a physician told you a patient's abdomen was nontender or the patient's skin was
pale, where would you document these pieces of information? - Answer-Physical Exam
What section focuses directly on the chief complaint? - Answer-History of Present
Illness (HPI)
What are the five vital signs? - Answer-Heart rate
Blood pressure
Temperature
Respiratory Rate
Oxygen Saturation
Name an example of something you may write in the surgical Hx portion of the chart. -
Answer-Tonsillectomy
Name an example of something you may write in the social Hx portion of the chart. -
Answer-Non-smoker
Name an example of something you may write in the Family Hx portion of the chart -
Answer-Father has CAD
Removal of appendix - Answer-appendectomy
Removal of gallbladder - Answer-Cholecystectomy
Removal of Uterus - Answer-Hysterectomy
Removal of Tonsils - Answer-Tonsillectomy
What are the two types of heart attacks and how are they diagnosed? - Answer-STEMI
(EKG)
Non-STEMI (Troponin)
What are three cardiac risk factors? - Answer-HTN
HLD
, CAD
Chest pain, Dyspnea, cough, and fever correlate to which DDx? And What study would
be ordered? - Answer-PNA
CXR
What are the three symptoms a patient with an ischemic CVA would present with? -
Answer-Unilateral weakness
Changes in Vision
Changes in speech
What heart rhythm would a physician hear if the patient were in atrial fibrillation and how
is this disease diagnosed? - Answer-Irregularly irregular rhythm
EKG
What physical exam finding is associated with Cholecystitis - Answer-RUQ Tenderness
or Murphey's Sign
How is altered mental status different from focal neurological deficit? What is the major
cause of AMS in the elderly? - Answer-Altered mental status is generalized/affects the
whole brain where as focal neurological deficits are localized.
UTIs commonly cause AMS in elderly patients
What is the "layman's name" for GERD - Answer-Heartburn, Indigestion, acid reflux
What is the most common cause for seizures in children? - Answer-Fevers
What is one medication that is used as a vasodilator? Bronchodilator? - Answer-NTG
(nitroglycerin)
Nebulizers/Inhalers
In your own words, describe the significance of an HPI. - Answer-The HPI is the story
as to why the patient is visiting the ED. It provides the chief complaint and important
details to help the doctor get started on their "medical investigation." The HPI creates
the road map for the whole ED visit.
Imagine a patient with the CC of a headache. Name five elements of the HPI and
provide an applicable example of each element. - Answer-Onset: Two days ago
Quality: Throbbing
Timing: Constant
Severity: 7/10
Modifying factors: Made worse when bending over
T/F: the patient's entire ED visit is based on their answers to the questions asked during
the interview - Answer-True
