SCRIBE EXAM 1 FINAL QUESTIONS WITH CORRECT ANSWERS

SCRIBE EXAM 1 FINAL QUESTIONS
WITH CORRECT ANSWERS
What is an HPI - Answer-story surrounding the chief complaint and context which
brought the patient to the clinic

T/F
do not use any abbreviations - Answer-T

Critical questions when a patient has received prior care - Answer-- who did they see
(name and specialty)
-when
-what symptoms
-treatment?
-diagnosis?
-prior testing? (what type, date, results)

components of subjective exam - Answer-HPI/ CC
ROS
PMSFHx

components of objective exam - Answer-PE
Dx
A and P

What do you document in an ROS - Answer-Sx a pt reports and denies under their
appropriate body system in the ROS

ROS template - Answer--constitutional
-eyes
-ent
-respiratory
-cardiovascular
-GI
-GU
-musculoskeletal
-integumentary
-neurologic
-psychiatric

PMSSFHx - Answer-past medical, social, surgical, and family history

Physical exam - Answer-findings the provider determines

,Physical exam components - Answer--general
-head/neck
-eyes
-ent
-respiratory
-cardiovascular
-GI
-musculoskeletal/ extremeties
-skin
-neurologic
-psychiatric

Diagnostic info consists of - Answer--labs
-imaging studies
-pathology
-clinic specific tests

CBC - Answer-complete blood count

BMP - Answer-basic metabolic panel

CMP - Answer-comprehensive metabolic panel

WBC - Answer-white blood cell

Hb - Answer-hemoglobin

Hct - Answer-hematocrit

Low hematocrit - Answer-anemia

Plt - Answer-platelets

low platelet count - Answer-decreased clotting

High glucose - Answer-diabetes

Electrolytes - Answer-Na, K, Cl

renal studies - Answer-GFR, creatinine, BUN

LFTs - Answer-liver function tests

Cmps - Answer-AST, ALT, Alk Phos

PT - Answer-prothrombin time (how long it takes blood to clot)

,INR - Answer-international normalized ratio

normal INR - Answer-less than 1

INR of patients on anticoagulants - Answer-around 2.5

Lipase - Answer-pancreatic enzyme

Amylase - Answer-enzyme in saliva and pancreatic fluid

lactate (lactic acid) - Answer-produced when glucose is broken down and oxidized

Lactic acid increases during - Answer--strenuous exercise
-heart failure
-sepsis
-shock

Ketones - Answer-produced when body burns lipids or fats for energy

Pt's with diabetes have elevated - Answer-ketones which indicate DBK

Cardiac Panel - Answer-Troponin, Ck

UTI has increased - Answer--bacteria
-WBCs
-Leukocyte esterase
-Nitrite

Kidney stones have increased - Answer--RBC's
-Blood

Culture - Answer-method to grow and identify bacteria

Sensitivity - Answer-helps determine what Abx are needed

hCG - Answer-hormone produced by placenta after implantation

Gravid - Answer-# of pregnancies

Para - Answer-# live births

Aborta - Answer-# abortions or miscarriages

Assesment - Answer-record diagnoses

, plan - Answer-record tx

EKG - Answer-checks for problems with the electrical activity of your heart

HEENT is responsible for - Answer-smell, hearing, and balance

Cephal/o - Answer-head

normocephalic - Answer-Normal head.

-eryth - Answer-red

erythematous - Answer-pertaining to redness of the skin

-itis - Answer-inflammation

ot/ itis - Answer-inflammation of the ear

-scope - Answer-instrument for viewing

otoscope - Answer-instrument for examining the ear

otitis media CC - Answer-ear pain/ pressure, ear pulling

Otitis media characteristic symptoms - Answer-ear pain/ pressure
potential decreased hearing
bleeding and hearing loss

Otitis media dx workup - Answer-via otoscope

Otitis media common exam findings - Answer--erythema
-effusion
-dullness
-TM bulging
-pus
-loss of landmarks

Otitis media tx - Answer--Abx otic drops
- tylenol
-motrin
-tube placement in pediatric patients to drain XS fluid

Otitis Exterana - Answer-external ear infection (outer ear or ear canal)
swimmers ear

Otitis externa CC - Answer-pain in canal