Scribe America Final Exam 2022 correct answers

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? 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? Uncomplicated laceration of the left foot - initial encounter What does AMS stand for? altered mental status What does GCS stand for? glasgow coma scale What does DNR stand for? do not resuscitate What does AAA stand for? abdominal aortic aneurysm What does PE stand for in the diagnosis section of the chart? pulmonary embolism What does DP stand for in "DP pulse"? dorsalis pedis What does DVT stand for? deep vein thrombosis What does NTG stand for? nitroglycerin What does URI stand for? upper respiratory infection What does CHF stand for? congestive heart failure What does s/p stand for? status post What does GERD stand for? gastroesophageal reflux disease What does EOMI stand for? extraocular movements intact What does DOE stand for? dyspnea on exertion What does LBBB stand for? left bundle branch block What does CVA stand for? costovertebral angle What does CSF stand for? cerebrospinal fluid What does PTX stand for? pneumothorax What does COPD stand for? chronic obstructive pulmonary disease What does PNA stand for? pneumonia What does CBC stand for? complete blood count What does IDDM stand for? insulin dependent diabetes mellitus What does TIA stand for? 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: 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 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. False Which section of the chart would you find AKA? a. PSHx b. PMHx c. SHx d. Disposition e. FHx f. PE PSHx PE