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
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
