Scribe America Final Exam Study Guide Latest 2022 Graded A+

Scribe America Final Exam Study Guide Latest 2022 Graded A+ What does ROS stand for? Review of symptoms, head to toe checklist of symptoms The HPI and ROS are considered what type of information? Subjective The physical exam is what type of information? Objective If a physician told you a patients abdomen was nontender or the patients skin was plale, where would you document this information Physical Exam (PE) What section focuses directly on the chief complaint? HPI (History of present illness) What are the 5 vital signs? 1. Heart rate (HR) 2. Respiratory rate (RR) 3. Blood pressure (BP) 4. Temperature (T) 5. Oxygen Saturation (SpO2) Surgical Hx example CABG (Coronary artery bypass graft) Social Hx example Smoker 1 ppd Family Hx example Brother diagnosed with CAD < 55 y/o Removal of appendix Appendectomy Removal of gallbladder Cholecystectomy Removal of uterus Hysterectomy Removal of tonsils Tonsillectomy What are the 2 types of heart attacks and how are they diagnosed? STEMI - EKG Non-STEMI - Troponin What are 3 cardiac risk factors? HTN, HLD, Smoking, CAD, DM, FHx CAD < 55 y/o Chest pain, dyspnea, cough and fever correlated to which DDx? What study would be ordered? PNA (Pneumonia) CXR What are 3 symptoms a patient with an Ischemic CVA would present with? Unilateral weakness/numbness, slurred speech, vision changes What heart rhythm would a physician hear if the patient were in atrial fibrillation and how is the disease diagnosed? Irregularly irregular rhythm (A-Fib) EKG Name 2 risk factors to hemorrhagic CVA Head Trauma, anticoagulants (blood thinner medication), uncontrolled HTN How is AMS different from a focal neurological deficit? What is the major cause of AMS in the elderly? AMS (confusion, lethargy, unresponsiveness) affects the whole brain (drugs, EtOH) and FND (one sided weakness/numbness, speech changes, vision changes) affects a small portion/localized of the brain AMS in elderly - UTI Layman's term for GERD Heartburn, Indigestion, Acid Reflux Most common cause for seizures in children? Fever Which drug causes smooth muscle relaxation, causing vasodilation and increase blood supply to heart muscle? NTG (Nitroglycerin) Describe the significance of an HPI Explains patients CC and answers "Why did the patient seek treatment?" CC of a headache, name 5 elements of the HPI and provide an applicable example of each element Onset - 3 weeks ago Timing - intermittent Quality - pressure Severity - 9/10 location - frontal/forehead Modifying factors - worse with light, better after Excedrin Context - does not take a blood thinner, no recent head injuries, Hx of similar HA True or False: Patients entire ED visit is based on their answers to the questions asked during the interview? True True or False: Accurate chronology is not important in an HPI False What is the main different between HPI and ROS? HPI - story of the CC ROS - head-to-toe checklist of subjective Sx True or False: Symptoms listed in ROS can contradict the Sx discussed in the HPI False How would you document GPA for a patient who is currently pregnant, has been pregnant 4 time in the past, and has one child at home? G - 5 P - 1 A - 3 List 5 body systems found in the ROS and provide 2 symptoms for each system. Skin - Rashes, itching, redness General - fever, chills, weight loss Cardio - Chest pain,Palpitations Pulmonary - shortness of breath, dyspnea, cough, wheezing GI - abdominal pain, acid reflux Neuro - headache, seizures, unilateral weakness/numbness Psych - anxiety hallucinations, depression Read the paragraph below and determine the following for the detailed HPI: A 36 y/o female with a Hx of asthma presents to the ED with worsening wheezing that started 4 days. The patient says feels like she cannot take a full breath similar to her previous asthma exacerbations, but the albuterol inhalers prescribed by her pulmonologist (Dr. Aranibar) have not provided relief. She reports dyspnea and a mild dry cough since last night, but no fever, chest pain, leg pain, leg swelling, or recent travel. The patient was unable to walk to her bathroom this afternoon secondary to her dyspnea, prompting the 911 call. When paramedics arrived to the patient's home 30 minutes ago, tight expiratory wheezes in all fields were appreciated and the patient's SpO2 was 90% on RA. The patient received a DuoNeb breathing treatment and Solumedrol 125 mg en route to the ED, with mild symptom relief. CC: wheezing