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ScribeAmerica Scribe Test / Revised Questions and Answers / Sure A+

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"Heart Disease" is also known as: - Coronary Artery Disease A 92 year old male presented to the ED without a heart rate and not breathing. He was successfully resuscitated in the Emergency Department, but he required a breathing tube (intubation) and is receiving oxygen through a ventilator. Where do you think he will go next? - Inpatient A gastrointestinal perforation (also known as ruptured bowel) is a highly emergent condition that occurs when there is a hole in the wall of part of the GI tract. What test would be best to evaluate this condition? - CT A/P A person who is very stressed while watching a scary movie is MOST likely: - Tachycardic A sick child who has had a fever for 2 hours most likely has which temperature? - 102.5 A UTI that is unresolved and goes to the k

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ScribeAmerica Scribe Test / Revised
Questions and Answers / Sure A+
"Heart Disease" is also known as: - Coronary Artery Disease


A 92 year old male presented to the ED without a heart rate and not breathing. He was successfully
resuscitated in the Emergency Department, but he required a breathing tube (intubation) and is
receiving oxygen through a ventilator. Where do you think he will go next? - Inpatient



A gastrointestinal perforation (also known as ruptured bowel) is a highly emergent condition that occurs
when there is a hole in the wall of part of the GI tract. What test would be best to evaluate this
condition? - CT A/P



A person who is very stressed while watching a scary movie is MOST likely: - Tachycardic



A sick child who has had a fever for 2 hours most likely has which temperature? - 102.5



A UTI that is unresolved and goes to the kidneys is known as: - Pyelonephritis



Abdominal tenderness belongs in which part of the chart - PE



An 11 year old patient fell off a trampoline earlier today, and presents with right wrist pain. Which test is
your provider likely to order, to evaluate the patient's pain? - X-ray of the right wrist



An 8 year old patient comes in for follow up on their Diabetes, what type of Diabetes do they most likely
have? - Type I



Blood pressure is defined as: - The pressure at which blood is being pumped throughout your
body



cc - chief complaint

, Components of MDM - procedures

rechecks on patients

medication reactions

case summary

consultation with other physicians

discussions with family

lab interpretations

EKG interpretations

radiology interpretations

*if it affected decision making it should be included*



Consultation - physician talks to/references a specialist

write: timestamp

full name of consultant

what specialty service



DDx - Differential Diagnosis; best guess as to what is the cause

(what was investigated and how? history, lab, procedure findings? how did this rule out certain
diagnoses? discuss why the physician chose a certain diagnosis?)



Discharge - physician goes in to discharge the patient home

write: guidelines for return (symptoms/concerns)

follow up (who/when/for what)

medicolegal (is the patient aware and understanding instructions?)



Each diagnosis becomes a permanent part of the patient's medical record. - True

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