Vituity scribe EXAM 1&2 Questions and
Answers Graded A+
Plantar \u2714\u2714Sole side of foot
Plantar flexion \u2714\u2714Foot movement when toes flex down
(pointing your toes)
Supine \u2714\u2714Body lying face up (chest up and back down)
Afebrile \u2714\u2714without fever
diaphoresis \u2714\u2714excessive sweating
dysuria \u2714\u2714painful urination
emesis \u2714\u2714vomiting
epistaxis \u2714\u2714bleeding from the nose
gait \u2714\u2714a person’s manner of walking
hematochezia \u2714\u2714Bright red, bloody stools
hematuria \u2714\u2714blood in the urine
hemoptysis \u2714\u2714coughing up blood<\/p>\n\n\n\n
incontinence \u2714\u2714inability to control bowel movements or urine
myocardial infarction (MI) \u2714\u2714heart attack
pruritis \u2714\u2714itching
syncope \u2714\u2714fainting
vertigo \u2714\u2714Condition of dizziness, “room spinning”
cyanosis \u2714\u2714bluish discoloration of the skin
laceration \u2714\u2714to cut
Bradycardia \u2714\u2714slow heart rate
Tachycardia \u2714\u2714fast heart rate
apnea \u2714\u2714absence of breathing
gravid \u2714\u2714pregnant
melena \u2714\u2714Black tarry stool
colectomy \u2714\u2714surgical removal of the colon
mastectomy \u2714\u2714surgical removal of a breast
ABG \u2714\u2714arterial blood gas<\/p>\n\n\n\n
Vituity Scribe Training Pre-Classroom
Training Exam Latest 2022 100% Pass
ALOC \u2714\u2714Altered Level of Consciousness
BM \u2714\u2714bowel movement
DOE \u2714\u2714Dyspnea on exertion
EOMI \u2714\u2714Extraocular Movement Intact (Appropriate function of the extra ocular muscles,
tested with “follow my finger”)
HA \u2714\u2714headache
MI \u2714\u2714Myocardial infarction
NAD \u2714\u2714no acute distress
NSR \u2714\u2714Normal Sinus Rhythm
PNA \u2714\u2714pneumonia
UTI \u2714\u2714Urinary Tract Infection
ASA \u2714\u2714Aspirin
CA \u2714\u2714Cancer<\/p>\n\n\n\n
PCN \u2714\u2714Penicillin
DM \u2714\u2714Diabetes Mellitus
PTX \u2714\u2714Pneumothorax
SOB \u2714\u2714Shortness of breath
FB \u2714\u2714Foreign Body
CVA \u2714\u2714Cerebral Vascular Accident (Stroke) – Can be ischemic or hemorrhagic)
TIA \u2714\u2714transient ischemic attack (mini stroke)
TX \u2714\u2714treatment
earwax \u2714\u2714cerumen
runny nose \u2714\u2714rhinorrhea
Vomiting blood \u2714\u2714hematemesis
fainting \u2714\u2714syncope
Sweating \u2714\u2714diaphoresis
bruising \u2714\u2714ecchymosis
itchiness \u2714\u2714pruritus<\/p>\n\n\n\n
cardiac bypass \u2714\u2714CABG (coronary artery bypass graft)
Hernia repair \u2714\u2714herniorrhaphy
Removal of gallbladder \u2714\u2714cholecystectomy
Removal of uterus \u2714\u2714hysterectomy
Rales \u2714\u2714wet, crackling sound with respirations (aka crackles)
Four main components of the medical chart you are responsible for? \u2714\u27141. HPI<\/p>\n\n\n\n
True or False: Whether a patient smokes or not should be documented in the PMFSH? \u2714\u2714True:
This is social history
True or False: The physical exam is objective \u2714\u2714True: From the doctor’s point of view
Fever \u2714\u2714febrile
vomiting \u2714\u2714emesis
pain with urination \u2714\u2714dysuria
RRR \u2714\u2714Regular Rate and Rhythm (cardio finding)
CVAT \u2714\u2714Costal Vertebral Angle Tenderness (Back finding sometimes GU)
BS present \u2714\u2714bowel sounds present
SNF \u2714\u2714Skilled Nursing Facility
BIBA \u2714\u2714brought in by ambulance
CP \u2714\u2714chest pain, cerebral palsy
ATX \u2714\u2714atelectasis
Pregnancy \u2714\u2714Gravid
oophorectomy \u2714\u2714surgical removal of one of both ovaries<\/p>\n\n\n\n
Scribe America Final Exam Study Guide
Latest 2022 Graded A+
What does ROS stand for? \u2714\u2714Review of symptoms, head to toe checklist of symptoms
The HPI and ROS are considered what type of information? \u2714\u2714Subjective
The physical exam is what type of information? \u2714\u2714Objective
If a physician told you a patients abdomen was nontender or the patients skin was plale, where
would you document this information \u2714\u2714Physical Exam (PE)
What section focuses directly on the chief complaint? \u2714\u2714HPI (History of present illness)
What are the 5 vital signs? \u2714\u27141. Heart rate (HR)<\/p>\n\n\n\n
Removal of gallbladder \u2714\u2714Cholecystectomy
Removal of uterus \u2714\u2714Hysterectomy
Removal of tonsils \u2714\u2714Tonsillectomy
What are the 2 types of heart attacks and how are they diagnosed? \u2714\u2714STEMI – EKG
Non-STEMI – Troponin
What are 3 cardiac risk factors? \u2714\u2714HTN, HLD, Smoking, CAD, DM, FHx CAD < 55 y\/o
Chest pain, dyspnea, cough and fever correlated to which DDx?
What study would be ordered? \u2714\u2714PNA (Pneumonia)
CXR
What are 3 symptoms a patient with an Ischemic CVA would present with? \u2714\u2714Unilateral
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? \u2714\u2714Irregularly irregular rhythm (A-Fib)
EKG
Name 2 risk factors to hemorrhagic CVA \u2714\u2714Head Trauma, anticoagulants (blood thinner
medication), uncontrolled HTN
How is AMS different from a focal neurological deficit?<\/p>\n\n\n\n
What is the major cause of AMS in the elderly? \u2714\u2714AMS (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 \u2714\u2714Heartburn, Indigestion, Acid Reflux
Most common cause for seizures in children? \u2714\u2714Fever
Which drug causes smooth muscle relaxation, causing vasodilation and increase blood supply to
heart muscle? \u2714\u2714NTG (Nitroglycerin)
Describe the significance of an HPI \u2714\u2714Explains 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 \u2714\u2714Onset – 3 weeks ago
Timing – intermittent
Quality – pressure
Severity – 9\/10
location – frontal\/forehead
Modifying factors – worse with light, better after Excedrin<\/p>\n\n\n\n
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?
\u2714\u2714True
True or False:
Accurate chronology is not important in an HPI \u2714\u2714False
What is the main different between HPI and ROS? \u2714\u2714HPI – 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 \u2714\u2714False
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? \u2714\u2714G – 5
P – 1
A – 3
List 5 body systems found in the ROS and provide 2 symptoms for each system. \u2714\u2714Skin –
Rashes, itching, redness
General – fever, chills, weight loss<\/p>\n\n\n\n
Scribe America Final Exam Review
Questions and Answers 100% Pass
AAA \u2714\u2714Abdominal Aortic Aneurysm
A Fib \u2714\u2714Atrial Fibrillation
Abd \u2714\u2714Abdomen, Abdominal
Abx \u2714\u2714Antibiotics
AMA \u2714\u2714Against Medical Advice
AMS \u2714\u2714Altered Mental Status
ASA \u2714\u2714Acetylsalicylic Acid (Aspirin)
BID \u2714\u2714Twice Daily
Bilat LE \u2714\u2714Bilateral Lower Extremities
BM \u2714\u2714Bowel Movement
BP \u2714\u2714Blood Pressure
CA \u2714\u2714Cancer, Carcinoma
CABG \u2714\u2714Coronary Artery Bypass Graft, “open heart surgery”<\/p>\n\n\n\n
CAD \u2714\u2714Coronary Artery Disease, “heart disease”
CT or CAT \u2714\u2714Computerized Assisted Tomography
CHF \u2714\u2714Congestive Heart Failure
COPD \u2714\u2714Chronic Obstructive Pulmonary Disease
CP \u2714\u2714Chest Pain
CPR \u2714\u2714Cardiopulmonary Resuscitation
C-section \u2714\u2714Caesarean Section
C-spine \u2714\u2714Cervical Spine (neck)
CSF \u2714\u2714Cerebrospinal Fluid
CVA \u2714\u2714Cerebrovascular Accident -or- Costovertebral Angle
CXR \u2714\u2714Chest X-Ray
c\/o \u2714\u2714complains of
DKA \u2714\u2714Diabetic Ketoacidosis
DM \u2714\u2714Diabetes Mellitus<\/p>\n\n\n\n
DNR \u2714\u2714Do Not Resuscitate
DOE \u2714\u2714Dyspnea On Exertion
DVT \u2714\u2714Deep Venous Thrombosis
Dx \u2714\u2714Diagnosis
Dz \u2714\u2714Disease
EKG\/ECG \u2714\u2714Electrocardiogram
EtOH \u2714\u2714Alcohol
FHx \u2714\u2714Family History
Fx \u2714\u2714Fracture
GI \u2714\u2714Gastrointestinal
G\/P\/Ab \u2714\u2714Gravida\/Para\/Abortion
GSW \u2714\u2714Gun Shot Wound
GU \u2714\u2714Genitourinary
HA \u2714\u2714Headache
HEENT \u2714\u2714Head, Eyes, Ears, Nose, Throat<\/p>\n\n\n\n
Scribe America Final Exam ED
Questions and Answers Already Graded
A+
High blood pressure layman’s\u2714\u2714Hypertension
Hypertension (abbv)\u2714\u2714HTN
High cholesterol layman’s\u2714\u2714Hyperlipidemia
Hyperlipidemia (abbv)\u2714\u2714HLD
Diabetes layman’s\u2714\u2714Diabetes mellitus
Diabetes mellitus (abbv)\u2714\u2714DM
“I only take pills for my diabetes”\u2714\u2714NIDDM (Type 2)
“I take insulin for my diabetes”\u2714\u2714IDDM (Type 1)
Heart disease layman’s\u2714\u2714Usually coronary artery disease
Coronary artery disease (abbv)\u2714\u2714CAD
Heart failure layman’s\u2714\u2714Congestive heart failure
Congestive heart failure (abbv)\u2714\u2714CHF<\/p>\n\n\n\n
Irregular heartbeat layman’s\u2714\u2714Atrial fibrillation (A-fib)
Murmur layman’s\u2714\u2714Heart murmur
Episodes of abnormally fast\/racing heartbeat\u2714\u2714Supraventricular tachycardia
Supraventricular tachycardia (abbv)\u2714\u2714SVT
Emphysema or chronic bronchitis layman’s\u2714\u2714Chronic obstructive pulmonary disease (COPD)
Blood clot in lung layman’s\u2714\u2714Pulmonary embolism (PE)
Pneumonia (abbv)\u2714\u2714PNA
Reflux layman’s\u2714\u2714Gastroesophageal reflux disease (GERD)
Gastroesophageal reflux disease (abbv)\u2714\u2714GERD
Ulcer layman’s\u2714\u2714Gastric ulcer or Peptic ulcer disease
Crohn’s or UC layman’s\u2714\u2714Crohn’s disease or Ulcerative colitis
Irritable bowel layman’s\u2714\u2714Irritable bowel syndrome (IBS)
Irritable bowel syndrome (abbv)\u2714\u2714IBS
Bladder infection layman’s\u2714\u2714Urinary tract infection (UTI)
Kidney infection layman’s\u2714\u2714Pyelonephritis (Pyelo)<\/p>\n\n\n\n
Kidney stones layman’s\u2714\u2714Renal calculi
“I’m on dialysis”\u2714\u2714Chronic renal failure (CRF) or End stage renal disease (ESRD) on dialysis
Enlarged prostate layman’s\u2714\u2714Benign prostate hypertrophy (BPH)
Document GPA for a pt who is currently pregnant, has been pregnant 3 times in the past, and has
2 kids at home.\u2714\u2714G: 4 P:2 A:1
Stroke layman’s\u2714\u2714Ischemic cerebrovascular accident (CVA)
“Mini-stroke” layman’s\u2714\u2714Transient ischemic attack (TIA)
Seizures layman’s\u2714\u2714Seizure disorder \/ Epilepsy
Brain bleed layman’s\u2714\u2714Hemorrhagic CVA
Bipolar layman’s\u2714\u2714Bipolar disorder
Schizophrenia layman’s\u2714\u2714Schizophrenia
“I drink a lot”\u2714\u2714EtOH abuse or Alcoholism
“I do drugs”\u2714\u2714Substance abuse
“Blood clot in my leg”\u2714\u2714Lower extremity deep vein thrombosis (DVT)
“Bulge in my aorta” or “Triple A”\u2714\u2714Abdominal aortic aneurysm (AAA)<\/p>\n\n\n\n
ScribeAmerica Final Exam Questions
and Answers Graded A+
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? \u2714\u2714acute 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? \u2714\u2714Uncomplicated
laceration of the left foot – initial encounter
What does AMS stand for? \u2714\u2714altered mental status
What does GCS stand for? \u2714\u2714glasgow coma scale
What does DNR stand for? \u2714\u2714do not resuscitate
What does AAA stand for? \u2714\u2714abdominal aortic aneurysm
What does PE stand for in the diagnosis section of the chart? \u2714\u2714pulmonary embolism
What does DP stand for in “DP pulse”? \u2714\u2714dorsalis pedis
What does DVT stand for? \u2714\u2714deep vein thrombosis
What does NTG stand for? \u2714\u2714nitroglycerin<\/p>\n\n\n\n
What does URI stand for? \u2714\u2714upper respiratory infection
What does CHF stand for? \u2714\u2714congestive heart failure
What does s\/p stand for? \u2714\u2714status post
What does GERD stand for? \u2714\u2714gastroesophageal reflux disease
What does EOMI stand for? \u2714\u2714extraocular movements intact
What does DOE stand for? \u2714\u2714dyspnea on exertion
What does LBBB stand for? \u2714\u2714left bundle branch block
What does CVA stand for? \u2714\u2714costovertebral angle
What does CSF stand for? \u2714\u2714cerebrospinal fluid
What does PTX stand for? \u2714\u2714pneumothorax
What does COPD stand for? \u2714\u2714chronic obstructive pulmonary disease
What does PNA stand for? \u2714\u2714pneumonia
What does CBC stand for? \u2714\u2714complete blood count
What does IDDM stand for? \u2714\u2714insulin dependent diabetes mellitus
What does TIA stand for? \u2714\u2714transient ischemic attack<\/p>\n\n\n\n
A 43 y\/o male presents to the ED with vomiting that began 5 hours ago. He has a history of Type Scribe America Final Exam ED Stroke If the doctor said the exam was “benign”, what does this mean? \u2714\u2714this means that the exam was Scribe America Final exam guide (AA) Scribe 101 Questions and Answers with ED Scribe – FINAL EXAM QUESTIONS What is the general documentation template? \u2714\u2714HPI > ROS > PHx > PE > ED course > Crohn’s\/UC means.. \u2714\u2714Crohn’s Disease or Ulcerative Colitis “Bad blood flow to my legs” means.. \u2714\u2714Peripheral Vascular Disease – PVD Medical Scribe- Final exam review PSHx: Past surgical history- appendectomy, cholecystectomy, CABG Scribe Final Exam Questions and Abduction \u2714\u2714Moving away from the midline. nl \u2714\u2714normal ScribeAmerica Final Exam Questions Second hand smoke exposure Scribe Final Review Questions and Select the EKG interpretation documentation guidelines. \u2714\u27142 positive or negative findings, rate Scribe Final Review Questions and Select the EKG interpretation documentation guidelines. \u2714\u27142 positive or negative findings, rate Scribe U Final Questions and Answers Back of foot: 2+ PTP Vituity scribe EXAM 1&2 Questions andAnswers Graded A+Plantar \u2714\u2714Sole side of footPlantar flexion \u2714\u2714Foot movement when toes flex down(pointing your toes)Supine \u2714\u2714Body lying face up (chest up and back down)Afebrile \u2714\u2714without feverdiaphoresis \u2714\u2714excessive sweatingdysuria \u2714\u2714painful urinationemesis \u2714\u2714vomitingepistaxis \u2714\u2714bleeding from the nosegait \u2714\u2714a person’s manner of walkinghematochezia \u2714\u2714Bright red, bloody stoolshematuria \u2714\u2714blood in the urinehemoptysis \u2714\u2714coughing […]<\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"site-sidebar-layout":"default","site-content-layout":"","ast-site-content-layout":"default","site-content-style":"default","site-sidebar-style":"default","ast-global-header-display":"","ast-banner-title-visibility":"","ast-main-header-display":"","ast-hfb-above-header-display":"","ast-hfb-below-header-display":"","ast-hfb-mobile-header-display":"","site-post-title":"","ast-breadcrumbs-content":"","ast-featured-img":"","footer-sml-layout":"","ast-disable-related-posts":"","theme-transparent-header-meta":"","adv-header-id-meta":"","stick-header-meta":"","header-above-stick-meta":"","header-main-stick-meta":"","header-below-stick-meta":"","astra-migrate-meta-layouts":"default","ast-page-background-enabled":"default","ast-page-background-meta":{"desktop":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center 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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: \u2714\u2714Onset: 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
<\/strong>: Answers phone calls, pages other specialists\/ doctors, and organizes the patient’s
paperwork<\/p>\n\n\n\n
Questions and Answers Already Passed
What are the 3 types of dispositions? \u2714\u2714Discharge, Admit, Transfer
What does HPI stand for? \u2714\u2714history of present illness
What does ROS stand for? \u2714\u2714review of systems
The HPI and ROS are considered what type of information? \u2714\u2714subjective
The physical exam is what type of information? \u2714\u2714objective
If a physician told you a patient’s abdomen was non tender, where would you document this?
\u2714\u2714PE
What section focuses directly on the chief complaint? \u2714\u2714HPI
If someone has a hx of CABG or MI, what is something you can also always document in the
PMHx section of the chart? \u2714\u2714CAD
Name an example of something you may write in the Social Hx portion of the chart. \u2714\u2714smokes
1 pack\/day
Name an example of something you may write in the Family Hx portion of the chart. \u2714\u2714Mother
had Hx of CAD at age 46
What are the abbreviations for the following past medical history terms?
Hypertension<\/p>\n\n\n\n
Diabetes
Heart Attack
High Cholesterol \u2714\u2714HTN
CVA (cerebrovascular accident)
DM
MI
HLD
What are the medical terms for the following past surgical terms?
Removal of the appendix
Removal of the gallbladder
Removal of the uterus
Removal of a fallopian tube
Removal of the tonsils
Removal of the breast \u2714\u2714appendectomy
cholecystectomy
hysterectomy
Salpingo-oophorectomy
tonsillectomy
mastectomy
What are the five vital signs? \u2714\u2714Blood pressure (BP), heart rate (HR), oxygen saturation
(SaO2), respiratory rate (RR), temperature (C or F)
What does NKDA stand for? \u2714\u2714no known drug allergies
What does LNMP stand for? \u2714\u2714Last Normal Menstrual Period<\/p>\n\n\n\n
normal and of no concern
Explain acute vs chronic. \u2714\u2714acute: serious, new condition, that could potentially be lifethreatening
chronic: not of much concern, long-lasting condition, typically not a death threat
What are the medical terms for the following pathophysiology abbreviations?
CAD
AAA
COPD
PNA
URI \u2714\u2714coronary artery disease
abdominal aortic aneurysm
chronic obstructive pulmonary disease
pneumonia
upper respiratory disease
How are the following diseases diagnosed?
-CHF (two answers)
-PE (three answers)
-Cholecystitis
-Pancreatitis
-Appendicitis
-Hemorrhagic CVA (two answers)
-DVT \u2714\u2714-chest x-ray, bnp (b-type natriuretic peptide)
-CT chest with IV contrast (CTA chest), VQ scan, D-dimer
-abdominal ultrasound (US) of RUQ
-elevated lipase lab test
-CT AP w\/ PO<\/p>\n\n\n\n
Latest 2022<\/p>\n\n\n\n\n
CP: \u2714\u2714Chest pain<\/li>\n\n\n\n
Complete Solutions
True or False: In order to take the final exam, I must complete each lesson quiz in order with a
passing score of 100% before I can attempt the final. \u2714\u2714TRUE
What happens if you do not complete the course in 15 days and\/or fail the final exam twice?
\u2714\u2714On the 15th day after passing the initial quiz, my course progress will be reset back to 0%. I
will then be able to re-progress through the course.
When does my certificate for passing Scribe101 expire? \u2714\u2714My certificate for completing
Scribe101 is good for 90 days, from the date I passed the final.
I have previous medical experience. Do I need to complete the Scribe101 course? \u2714\u2714No. All
individuals will be given the option to test out of Scribe101. To test out, please access the
“Scribe101 – Test Out” course. The “Scribe101 – Test Out” course is composed of a 100 question
final. You will have 1 attempt to pass this final and test out. If you do not pass this final, you will
need to complete the Scribe101 course.
Vital signs are: \u2714\u2714A series of measures that give an overview of a patient’s overall health
Heart rate is defined as: \u2714\u2714The rate that your heart is pumping blood
Blood pressure is defined as: \u2714\u2714The pressure at which blood is being pumped throughout your
body
Which of the following is NOT a vital sign: \u2714\u2714Body Weight
Someone who is breathing really fast and short of breath is MOST likely: \u2714\u2714Tachypneic<\/p>\n\n\n\n
AND ANSWERS ALREADY PASSED
Medical Decision Making (MDM) \u2714\u2714The physician’s thought process
Pain vs. Tenderness \u2714\u2714Patient’s feeling vs. physician’s assessment
What does distress mean? \u2714\u2714The doctor’s judgment of discomfort
Baseline \u2714\u2714An individual’s normal state of being
What does Auscultation mean? \u2714\u2714Listening with a stethoscope
Palpation \u2714\u2714The act of pressing on an area by the doctor
Inpatient \u2714\u2714Admitted to the hospital overnight
Outpatient \u2714\u2714Seen and sent home the same day
What is the ED flow (overview)? \u2714\u27141. Check in and Chief Complaint 2. Physician assessment<\/p>\n\n\n\n\n
What is the ED flow before orders are made? \u2714\u27141. Arrival 2. Triage 3. Vital Signs \/ Bed
Placement 4. Nurse Assessment 5. HPI, ROS, Hx, PE
What is the ED flow after orders are made? \u2714\u27141. Differential Dx 2. Physician orders > labs,
imaging, procedures, medications 3. Results and ED course 4. Final Dx 5. Disposition<\/li>\n<\/ol>\n\n\n\n
Disposition
Thyroid problem means.. \u2714\u2714Usually Hypothyroidism, sometimes hyperthyroidism
“I only take pills for my diabetes” means.. \u2714\u2714Non-Insulin Dependent Diabetes Mellitus –
NIDDM
“I take shots (insulin) for my diabetes” means.. \u2714\u2714Insulin Dependent Diabetes Mellitus – IDDM
Heart disease means.. \u2714\u2714Usually Coronary Artery Disease – CAD
Heart attack means.. \u2714\u2714Myocardial Infarction – MI and CAD
Irregular heartbeat means.. \u2714\u2714Atrial Fibrillation (A-Fib)
Murmur means.. \u2714\u2714Heart murmur
Episodes of abnormally fast\/racing heartbeat means.. \u2714\u2714Supraventricular Tachycardia – SVT
Emphysema\/Chronic Bronchitis means.. \u2714\u2714Chronic Obstructive Pulmonary Disease – COPD
Blood clot in lung means.. \u2714\u2714Pulmonary Embolism – PE
Reflux means.. \u2714\u2714Gastroesophageal Reflux Disease – GERD
Ulcer means.. \u2714\u2714Gastric Ulcer or Peptic Ulcer Disease
Hepatitis means.. \u2714\u2714Hepatitis A, Hepatitis B, or Hepatitis C<\/p>\n\n\n\n
Kidney infection means.. \u2714\u2714Pyelonephritis – Pyelo
Kidney stones means.. \u2714\u2714Renal calculi
“I’m on dialysis” means.. \u2714\u2714Chronic Renal Failure – CRF or End Stage Renal Disease – ESRD
on dialysis
Enlarged prostate means.. \u2714\u2714Benign Prostate Hypertrophy – BPH
What is the convention for documenting gynecological PMHx? \u2714\u2714G: P: A:
Stroke means.. \u2714\u2714Ischemic Cerebrovascular Accident – CVA
Mini-stroke means.. \u2714\u2714Transient Ischemic Attack – TIA
Seizures means.. \u2714\u2714Seizure disorder\/Epilepsy
Brain bleed means.. \u2714\u2714Hemorrhagic CVA
“I drink a lot” means.. \u2714\u2714ETOH abuse or Alcoholism
“I do drugs” means.. \u2714\u2714Substance abuse
“Blood clot in my leg” means.. \u2714\u2714DVT
“Bulge in my aorta” or “Triple A” \u2714\u2714Abdominal Aortic Aneurysm<\/p>\n\n\n\n
“Numbness in my legs” means.. \u2714\u2714Peripheral Neuropathy
Bulging\/Herniated disc means.. \u2714\u2714Degenerative Disc Disease – DDD
What does Arthritis mean? \u2714\u2714Osteoarthritis, Rheumatoid Arthritis
Joint pain (chronic) means.. \u2714\u2714Degenerative Joint Disease -DJD
Weak\/fragile bones means.. \u2714\u2714Osteoporosis
Spread to my means.. \u2714\u2714With metastases to the..
“They cut it out” (in regards to cancer) means.. \u2714\u2714Status-post surgical resection
“It’s gone” (in regards to cancer) means.. \u2714\u2714In remission
Tonsils removed means.. \u2714\u2714Tonsillectomy
Adenoids removed means.. \u2714\u2714Adenoidectomy
Ear tubes means.. \u2714\u2714Pressure Equalizer Tubes
Heart bypass means.. \u2714\u2714Coronary Artery Bypass Graft – CABG > PMHx CAD
Stents means.. \u2714\u2714Coronary Stents<\/p>\n\n\n\n
questions and answers 100% pass
What are the 5 vital signs? \u2714\u27141. Heart rate<\/p>\n\n\n\n\n
The HPI and the ROS are what type of information? \u2714\u2714
The physical exam is what kind of information? \u2714\u2714
While evaluating a patient complaining of chest pain, your physician tells you that the heart
sounds are normal. Would you document this in the HPI, ROS, or PE? \u2714\u2714Physical exam
Would you be contradicting yourself if you wrote, ” the patient has abdominal pain”, in the HPI,
but then later in the physical exam documented, “the abdomen is non-tender”, why or why not?
\u2714\u2714No, because the patient stating that they have abdominal pain is a subjective complaint. A
non-tender abdomen is an objective finding.
What is the difference between the HPI, and the ROS? \u2714\u2714HPI focuses on the details related to
their chief complaint, ROS is a head to toe checklist of symptoms. It includes the chief
complaint, associated symptoms, and all other complaints the patient may have.
What does disposition (dispo) mean? \u2714\u2714The patient’s destination after they leave the ED.
What subcategories are included within the past history section of the template? \u2714\u2714PMHx: Past
medical history- HTN, DM, HLD, CAD, MI<\/li>\n<\/ol>\n\n\n\n
FHx: Family history- Hx of CAD<55 years old
SHx: Social history- ETOH, smoking, drug abuse, occupation
What is the abbrieviation for heart attack? \u2714\u2714MI- myocardial infarction
What is the abbreviation for high blood pressure? \u2714\u2714HTN- hypertension
What is the medical term for acid reflux? \u2714\u2714Gastroesophageal reflux disease
What is the medical term for stroke? \u2714\u2714CVA- cerebral vascular accident
What is the term for gallbladder removal? \u2714\u2714Cholecystectomy
What does NKDA stand for? \u2714\u2714No know drug allergies
What is the medical term for redness? \u2714\u2714Erythema
What is the medical term for bruising? \u2714\u2714Ecchymosis
If the doctor says the exam was “benign”, what does that mean? \u2714\u2714Normal- nothing of concern
What is CAD? \u2714\u2714coronary artery disease
What other past histories would suggest that a patient has CAD? \u2714\u2714MI, angina, CABG, stent,
angioplasty
Does a PMHx of CVA mean the patient has CAD? \u2714\u2714No<\/p>\n\n\n\n
Answers Rated A
SOAP \u2714\u2714Subjective-HPI, ROS, Past Med, Fam, and Social Hx (Patient’s point of view)
Objective-Physical exam, Medical Decision Making (labs, x-rays, etc.)
Assessment-Diagnosis (determined by combining subjective\/objective info)
Plan-Disposition (Admission, Discharge, Transfer instructions)
7 Parts of the HPI \u2714\u27141. Context<\/p>\n\n\n\n\n
etc.); duration = total time symptoms have been present<\/li>\n\n\n\n
Level 5 Chart \u2714\u2714HPI: 4-7
ROS: 10+
PFSH: 2+
PEx: 8+ systems
Supination \u2714\u2714Turning the hand so that the palm faces upward.
Volar \u2714\u2714Pertaining to the palm of the hand or the sole of the foot.
Inferior \u2714\u2714Situated below or further away from the head.
Midline \u2714\u2714Line that divides the body into right and left halves.<\/li>\n<\/ol>\n\n\n\n
ACLS \u2714\u2714Advanced cardiac life support.
AMA \u2714\u2714Against medical advice.
DNR \u2714\u2714do not resuscitate
DOA \u2714\u2714Dead on arrival
OSH \u2714\u2714Outside hospital
PCP \u2714\u2714Primary care physician
PTA \u2714\u2714Prior to arrival
UTD \u2714\u2714Up to date (as in immunizations)
WNL \u2714\u2714within normal limits
yo \u2714\u2714year old
B\/L \u2714\u2714bilateral
D\/C \u2714\u2714discharge
H&P \u2714\u2714history & physical<\/p>\n\n\n\n
s\/p \u2714\u2714status post
TTP \u2714\u2714tenderness to palpation
Proximal \u2714\u2714closer to the body
Lateral \u2714\u2714farther from the midline
Extension \u2714\u2714straightening out
Distal \u2714\u2714farther from the body
Adduction \u2714\u2714Draws toward the midline
Pronation \u2714\u2714turning of the hand so the palm faces downward
Posterior \u2714\u2714situated behind or directed towards the rear
Plantar \u2714\u2714referring to the sole of the foot
Inverted \u2714\u2714turned inward
Deep \u2714\u2714Farther from the surface
Flexion \u2714\u2714bending or angulation
Percussion \u2714\u2714physician taps on a surface to determine the underlying structure<\/p>\n\n\n\n
and Answers Already Passed
Which of the following would belong in a psychiatric exam? \u2714\u2714Affect
Certain words or phrases act as “red flags” to grab your provider’s attention to let them know that
a patient may require timely and comprehensive medical action. Which of the following words
or phrases are NOT considered “red flags”? \u2714\u2714nocturia in a 65 year old male
What does LBBB stand for? \u2714\u2714Left Bundle Branch Block
What does URI stand for? \u2714\u2714Upper Respiratory Infection
What does IDDM stand for? \u2714\u2714Insulin Dependent Diabetes Mellitus
What term describes “the patient destination is home?” \u2714\u2714Discharged
If a patient signs a waiver giving you permission to capture photo of their unique rash, would
you be committing a HIPAA violation by using your cellphone to capture the photo? \u2714\u2714Yes
because the phone is not an approved hospital device and it is not encrypted.
An ED technician informs the provider that they have just finished applying a splint and sling for
the patient with the wrist fracture. What PE finding is important for your provider to assess and
include in the procedure note before the patient can be discharged home? \u2714\u2714CSMT
What condition correctly describes “A vascular change that temporarily deprives a part of the
brain of oxygen but does not result in any long lasting deficits?” \u2714\u2714TIA
What FHx\/SHx information is usually asked for pediatric patients? \u2714\u2714Immunization status<\/p>\n\n\n\n
What does AMS stand for? \u2714\u2714Altered Mental Status
Expand the following medical abbreviation. DNR \u2714\u2714Do Not Resuscitate
What does GCS stand for? \u2714\u2714Glasgow Coma Scale
What is the medical term for infection of the gall bladder? \u2714\u2714Cholecystitis
How would you diagnose AFIB? \u2714\u2714EKG
A 13 y\/o male patient was riding his bike earlier today and accidentally fell off after traveling on
an uneven patch of sidewalk. He landed on to his outstretched right hand and subsequently
experienced localized pains and swelling to his right wrist. An x-ray of the right wrist shows a
distal radial fracture. Now that results are back, the physician will be ready to discharge the
patient home. Which of the following would need to go into this patient’s disposition note? \u2714\u2714-
F\/u with specialist or PCP
-Condition at time of disposition
-Timing of disposition
-Time period for f\/u
-Specific conditions for return to the ED
An ROS has marked positive for head trauma with accompanying LOC. What DDx would your
provider be concerned about? \u2714\u2714Hemorrhagic CVA
Which of the following are considered to be cardiac risk factors for CP patients? \u2714\u2714-Tobacco
use
-DM
-CAD<\/p>\n\n\n\n
Answers Already Graded A
How would you diagnose Hemorrhagic CVA? \u2714\u2714LP and Head CT
Which of the following lab results need to be monitored closely for efficiency? \u2714\u2714d-dimer,
troponin
Which of the following tests would likely be immediately ordered for a Cardiac Workup in the
ED? \u2714\u2714troponin, EKG, CXR
What procedure would be used to diagnose Meningitis? Expand the abbreviation. \u2714\u2714lumbar
puncture
Which of the following would be ordered to investigate thyroid disease? \u2714\u2714TSH, T4, T3
How would you diagnose AFIB? Use the abbreviation to answer the question. \u2714\u2714EKG
Which of the following diseases may be diagnosed using a CXR? \u2714\u2714CHF, PTX, PE, Rib
fracture, PNA
How would you diagnose an AAA? \u2714\u2714CT A\/P with IV contrast
How would you diagnose a pneumothorax? \u2714\u2714CXR
Consent should be documented any time a procedure is performed, but there maybe certain
situations in which consent is unobtainable. In that case, consent is precluded by clinical
urgency. During which of the following procedures would consent usually be unobtainable?
\u2714\u2714CPR<\/p>\n\n\n\n
and rhythm
Select terms you might find on an x-ray interpretation. \u2714\u2714pneumothorax
An ED technician informs the provider that they have just finished applying a splint and sling for
the patient with the wrist fracture. What PE finding is important for your provider to assess and
include in the procedure note before the patient can be discharged home? \u2714\u2714CSMT
Match the oxygen administration route to the corresponding definition. \u2714\u2714nonrebreather maska plastic mask fit over the nose and mouth
RA- this means the patient is not on oxygen
NC- a plastic tube placed into the patient’s nostrils
BVM- a large facial mask held in place by hand and attached to an Ambu-bag used to manually
inflate the patient’s lungs
Intubation- an EET goes through the patient’s mouth and down the trachea
FM- a facial mask with a reservoir bag attached
A 13 y\/o male patient was riding his bike earlier today and accidentally fell off after traveling on
an uneven patch of sidewalk. He landed onto his outstretched right hand and subsequently
experienced localized pain and swelling to the his right wrist. An x-ray of the right wrist shows a
distal radial fracture. Now that the results are back, the physician will be ready to discharge the
patient home. Which of the following would need to go into this patient’s disposition note?
\u2714\u2714F\/U with specialist or PCP, Specific conditions for return to the ED, Condition at time of
disposition, Time period for f\/u, Timing of disposition, patient mental capacity
What abbreviation describes the scenario in which a patient declines a hospital stay and decides
to go home instead? \u2714\u2714AMA<\/p>\n\n\n\n
Answers Already Graded A
How would you diagnose Hemorrhagic CVA? \u2714\u2714LP and Head CT
Which of the following lab results need to be monitored closely for efficiency? \u2714\u2714d-dimer,
troponin
Which of the following tests would likely be immediately ordered for a Cardiac Workup in the
ED? \u2714\u2714troponin, EKG, CXR
What procedure would be used to diagnose Meningitis? Expand the abbreviation. \u2714\u2714lumbar
puncture
Which of the following would be ordered to investigate thyroid disease? \u2714\u2714TSH, T4, T3
How would you diagnose AFIB? Use the abbreviation to answer the question. \u2714\u2714EKG
Which of the following diseases may be diagnosed using a CXR? \u2714\u2714CHF, PTX, PE, Rib
fracture, PNA
How would you diagnose an AAA? \u2714\u2714CT A\/P with IV contrast
How would you diagnose a pneumothorax? \u2714\u2714CXR
Consent should be documented any time a procedure is performed, but there maybe certain
situations in which consent is unobtainable. In that case, consent is precluded by clinical
urgency. During which of the following procedures would consent usually be unobtainable?
\u2714\u2714CPR<\/p>\n\n\n\n
and rhythm
Select terms you might find on an x-ray interpretation. \u2714\u2714pneumothorax
An ED technician informs the provider that they have just finished applying a splint and sling for
the patient with the wrist fracture. What PE finding is important for your provider to assess and
include in the procedure note before the patient can be discharged home? \u2714\u2714CSMT
Match the oxygen administration route to the corresponding definition. \u2714\u2714nonrebreather maska plastic mask fit over the nose and mouth
RA- this means the patient is not on oxygen
NC- a plastic tube placed into the patient’s nostrils
BVM- a large facial mask held in place by hand and attached to an Ambu-bag used to manually
inflate the patient’s lungs
Intubation- an EET goes through the patient’s mouth and down the trachea
FM- a facial mask with a reservoir bag attached
A 13 y\/o male patient was riding his bike earlier today and accidentally fell off after traveling on
an uneven patch of sidewalk. He landed onto his outstretched right hand and subsequently
experienced localized pain and swelling to the his right wrist. An x-ray of the right wrist shows a
distal radial fracture. Now that the results are back, the physician will be ready to discharge the
patient home. Which of the following would need to go into this patient’s disposition note?
\u2714\u2714F\/U with specialist or PCP, Specific conditions for return to the ED, Condition at time of
disposition, Time period for f\/u, Timing of disposition, patient mental capacity
What abbreviation describes the scenario in which a patient declines a hospital stay and decides
to go home instead? \u2714\u2714AMA<\/p>\n\n\n\n
Already Passed
What does DOE stand for? \u2714\u2714Dyspnea on Exertion
A 43-year-old 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 \u2714\u2714PSHx: Right BKA
ED Course: Hyperglycemia and elevated ketones
Diagnosis : DKA
CC: Vomiting
Onset: 5 hours ago
Disposition: Admit
PMHx: Type II DM
A patient is seen in the emergency department complaining of dysuria and tells you that she is 23
weeks pregnant. \u00c2 Your doctor diagnoses her with a UTI. \u00c2 Which of the following would be
the best diagnosis? \u2714\u2714Acute urinary tract infection in pregnancy, 2nd trimester
Medical terminology. What is the medical term for infection of the gall bladder?
\u2714\u2714Cholecystitis
You see the physician check the patient’s pulses in four places; the right wrist, the top of the right
foot, the back of the right foot and the left neck. The doctor states “The pulses are fine”. Match
the location with the appropriate pulse that you would document in the physical exam?
\u2714\u2714Wrist: 2+ radial pulse
Top of foot: 2+ DDP
Neck: 2+ Carotid<\/p>\n\n\n\n
What do you need to make sure to document for every admitted patient? (select the best option.)
\u2714\u2714A consultation note indicating the admitting physician
Quality is an important descriptor that can paint a picture for concerning DDx. Match the
following HPI detail with the corresponding DDx. \u2714\u2714Chest pains when taking a deep breath:
PTX
Sharp, stabbing pains that alternately becomes a dull heavy pressure like an elephant sitting on
the chest, but regardless of quality, pain is always brought on by exertion: CAD\/MI
Burning Chest pain: GERD
Medical terminology. What is the medical term for stones in the gallbladder? \u2714\u2714Cholelithiasis
A 45 year old male presents to the ED with a constant, ripping, tearing pain to his central chest
radiating straight to his back with associated nausea that began 1 hour ago. What element is
constant? \u2714\u2714Timing
You are starting your shift and your physician immediately picks up 3 patients. The first patient
is presenting with a productive cough steadily worsening since onset 4 weeks ago. The second
patient has had abdominal discomfort slowly localizing into the right lower abdomen with
accompanying fever over the last 6 hours and on PE, the patient has RLQ tenderness on
palpation. The third patient has urinary sx and urinedip has already resulted and is positive for
leukocytes and bacteria. Given the information, what might the most likely diagnoses’ end up
being for these patients? \u2714\u2714PNA, Appendicitis, UTI
What does “PE” stand for in the Diagnosis section of the chart? \u2714\u2714Pulmonary Embolism<\/p>\n","protected":false},"excerpt":{"rendered":"