SCRIBE AMERICA FINAL
Quality measures- site specific health criteria that are tracked
PHI- Protected health information
all symptoms in ROS are documented in the HPI False
what condition correctly describes “ narrowing of the coronary arteries limits blood supply to the heart muscle causing ischemia"
DOE (dyspnea on exertion) + EKG + BW = ST-Elevation Myocardial Infarction (STEMI)
- If pt has DOE and EKG (elevated ST wave) and BW (elevated Troponin)
-EKG + Blood Work (BW) = Non-ST-Elevation Myocardial Infarction (NSTEMI)
- EKG has No ST elevation; but BW has elevated Troponin
-EKG -BW = NO MI
Was
Dyspnea on Exertion = DOE, Blood Work = BW (how to see Troponin levels btw)
painful urination- Dysuria
reflux - GERD
53. An ROS has marked positive for head
trauma with accompanying LOC. What
DDx would your provider be concerned
about?
- Traumatic Brain Injury (TBI) or hemorrhagic CVA
- Loss of consciousness
- DDx- differential diagnosis
54. T/F All symptoms documented in the HPI
are also documented in the ROS.
- True
54. T/F All symptoms documented in the ROS
are also documented in the HPI.
- False
gallbladder - Cholelithiasis
CVA in PE - Costovertebral angle (tenderness indicate kidney problems)
- FYI = Cerebrovascular Accident is DIAGNOSTIC not PE.
PSHx = Right BKA
ED Course = Hyperglycemia
Onset = 5 hrs
Deposition = Admit
PMHx = Type 2 DM
CC = Vomiting
Diagnosis = DKA
G5, P2, A2
- G = total number of pregnancies
- P = Live births (Children at home)
- A = Abortions
PE- Pulmonary Embolism
LP- Lumbar Puncture
DOE- Dyspnea on Exertion
type 1 diabetes - IDDM - Insulin Dependent Diabetes Mellitus
76. What do you need to make sure to
document for every admitted patient?
(select the best option)
A consultation note indicating the admitting physician
CSF - Cerebrospinal fluid
CHF - Congestive Heart Failure
DVT - Deep Vein Thrombosis
Suprapubic = urinary
RUQ = gallbladder
Left lower extremity = DVT
RLQ = appendicitis
A vascular change that temporarily deprives part of
the brain of O2 but does not result in any long
lasting deficits? - TIA
coughing up - blood”? Hemoptysis
AAA = Abdominal aortic aneurysm- bulge in aorta
AAA diagnosis = CT A/P with IV contrast
eomi = extraocular movements intact
ntg = nitroglycerin
medical term for infection of gallbladder = cholecystitis
painful urination = dysuria
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. = wrist: 2+ radial pulse, top of foot: 2+ DP, neck: 2+ carotid, back of foot: 2+PT
23 y/o female is brought in by EMS for a motor vehicle crash. Your physician verbalizes outloud that the patient appears to be on a backboard and her cervical spine is stabilized with a hard collar. the patient also appears to be lethargic with obvious lacerations above her right eyebrow, left hand, and left thigh. Match the following exam findings with the appropriate organ system = patient back-boarded: back, patient with a c-collar: neck, patient lethargic: decreased responsiveness; neuro lacerations to the right eyebrow, left hand, and left thigh: integumentary
Your physician tells you the patient has scleral icterus. In which organ system do you document this medical finding? = eyes
which abbreviation describes the scenario in which a patient declines a hospital stay and decides to go home instead? = AMA
Quality is an important descriptor that can paint a picture concerning DDx. Match the following HPI details with the corresponding DDx = pleuritic chest pain -> pulmonary embolism, chest pressure/heaviness -> myocardial infarction
For chest pain patients, administering this medication can prevent onset of MI by thinning out the blood and improving blood flow to the heart. Because of this, it is important to document in the HPI if the patient received this medication, and if so who gave the medication and what was the dosage of the medication. What medication is important for meeting this core measure? = ASA
Which of the following are considered to be cardiac risk factors for CP patients? = HTN, HLD, FMHx of CAD 55 y/o >, PSHx of CABG, angioplasty and stent, DM, CAD, tobacco use\
A 45 y/o male presents to the ED with a ripping, tearing pain to his central chest radiating straight to his back with associated nausea that began 1 hour ago. What emergency conditions from the following list may explain the patients symptoms = MI, aortic dissection
A 45 y/o male presents to the ED with a ripping, tearing pain to his central chest radiating straight to his back with associated nausea that began 1 hour ago. What element is constant? = timing
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 urine-dip has already resulted in and is positive for leukocytes and bacteria. Given the info, what might the most likely diag end up[ being for these patients = PNA, appendicitis, UTI
you've just caught up on all your charting. what are some things you can do to increase your providers efficiency = accompanying your provider on re-evals, tracking results, preparing for dispositions, preparing charts for patients that are assigned to your provider
consequences of a HIPPA violation = termination, monetary fines, prison time, lawsuit against you and hospital, violator is blacklisted from med programs, scribe program cancellation
which is not an example of PHI = none of above
match the following results with the corresponding diagnosis = combo of + EKG and + blood work -> STEMI, combo of - EKG and + blood work -> NSTEMI, combo of - EKG and - blood work -> no MI
how would you diag hemorrhagic CVA = LP, Head CT
Which of the following tests would likely be immediately ordered for a Cardiac workup in the ED?
___ occurs when there is fluid buildup around the heart resulting ina decreased pumping efficiency to the heart = CHF
“containing pus, pus-like” is the definition of what medical term? = purulent
NAD = no acute distress
the physician requests you hold the patient’s arm during a procedure. What is the best way to respond? = not qualified to help, find another staff member
Bed 6 is 75 y/o male..chest pain…14 hours…previous heart attack..stents…= MI CABG CAD coronary stent placement
Bed 14, 54 female = COPD
Layman's terms = high cholesterol -> hyperlipidemia, heart failure->CHF, lung blood clot-> PE, kidney infection-> pyelonephritis, enlarged prostate-> BPH, mini stroke->TIA, bulge aorta-> aortic aneurysm, bad blood flow legs-> PVD
44 y/o female w/ history of hypertension, congestive heart failure, on dialysis presents for eval of shortness of breath and fluid retention. Which history explains dialysis? = history of chronic kidney disease which requires dialysis to filter out toxins
elevated creatinine and BUN = kidney
34 male alcoholism LUQ abdominal pain, history of pancreatitis, What lab? = lipase
92 y/o patient evaluation rectal bleeding 72 hours relevant info documented=DDx of anemia secondary to acute blood loss, phys. exam showing pale conjunctiva and pallor throughout, low hemoglobin and hematocrit,
subjective= CC, HPI, ROS
objective= labs/ imaging, PE, vitals
investigated via auscultation = lung sound clear, normal heart sounds, bowel sounds, carotid bruit, regular rate/rhythm, systolic murmur,
19 y/o male assault, cervical collar, backboard, lacerations, contusions, speech slowed, what would you have to remove from the physical exam template = GCS 15, head is atraumatic, alert and oriented x4
Positive Murphy’s sign increases concern for which = acute cholecystitis
Positive McBurney's point tenderness increased concern for = acute appendicitis