Final Exam Scribe America 2023 With Complete Solutions

Final Exam Scribe America 2023 With Complete Solutions

What does "IDDM" stand for? Do not include any hyphenations for your answer. - Correct Answer-Insulin Dependent Diabetes Mellitus

What does "AMS" stand for? - Correct Answer-Altered Mental Status

A patient states she has had a productive cough for 4 days, and yesterday she developed a fever. Would her fever be considered an associated symptom for her productive cough? Why or why not? - Correct Answer-Yes, because the fever started soon after the cough

Match each critical care dx with its associated procedure. - Correct Answer-Respiratory Failure: Intubation

Acute exacerbation: CPAP/BiPAP

Cardiac arrest: CPR

PTX: Chest Tube

Sepsis: central line placement Abnormal

heart rhythm: cardioversion

What does "GCS" stand for? - Correct Answer-Glasgow Coma Scale

What does "PE" stand for in the Diagnosis section of the chart? - Correct answer- Pulmonary Embolism

What does "DVT" stand for? - Correct Answer-Deep vein thrombosis

Among the following diseases listed, select the ones that qualify for CCT. - Correct answer-ACS CVA Afib acute MI DKA PTX PE sepsis

What is the medical term for "coughing up blood"? - Correct Answer-Hemoptysis

Which of these procedures qualify as critical care procedures and would indicate that critical care time must be documented on a patient? (select all that apply) - Correct answer-?

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? (Select the best option.) - Correct Answer-Yes because the phone is not an approved hospital device and it is not encrypted.

What procedure would be used to diagnose Meningitis? Expand the medical abbreviation into the full medical term. - Correct Answer-Lumbar puncture

A female patient has been pregnant four times in the past, is currently pregnant, and has two children at home. Calculate the G, P and A, respectively. (Type your answer using the following format: "G,P,A" "#,#,#"; so for example you would type 0,0,0 with no spaces before or after the answer) - Correct answer-5,2,2

What does "AAA" stand for? - Correct Answer-Abdominal Aortic Aneurysm

George is employed with SA as a scribe. He was off today and accidentally cut his cheek while practicing his sword swallowing skills. He goes to the Emergency Department and is seen by a doctor and another scribe. The Emergency Department is extremely busy, and so George decides to help out the doctor by scribing his own note using the computer in the room. Has George taken the appropriate steps in this situation? - Correct answer-No, because George accessed his own medical record using his EMR login.

What FHx/SHx information is usually asked for pediatric patients? (Select all that apply.)

• Correct Answer-Second hand smoke exposure, immunization records

Which of the following would be ordered to investigate thyroid disease? - Correct answer-THS, T3, T4

What does "DOE" stand for? - Correct answer-dyspnea on exertion

You are writing an HPI for a very complex patient who has had multiple recent hospital admissions and several significant complaints; what is the best way to organize the information in your HPI? - Correct Answer-Chronological order

What does "PNA" stand for? - Correct answer-pneumonia

What does ETT stand for? - Correct answer-endotracheal tube

What are the possible consequences of a HIPAA violation? (select all that apply) - Correct answer-ALL OF THEM

What does the DP stand for in "DP pulse"? - Correct Answer-Dorsalis pedis

How would you diagnose a pneumothorax? - Correct answer-CXR

Location is an important element that can paint a picture for concerning DDx. Match location with the corresponding DDx. - Correct answer-RLQ= appendicitis LUQ= pancreatic disease RUQ= gall bladder disease LLQ= diverticulitis

Which of the following would need to go into a consult note for a patient that will be admitted to the hospital for treatment of bacterial meningitis? - Correct Answer-Name of the accepting physician Location in the hospital Condition at time of admission Consultation note with accepting physician Timing of admission

Which of the following are not valid DDx for a patient with CC of HA? - Correct answer- Syncope Vertigo Bell's Palsy

What is the medical term for painful urination? - Correct answer-dysuria

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? - Correct answer-ASA

Medical terminology. What is the medical term for stones in the gallbladder? - Correct Answer-Calculi

Certain words or phrases act as "red flags" to grab your provider's attention to let let them know that a patient may require timely and comprehensive medical action. Which of the following words or phrases are NOT considered a "red flag?" - Correct answer- "nocturia" in a 65 y/o male

Which section of the chart would you find AKA? (Select all that apply.) - Correct answer- PSHx PE

T/F. All symptoms documented in the ROS are also documented in the HPI. - Correct answer- true

Match the following Dx with it's patient presentation. - Correct answer-?

What does "COPD" stand for? - Correct answer-choronic obstructive pulmonary disease

Diagnosis: What condition correctly describes "An immune response that leads to rash, itching, swelling, or difficulty breathing"? Hint: 2 words. - Correct answer-allergic reaction

What does "DNR" stand for? - Correct answer-do not resuscitate

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. Do not change the positioning of an answer after it is placed. - Correct answer-PMD= Type 2 DM CC= Vomiting Diagnosis= DKA Disposition= admit Onset= 5 hours ago ED Course= hyperglycemia and elevated ketones PSHx= Right BKA

Which of the following would NOT be considered an example of PHI? (select all that apply.) - Correct Answer-None of the above

Which of the following diseases may be diagnosed using a CXR? (select all that apply.)

• Correct answer-PTX

Rib fracture CHF PNA

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? - Correct answer- CSMT

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 and is positive for leukocytes and bacteria. Given the information, what might the most likely diagnoses' end up being for these patients? - Correct answer-PNA, Appendicitis, UTI

How would you diagnose AFIB? Use the abbreviation to answer the question. - Correct answer- EKG

What medical term describes "blood present in vomit"? - Correct answer-hematemesis