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Medical Scribe- Final EXAM QUESTIONS AND ANSWERS
UPDATED (202 5 /202 6 ) (VERIFIED ANSWERS)
What are the 5 vital signs? ✔✔1. Heart rate
- Blood pressure
- Respiratory rate
- Temperature
- Oxygen saturation The HPI and the ROS are what type of information? ✔✔ The physical exam is what kind of information? ✔✔ 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? ✔✔Physical 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? ✔✔No, 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? ✔✔HPI 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? ✔✔The patient's destination after they leave the ED. What subcategories are included within the past history section of the template? ✔✔PMHx: Past medical history- HTN, DM, HLD, CAD, MI
PSHx: Past surgical history- appendectomy, cholecystectomy, CABG FHx: Family history- Hx of CAD<55 years old SHx: Social history- ETOH, smoking, drug abuse, occupation What is the abbrieviation for heart attack? ✔✔MI- myocardial infarction What is the abbreviation for high blood pressure? ✔✔HTN- hypertension What is the medical term for acid reflux? ✔✔Gastroesophageal reflux disease What is the medical term for stroke? ✔✔CVA- cerebral vascular accident What is the term for gallbladder removal? ✔✔Cholecystectomy What does NKDA stand for? ✔✔No know drug allergies What is the medical term for redness? ✔✔Erythema What is the medical term for bruising? ✔✔Ecchymosis If the doctor says the exam was "benign", what does that mean? ✔✔Normal- nothing of concern What is CAD? ✔✔coronary artery disease What other past histories would suggest that a patient has CAD? ✔✔MI, angina, CABG, stent, angioplasty Does a PMHx of CVA mean the patient has CAD? ✔✔No
What are the risk factors of a PE? ✔✔Known DVT, PMHx of DVT or PE, FHx of DVT or PE, recent surgery, CA, A fib immobility, pregnancy, BCP, smoking What study would diagnose a PE? ✔✔CTA chest/VQ scan. D-Dimer can only rule it out. What part of the heart does CAD affect? ✔✔Artery Can a CT chest without IV contrast diagnose a PE? Why or why not? ✔✔No. You need to be able to see the blood flow. If you can see where the blockage is then you cant determine the flow of blood. You wont see anything with a dry CT. What is an aortic dissection? ✔✔The separation of the muscular wall from the membrane of the artery, putting the patient at risk for aortic rupture and death. What is PTX? ✔✔Pneumothorax, collapsed lung What is the most common cause of PTX? ✔✔Trauma How is the PTX diagnosed? ✔✔CXR What social history will most COPD patients also have? ✔✔Smoking What is the difference between a nebulizer, and an inhaler for asthma? ✔✔An inhaler is portable and gives a one-time dose and provides a rapid release of medication. A nebulizer is a home machine that delivers continuous treatment over a period of time. What is asthma? ✔✔Constricting of the airway due to inflammation and muscular contraction of the bronchioles. Also called, reactive airway disease.
What physical exam finding also associates with asthma? ✔✔Wheezing What is PNA? ✔✔Pneumonia. Bacterial infection and inflammation inside the lung. What might a person with PNA complain of? ✔✔Productive cough and fever. How is PNA diagnosed? ✔✔CXR Name all 7 areas of the abdomen? ✔✔Epigastrium, RUQ, LUQ, RLQ, LLQ, Suprapubic, Periumbilical (right/left flank) What does GERD stand for? ✔✔Gastro esophageal reflux disease. What is the Layman's name for GERD? ✔✔Heart burn or acid reflux What might someone with GERD complain of ✔✔Epigastric pain or "burning". For older patients with GERD symptoms, what life threatening disease may also need to be ruled out? ✔✔MI What does bile do? Where is it stored? ✔✔Bile emulsifies the fat in foods. It is produced by the liver, and stored in the gallbladder. What is the difference between cholelithiasis and cholecystitis? ✔✔Cholelithiasis is gallstones, cholecystitis is acute gallbladder inflammation/infection. What might be the chief complaint of a person with gallstones? ✔✔RUQ abdominal pain What physical exam finding is closely associated with cholecystitis? ✔✔Murphy's signs
How is an SBO diagnosed? ✔✔CT w/ PO contrast or AAS (acute abd series) X-ray. What is pyelo? ✔✔Pyelonephritis, kidney infection (different and worse than a UTI), usually spread from a UTI What will be the chief complaint from someone with a UTI? ✔✔Painful urination (dysuria), frequency, burning, hesitancy, malodourous urine. Where would a patient feel pain if they had pyelo? ✔✔Flank pain, fever and dysuria. How is a UTI diagnosed? ✔✔Urine drip or urinalysis (UA), showing white blood cells. What might a person with kidney stones complain of? ✔✔Flank pain, sudden onset, radiating pain How are kidney stones diagnosed? ✔✔CT, A/P, or RBC in UA. What is an ectopic pregnancy? ✔✔Tubal pregnancy, when a fertilized egg develops outside of the uterus (usually in the fallopian tube). High risk for rupture and death. How is an ectopic pregnancy diagnosed? ✔✔US of the pelvis What is an ovarian torsion? ✔✔Twisting of the ovarian artery, which reduces the blood flow to the ovary. Could result in infarct of the artery How is ovarian torsion diagnosed? ✔✔US pelvis Name the two types of CVA's(strokes): ✔✔Hemmorhagic CVA, Ischemic CVA. (TIA is not a type of stroke)
What symptoms might a person with a brain bleed complain of? ✔✔Thunder clap onset, Worst headache of their life, changes speech, vision, motor (weakness), sensation (numbness), AMS What study would diagnose a brain bleed? ✔✔CT head or puncture What sx might a person with an ischemic CVA complain? ✔✔Focal neurological deficit: Changes in speech, changes in vision, one-sided motor changes (weakness), one-sided sensation changes (numbness). How is an ischemic CVA diagnosed? ✔✔Clinically, potentially normal CT head What is a TIA? ✔✔Transient ischemic attack. Mino stroke. Temporary loss of blood supply to the brain. How does a TIA differ from a CVA? ✔✔TIA- mini stroke, symptoms usually resolve in less than an hour. CVA- stroke, symptoms last longer, and potentially may not go away. What is a common cause for seizures in children? ✔✔Fever What is the name of the state after a seizure? ✔✔Postical What are the 3 symptoms of meningitis? ✔✔Fever, neck pain/stiffness, headache What study would diagnose meningitis? ✔✔LP- Lumbar puncture What are 4 important things to document for syncopal episodes? ✔✔How they felt before, during, after, and how they currently feel
What is the emergency physicians main responsibility for psychiatric patients? ✔✔Medical clearance Name three important things to document for any trauma patient? ✔✔LOC, head injury, neck pain, back pain, numbness and weakness. In your own words, describe the significance of an HPI: ✔✔The HPI is the story of the symptoms and events that lead to the patients ED visit. It includes the CC and the associated symptoms. How is the HPI different from the ROS? ✔✔HPI focus is a story about the chief complaint and its associated symptoms. ROS is a checklist of symptoms. It includes the CC, its associated sx and all of the other complaints the pt might have. Name 5 elements of the HPI? ✔✔Onset, timing, associated symptoms, location, quality, severity, modifying factors, associated symptoms, context. Name 8 of the body systems included in the ROS. ✔✔Constitutional, eyes, ENT, CV, resp, GI, GU, MS, skin, neuro, psych, endocrine, heme/lymph, immunological. Can the systems listed in the ROS ever contradict the symptoms described in the HPI? Why? ✔✔No, symptoms that are documented in the HPI, also need to be documented in the ROS. What do you need to remember to document In the HPI and ROS for any patient that is unconscious or incapable of providing information? ✔✔"HPI, ROS limited by ... " Identify the error in this sentence from an example HPI: "patient states the CP has been intermittent since Thursday" ✔✔We do not document days of the week in the HPI. Instead, we would count back the number of days and document this numerically.
Why is it important to remember to document if the patient has had similar symptoms in the past? ✔✔Because it is less likely that their current symptoms are life threatening if they have survived similar symptoms in the past. Name on detail that is important to document if the patient has been evaluated in the past for a similar complaint. What symptoms prompted the prior evaluation? How long ago did the prior evaluation occur? Who did they see? (Name and specialty) What treatment did they receive? Did it help what diagnosis was given? Any prior test results? ✔✔ What should you focus on when writing an HPI? (Choose one) ✔✔Documenting the answers to every question asked by the doctor. Which is the first item in the formula for an HPI? ✔✔ What does MOI stand for in a Trauma HPI? ✔✔Mechanism of injury. True or false: In the ROS you should document "all other systems negative except as mark" for every patient: ✔✔ Based on your knowledge from day 2, why should you always pay special attention to the complaints of chest pain and SOB? ✔✔Direct concern for MI Name three past surgical histories that indicate that the patient has a history of CAD. ✔✔Angioplasty, CABG, stents What is the difference between a cardiac stress test and cardiac catheterization? ✔✔Cardiac catheterization is insertion of a catheter with injection of dye into the coronary artery, used to diagnose CAD. Stress test- measures the hearts ability to respond to physical stress to determine if there is adequate blood flow to your heart during increasing levels of activity. There are two
Pedal edema ✔✔swelling under skin of feet and ankles, related to CHF Bruise ✔✔Ecchymosis nose bleed ✔✔Epistaxis Guarding and rebound would be positive findings for this region of the body ✔✔abdomen This body part to determine if there is JVD ✔✔neck The presence of fluctuance would likely indicate this in the body tissue ✔✔ Distal lungs ✔✔wheezing, coughing etc.. This lab test would be high in patients with pancreatitis ✔✔Lipase Salpingo oopherectomy ✔✔removal of the ovaries and the fallopian tube What is BUN ✔✔blood urea nitrogen What is crenanin? ✔✔ D-Dimer rules out ✔✔DVT or blood clots.. cannot diagnose PE What is pitting edema ✔✔Edema that leaves an imprint when touched What are the 4 most important symptoms to write for ay trauma patient ✔✔LOC, head injury, neck pain, back pain
exacerbate ✔✔to make worse subjective ✔✔based on the patients feelings objective ✔✔factual info from provider intermittent ✔✔comes and goes waxing and waning ✔✔always present but changing in intensity modifying factor ✔✔something that makes a symptom better or worse EOMI ✔✔extra ocular movements intact easily palpable (normal) ✔✔2+ barely palpable ✔✔1+ absent ✔✔ 0 Full ✔✔3+ bounding/aneurysmal ✔✔4+
