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SCRIBE AMERICA FINAL EXAM QUESTIONS AND ANSWERS
UPDATED (202 5 /202 6 ) (VERIFIED ANSWERS)
Which of the following would belong in a psychiatric exam? ✔✔Affect 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"? ✔✔nocturia in a 65 year old male What does LBBB stand for? ✔✔Left Bundle Branch Block What does URI stand for? ✔✔Upper Respiratory Infection What does IDDM stand for? ✔✔Insulin Dependent Diabetes Mellitus What term describes "the patient destination is home?" ✔✔Discharged 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? ✔✔Yes 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? ✔✔CSMT 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?" ✔✔TIA What FHx/SHx information is usually asked for pediatric patients? ✔✔Immunization status
Second hand smoke exposure What does AMS stand for? ✔✔Altered Mental Status Expand the following medical abbreviation. DNR ✔✔Do Not Resuscitate What does GCS stand for? ✔✔Glasgow Coma Scale What is the medical term for infection of the gall bladder? ✔✔Cholecystitis How would you diagnose AFIB? ✔✔EKG 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? ✔✔- 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? ✔✔Hemorrhagic CVA Which of the following are considered to be cardiac risk factors for CP patients? ✔✔-Tobacco use
- DM
- CAD
Match the normal grading scale with the corresponding PE finding. ✔✔2+- reflexes 5/5- strength 15 - GCS Which of the following diseases may be diagnosed using a CXR? ✔✔Rib fracture PTX PNA CHF 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? ✔✔Acute urinary tract infection in pregnancy, 2nd trimester Select terms you might find on an x-ray interpretation. ✔✔Pneumothorax Infiltrate Which of the following would be documented in ED Course? ✔✔Treatments Re-Evals Interpretations Orders Which of the following are not valid DDx for a patient. with CC of HA? ✔✔Vertigo Syncope Bell's Palsy What does EOMI stand for? ✔✔Extraocular Movements Intact George is employed with SA as a scribe. He was off today and accidentally cut his cheek while practicing his sward 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 appropriate steps in this situation? ✔✔No, because George accessed his own medical record using his EMR login. What is the medical term for painful urination? ✔✔Dysuria Select the EKG interpretation documentation guidelines. ✔✔Rate and rhythm 2 positive or negative findings Match each critical care dx with it's associated procedure. ✔✔-PTX: chest tube
- Sepsis: central line placement
- Cardiac arrest: CPR
- Respiratory failure: Intubation
- Acute exacerbation CHF/ COPD (severe): CPAP/ BiPAP
- Abnormal heart rhythm: cardioversion What is a "GI cocktail"? ✔✔Liquid consumed by mouth to treat an upset stomach. 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? ✔✔Uncomplicated laceration of the left foot - initial encounter Match the following Dx with it's patient presentation. ✔✔-Asthma- SOB+wheezing on exam
- CHF- SOB+bilateral pedal edema+CP
- COPD- SOB+wheezing on exam+ Shx of 3 ppd
- PE- SOB+unilateral pedal edema+pleuritic CP
What is the medical term for "bright red blood in stools"? ✔✔Hematochezia 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? ✔✔Chronological order How would you document GPA for a patient who has previously been pregnant four times in the past, has three children at home, and is not currently pregnant? ✔✔4,3, T/F All symptoms documented in the HPI are also documented in the ROS. ✔✔True What is the medical term for "carotid artery cleaning"? ✔✔Carotid Endarterectomy What does s/p stand for? ✔✔Status Post A 23 y/o female is brought in by EMS for a motor vehicle crash. Your physician verbalized outlaid that the patient appears to be on a backboard and her cervical spine is stabilized with a hand 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 he appropriate organ system. ✔✔Neck: patient with a c-collar Back: patient back-boarded Integumentary: lacerations to the right eyebrow, left hand, and left thigh Neurological: patient lethargic What abbreviation describes the scenario in which a patient declines a hospital stay and decided to go home instead? ✔✔AMA A 43 y/o 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. ✔✔Onset: 5 hours ago Disposition: admit ED Course: hyperglycemia and elevated ketones CC: vomiting PMHx: Type II DM Diagnosis: DKA PSHx: right BKA A 45 year old male presents to the ED with a constant ripping, tearing pain to his central chest radiating strait to his back with associated nausea that began 1 hour ago. What element is constant? ✔✔Timing What is the medical term for stones in the gallbladder? ✔✔Cholelithiasis You see the physician check the patients pulses I 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. ✔✔Neck: 2+ carotid Back of foot: 2+ PTP Wrist: 2+ radial pulse Top of foot: 2+ DPP What are the possible consequences of a HIPAA violation? ✔✔Monetary fines to you and the hospital Scribe program cancellation Violator is blacklisted from medical programs Lawsuit against you and the hospital Prison time Termination
Which section of the chart would you find AKA? ✔✔PSHx What does GERD stand for? ✔✔Gastroesophageal Reflux Disease T/F. It is the middle of the day. Your provider is busy dealing with a critical ill patient and during this time the ED Strats to pick up tase as more patients arrive. While your provider is prepping the critical patient for a procedure, she asks you to look up the CBC result on another patient. You quickly look up the information on your laptop and tell the physician that the labs came back normal except for a blood glucose level of 356, so your provider subsequently asks you to tell the nurse to start that patient on an insulin drip. You locate the nurse and relay the message. This scenario is acceptable and within the bounds of your scribe scope. ✔✔False Which of the following lab results need to be monitored closely for efficiency? ✔✔Troponin Creatinine D-dimer What condition correctly describes "Fertilized egg developed outside the uterus"? ✔✔Ectopic Pregnancy What does PE stand for in the Diagnosis section of the chart? ✔✔Pulmonary Embolism What condition describes "translocation of a thrombus leading to dyspnea and hypoxia"? ✔✔PE Consent should be documented any time a procedure is preformed, but there are 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? ✔✔CPR Match location with the corresponding DDx. ✔✔LLQ: diverticulitis
RLQ: appendicitis LUQ: pancreatic disease RUQ: gall bladder disease What ROS system would include Dyspepsia, the medical term for indigestion? ✔✔Gastrointestinal Which of the following tests would likely be immediately ordered for a Cardiac Workup in the ED? ✔✔CBC and BMP Troponin CXR EKG What does the DP stand for in "DP pulse"? ✔✔Dorsalis Pedis Which of these procedures qualify as critical care procedures and would indicate that critical care time must be documented on a patient? ✔✔CPAP/ BiPAP Central line placement CPR Chest tube Intubation Cardioversion A patient has the following history: breast CA s/p chemoradiation therapy and mastectomy. Based on this, does the patient meet level 5 billing criteria for this scenario of the chart? ✔✔Yes, the PHx meets Level 5 billing criteria. What does AAA stand for? ✔✔Abdominal Aortic Aneurysm What does PTX stand for? ✔✔Pneumothorax
Read through the PE and decide if this meets Level 5 billing criteria.Genera/Constitutional: NC, ATEyes: PERRL, EOMIENT: moist oral mucosaCardiac: irregularly irregular rhythm, tachycardic, no murmurs, no rubs, no gallopsRespiratory: Lungs clear, no respiratory distress, no wheezing, no rales, no rhonchiNeurological: A&O x 4Psychiatric: normal affect ✔✔No, the PE does not meet Level 5 billing criteria. Which of the following would NOT be considered an example of PHI? ✔✔None of the above. What is the medical term for "coughing up blood"? ✔✔Hemoptysis What medical term describes "blood present in vomit"? ✔✔Hematemesis 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? ✔✔Name of the accepting physician Location in the hospital Condition at time of admission Timing of admission consultation note with accepting physician Match the following description to the appropriate team member. ✔✔Scribe: Documents the patient's visits on behalf of the physician Unit Secretary: Answers phone calls, pages other specialists/ doctors, and organizes the patient's paperwork ED Nurse: Records medical histories, symptoms, monitors the patient, starts IVs, administers mediations, and assists with procedures ED Tech: Helps the nurse and assists with procedures RT: Administers "breathing treatments" and assists with managing a patient's airway Mis-Level Provider: NP or PA that works under the supervision of a physician to diagnose and treat patients Charge Nurse: Manages the ED patient flow
