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SCRIBE AMERICAN FINAL EXAM ED QUESTIONS AND ANSWERS
UPDATED (202 5 /202 6 ) (VERIFIED ANSWERS)
What are the 3 types of dispositions? ✔✔Discharge, Admit, Transfer What does HPI stand for? ✔✔history of present illness What does ROS stand for? ✔✔review of systems The HPI and ROS are considered what type of information? ✔✔subjective The physical exam is what type of information? ✔✔objective If a physician told you a patient's abdomen was non tender, where would you document this? ✔✔PE What section focuses directly on the chief complaint? ✔✔HPI If someone has a hx of CABG or MI, what is something you can also always document in the PMHx section of the chart? ✔✔CAD Name an example of something you may write in the Social Hx portion of the chart. ✔✔smokes 1 pack/day Name an example of something you may write in the Family Hx portion of the chart. ✔✔Mother had Hx of CAD at age 46 What are the abbreviations for the following past medical history terms? Hypertension
Stroke Diabetes Heart Attack High Cholesterol ✔✔HTN 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 ✔✔appendectomy cholecystectomy hysterectomy Salpingo-oophorectomy tonsillectomy mastectomy What are the five vital signs? ✔✔Blood pressure (BP), heart rate (HR), oxygen saturation (SaO2), respiratory rate (RR), temperature (C or F) What does NKDA stand for? ✔✔no known drug allergies What does LNMP stand for? ✔✔Last Normal Menstrual Period
- CTA w/ IV contrast, LP (lumbar puncture)
- ultrasound (US) What are the two types of heart attacks and how are they diagnosed? ✔✔STEMI (ST elevation myocardial infarction) and NSTEMI (non ST elevation myocardial infarction) STEMI: EKG NSTEMI: troponin What are three cardiac risk factors? ✔✔HTN, DM, HLD, CAD, Smoking, FHx CAD < 55 y/o What are four associated symptoms of an MI other than CP? (Hint: catch phrase) ✔✔Chest pressure with diaphoresis, N/V (nausea and vomiting), and SOB What are three symptoms a patient with an Ischemic CVA might present with? ✔✔Unilateral focal neurological deficits: One-sided weakness, one-sided numbness or changes in speech/vision What are the only three symptoms of a true allergic reaction? ✔✔SOB (difficulty breathing), rash, itching/swelling What heart rhythm would a physician hear if the patient were in atrial fibrillation and how is this disease diagnosed? ✔✔an irregularly irregular rhythm, this is diagnosed by and EKG What physical exam finding is associated with asthma? ✔✔wheezes (while inspiring or expiring) How is altered mental status different from a focal neurological deficit? ✔✔AMS is very different than a focal neurological deficit. AMS is generalized and is typically caused by things that affect the whole brain (drugs, low blood sugar). Focal neurological deficits are localized weakness/numbness in one specific area, corresponding with damage at one specific site in the
brain. The most common cause of AMS for patients without a Hx of dementia is from infection, most often caused by a UTI. What is the major cause of AMS in the elderly? ✔✔UTI Name one medication associated with seizures. ✔✔Dilantin, Tegretol, Keppra, Depakote, Neurontin What question is every patient asked who comes in with a chief complaint of syncope? ✔✔Document what happened prior, during, and after the syncopal episode, as well as how the patient currently feels What is the medication administered for CVAs and when is it used vs when would it not be indicated? ✔✔Ischemic CVA: tPA or another anticoagulant (not used for a hemorrhagic CVA because it breaks down blood clots and if there is a brain bleed, this would not be helpful in this case) Hemorrhagic CVA: anticonvulsants What is "layman's name" for GERD? ✔✔Acid Reflux/Heartburn What is the most common cause for seizures in children? ✔✔fever In your own words, describe the significance of an HPI. ✔✔The HPI is the beginning of every chart summarizing the reason for the visit and this describes the CC *The HPI should ONLY include information directly related to the CHIEF COMPLAINT and IMPORTANT CONTEXT for that patient. Name three people who will read the HPI other than the physician. ✔✔Nurses, Coders, and admitting doctors
How would you document the GPA for a patient who is currently pregnant, has been pregnant two times in the past, and has one child at home? ✔✔4/1/ What box would you check to communicate that the patient did not mention any other complaints other than those mentioned? ✔✔We do not mark a box at Sparrow for "all other symptoms must be negative" Write the meaning of the following physical exam abbreviations. NAD AT/NC PERRL EOMI TM RRR JVD TTP FROM CVA tenderness A&O SI/HI ✔✔-no acute distress
- atraumatic/normocephalic
- pupils equal, round, reactive to light
- extraocular movements intact
- tympanic membrane
- regular rate and rhythm
- jugular vein distention
- tenderness to palpation
- full range of motion
- costovertebral angle tenderness
- alert and oriented
- Suicidal and Homicidal ideations
Answer the following questions by writing the condition or disease that is associated with each physical exam finding.
- Scleral icterus
- Fluorescein uptake
- Bulging and erythematous TM
- Dry mucous membranes
- Tonsillar exudate
- Sinus tenderness
- Nuchal rigidity
- Irregularly irregular
- JVD
- Wheezing
- Pale conjunctiva
- Rales
- McBurney's Point Tenderness
- Murphy's Sign
- Hypoactive Bowel Sounds
- Guaiac Positive (Heme +)
- CVA tenderness
- Urticaria
- Fluctuance and Induration
- Bilateral pitting pedal edema
- Calf tenderness
- Facial asymmetry
- Unilateral weakness ✔✔1. liver failure
- corneal abrasions or ulcerations
- otitis media (ear infection)
- dehydration
- strep throat
- sinusitis
Which words do you think are synonyms with the word "red" ✔✔erythematous, indurated What organ is in the following abdominal quadrant? RUQ RLQ LUQ LLQ ✔✔gallbladder appendix pancreas large intestine What is the physician checking for when they hold their stethoscope to both sides of the patient's neck? ✔✔a carotid bruit What is an extrasystole? ✔✔extra beats What does an elevated White Blood Cell (WBC) count indicate? ✔✔infection What does a low Hemoglobin and Hematocrit (H&H) indicate? ✔✔anemia What is the term for high sodium levels called? ✔✔hypernatremia What body organ do LFT's investigate? ✔✔liver function Name two of the LFTs? ✔✔T bili AST ALT Alk Phos
What labs show kidney function? ✔✔creatinine, BUN Name three parts of the "Cardiac Order Set" ✔✔CBC, BMP, Troponin, EKG, CXR What is the medical term for low potassium? ✔✔hypokalemia How many tubes of CSF fluid are collected during a lumbar puncture? Why? ✔✔ 4 tubes are collected of CSF fluid during an LP because the first two are likely to be contaminated What does a positive HCG result indicate? ✔✔pregnancy What is more accurate? Urine Dip - or- Urine Micro ✔✔Urine Micro is much more accurate What are the three labs to monitor closely for efficiency? (Hint: "rate limiting steps") ✔✔D- dimer Troponin Creatinine True or False: Cultures will never result in the same day they are ordered. ✔✔True True or False: Emergency physicians are not able to interpret their own Xrays. ✔✔True What is the name of the procedure used to treat an abscess? ✔✔Incision and Drainage (I&D) What does NSR stand for as an EKG abbreviation? ✔✔normal sinus rhythm What would you write if the doctor said, "ST elevation noted in leads two, three, A-V-L, and V one through V three."? ✔✔Acute ST elevation
HPI
ROS
PMHx/PSHx,FHx, SHx Physical Exam ✔✔ 4 10 2 8 True or False: If any part of the patient care is not documented then the physician cannot legally be reimbursed for their time or expertise. ✔✔true True or False: Your little brother was recently seen in the ED last week and had blood cultures taken. As a scribe, you can look up his results. ✔✔false True or False: I can look up my own past medical records. ✔✔false Give an example of PHI. ✔✔Patient name, Geographic subdivisions, Telephone numbers, Email addresses, Fax Numbers, Health Plan beneficiary numbers, Social Security Numbers, Certificate/license numbers, Healthcare Record numbers, Account Numbers, Dates (except years), Any other Unique number, code, or characteristic that can be linked to an individual What word should you never document in a pediatric chart unless your provider specifically asks you to? ✔✔lethargic What is the goal of a scribe? ✔✔to decrease the number of down-coded charts What might a person with PNA complain of? ✔✔Productive cough and fever What lab order contains the H&H? ✔✔CBC
What does Creatinine measure? ✔✔renal function What does a negative D-dimer mean? ✔✔No evidence of PE What does a positive D-Dimer mean? ✔✔Possible PE, must order a CTA Chest or VQ Scan What do "Coag" lab tests examine? ✔✔Blood coagulation (how fast the blood clots) / Coumadin levels ED Flow ✔✔Walk in-->Triage-->Bed-->Physician assessment--->LAB/RAD/MEDS--> RESULTs-->MDM--->Diagnosis-->Consults--->Dispo What are the four types of history? ✔✔Medical Hx, Surgical Hx, Family Hx, Social Hx What subcategories are included within the Past History section of the template? ✔✔Past Medical History (PMx) HTN, DM, HLD, CAD, MI Past Surgical History (PSx) Appendectomy, Cholecystectomy, CABG Family History (FHx) Hx of CAD < 55 y/o Social History (SHx) ETOH, Smoking, Drug Abuse, Occupation What is the medical term for bruising? ✔✔Ecchymosis What other past histories would suggest that a patient has CAD? ✔✔MI, Angina, CABG, Stent, Angioplasty How is CAD diagnosed? ✔✔By a cardiologist during a cardiac catheterization. Not done in the ED
Name four possible CC's for a GI bleed pt. ✔✔Hematemesis, coffee ground emesis, hematochezia, melena What is the pre-existing condition you must have before you can get diverticulitis? ✔✔Diverticulosis What will be the CC for someone with diverticulitis? ✔✔LLQ abdominal pain What is pyelo? ✔✔Pyelonephritis, Kidney infection (different and worse than a UTI), usually spread from an UTI Where would a patient feel pain if they had pyelo? ✔✔Flank pain, fever and dysuria What is an ectopic pregnancy? ✔✔Tubal pregnancy, when a fertilized egg develops outside the uterus (usually in the fallopian tube). High risk for rupture and death. What is ovarian torsion? ✔✔Twisting of the ovarian artery, which reduces the blood flow to the ovary. Could result in infarct of the ovary. What sx might a person with a brain bleed c/o? ✔✔HA- sudden ("thunderclap") onset, worst HA of their life, changes in speech, vision, motor (weakness), sensation (numbness), AMS What is the name of the state after a seizure? ✔✔Post-ictal What are 3 symptoms of meningitis? ✔✔Fever, neck pain/stiffness, headache Between bacterial and viral, which meningitis is more serious? ✔✔Bacterial What study would diagnose meningitis? ✔✔LP- Lumbar puncture
Name 4 causes of altered mental status. ✔✔Hypoglycemia, infection, intoxication, neurological What is an aortic dissection? ✔✔The separation of the muscular wall from the membrane of the artery, putting the pt at risk for aortic rupture and death How is an abscess different from cellulitis? ✔✔Abscess is cellulitis with fluctuance (pus pocket) How can Diabetic Ketoacidosis (DKA) be diagnosed? ✔✔Arterial Blood Gas showing low pH or Positive Serum Ketones Name three important things to document for any trauma patient. ✔✔LOC, head injury, neck pain, back pain, numbness, weakness Name eight of the body systems included in the ROS. ✔✔Constitutional, eyes, ENT, CV, Resp, GI, GU, MS, skin, neuro, psych, endocrine, heme/lymph, immunological 5. Can the symptoms listed in the ROS ever contradict the symptoms described 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..." What is the difference between a cardiac stress test and a cardiac catheterization? ✔✔Cardiac catheterization - insertion of a catheter with injection of dye into the coronary artery, used to diagnose CAD. Stress test - measures the heart's 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 different types of stress tests. Exercise (treadmill) stress test. Nuclear stress test is for patients with a medical problem (e.g. arthritis) that prevents you from exercising. They use a medication to stresses the heart (mimicking exercise) General
If the doctor takes 1 finger and presses in a specific spot in the RLQ, what is the name of the finding they are investigating? ✔✔McBurney's point tenderness What phrase do you have to document in the GU exam for every female pelvic exam performed by a male physician? ✔✔Female Chaperone present What is the difference between a laceration and abrasion? ✔✔Laceration - incision in the skin that typically need sutures. Abrasion- scrape of the skin What does A&Ox3 mean? ✔✔Alert and oriented to person, place, time High lymphocytes indicates ✔✔viral infection high monocytes indicates ✔✔bacterial infection high eosinophils indcates ✔✔parasitic infection What lab is used to determine blood sugar? ✔✔Accu-Chek --> Finger-Stick Blood Glucose (FSBG) For a joint injury, the following procedure would be used: ✔✔Splint application for a distal CSMT intact What what indicate a cardioversion (Conscious sedation. Attached to cardiac monitor and pulse oximetry)? ✔✔A-fib
Critical care procedures include: ✔✔Intubation Central Line Placement Chest Tube Cardioversion CPR CPAP/BiPAP What is the difference between a BMP and a CMP? ✔✔BMP- Basic metabolic panel. Contains electrolytes, kidney function, and glucose levels. CMP- comprehensive metabolic panel. BMP in addition to LFTs (liver function tests) What is the difference between a CTA and a CT? ✔✔CTA - CT angiogram looks at the arteries (uses IV contrast). CT - no IV contrast but may or may not use PO contrast What does LAD stand for as an EKG abbreviation? ✔✔Left Axis Deviation When might an ER doctor obtain a Physician Consult? ✔✔Regarding admission, advice over treatment plan, inform primary physician of results, etc. Heart Rate (HR): Normal HR is between 60 - 100 bpm ✔✔Severely abnormal: Less than 50 bpm or greater than 120 bpm (for adults) Blood Pressure (BP): Normal BP is between 90/60 and 140/90 ✔✔Severely abnormal: Less than 80/-- or greater than 180/-- Oxygen Saturation (SaO2): Normal 96% or above on room air ✔✔Severely abnormal: Less than 90% on room air
