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SCRIBE FINAL EXAM QUESTIONS AND ANSWERS UPDATED
(202 5 /202 6 ) (VERIFIED ANSWERS)
SOAP ✔✔Subjective-HPI, ROS, Past Med, Fam, and Social Hx (Patient's point of view) Objective-Physical exam, Medical Decision Making (labs, x-rays, etc.) Assessment-Diagnosis (determined by combining subjective/objective info) Plan-Disposition (Admission, Discharge, Transfer instructions) 7 Parts of the HPI ✔✔1. Context
- Time/Duration; time = course of symptoms (improving, worsening, constant, intermittent, etc.); duration = total time symptoms have been present
- Location
- Quality
- Severity
- Modifying Factors
- Pertinent positive and negatives Level 5 Chart ✔✔HPI: 4 - 7 ROS: 10+ PFSH: 2+ PEx: 8+ systems Supination ✔✔Turning the hand so that the palm faces upward. Volar ✔✔Pertaining to the palm of the hand or the sole of the foot. Inferior ✔✔Situated below or further away from the head. Midline ✔✔Line that divides the body into right and left halves.
Abduction ✔✔Moving away from the midline. ACLS ✔✔Advanced cardiac life support. AMA ✔✔Against medical advice. DNR ✔✔do not resuscitate DOA ✔✔Dead on arrival OSH ✔✔Outside hospital PCP ✔✔Primary care physician PTA ✔✔Prior to arrival UTD ✔✔Up to date (as in immunizations) WNL ✔✔within normal limits yo ✔✔year old B/L ✔✔bilateral D/C ✔✔discharge H&P ✔✔history & physical
Auscultation ✔✔Physician listens to the internal sounds of the body using a stethoscope Organomegaly ✔✔Enlargement of organs Palpation ✔✔Physician feels the different parts of the body Idiopathic ✔✔no known cause Necrosis ✔✔Premature death of cells in living tissue Ostomy ✔✔surgically created opening connecting an internal organ to the surface of the body Infarct ✔✔Tissue death caused by a local lack of oxygen due to obstruction of the tissue's blood supply Stenosis ✔✔narrowing of a body opening or passage Ischemia ✔✔Decrease in the blood supply to a bodily organ, tissue, or part caused by constriction or obstruction of the blood vessels Ambulatory ✔✔Able to walk about, not confined to bed Febrile ✔✔having a fever Post-prandial ✔✔after eating Cachectic ✔✔Malnutritioned, wasting, or in poor health
Orthostatic ✔✔vital signs taken sitting, standing, and supine Polydipsia ✔✔excessive thirst A&W ✔✔alive and well NAD ✔✔no acute distress WDWN ✔✔well-developed, well-nourished CA ✔✔cancer MRSA ✔✔methycillin resistant staphylococcus aureus; one strain of the staphylococcus bacteria that is resistant to medications conventionally used to treat it DKA ✔✔diabetic ketoacidosis-occurs when the body cannot use sugar (glucose) as a fuel sources because there is no insulin or not enough insulin. Fat is used for fuel instead and produces ketones. DM ✔✔diabetes mellitues-a condition characterized by high blood glucose due to inability to produce insulin or to the cells' inability to respond to insulin FSBS ✔✔finger stick blood sugar IDDM ✔✔insulin-dependent diabetes mellitus Afebrile ✔✔Without fever Diaphoresis ✔✔Excessive sweating
CMP ✔✔complete metabolic panel-BMP plus LFTs and calcium level H&H ✔✔HGB&HCT (hemoglobin and hematocrit) LFTs ✔✔liver function tests-tests the livers ability to get rid of bilirubin from the blood and to produce albumin T&S ✔✔type and screen UA ✔✔urine analysis UDS ✔✔urine drug screen IM ✔✔intramuscular IV ✔✔intravenous SQ ✔✔subcutaneous NPO ✔✔nothing by mouth PR ✔✔per rectum BID ✔✔twice a day PRN ✔✔as needed TID ✔✔three times a day
NS ✔✔normal saline Abx ✔✔antibiotics NKDA ✔✔no known drug allergies IVF ✔✔IV fluid D-Dimer ✔✔Measures fibrin split products. Non-specific test used to help rule out PE or DVT. Advair ✔✔Pulmonary Percocet ✔✔Pain control/sedation Zoloft ✔✔Psychiatric Lasix ✔✔Cardiovascular; diuretic Fentanyl ✔✔Pain control/sedation Lantus ✔✔Endocrine Atenolol ✔✔Cardiovascular; beta-blocker Zofran ✔✔Anti-emetic Penicillin ✔✔Abx
BP ✔✔blood pressure CP ✔✔chest pain EKG ✔✔electrocardiogram-transthoracic interpretation of the electrical activity of the heart over a period of time, as detected by electrodes attached to the outer surface of the skin and recorded by a device external to the body EF ✔✔ejection fraction-volume of blood pumped from the left and right ventricles with each heart beath HR ✔✔heart ratd PND ✔✔paroxysmal nocturnal dyspnea-sudden, severe shortness of breath that usually occurs at night and wakes a person from sleep HTN ✔✔hypertension Angina ✔✔chest pain or discomfort that occurs when an area of your heart muscle doesn't get enough oxygen rich blood Arteries ✔✔blood vessels that carry blood away from the heart Veins ✔✔blood vessels that carry blood to the heart Bradychardia ✔✔slow heart rate (<60)
Gallop ✔✔extra heart sound called S3 or S4 dependent upon where in the cycle this added sound comes Edema ✔✔swelling of tissue due to excess accumulation of fluid Tachycardia ✔✔fast heart rate (>100) Reproducible chest pain ✔✔Chest pain that is elicited by palpating the chest BPM ✔✔beats per minute DP pulse ✔✔dorsalis pedis pulse PT ✔✔posterior tibia pulse NSR ✔✔normal sinus rhythm JVD ✔✔jugular vein distension-bulging of veins in the neck AA ✔✔abdominal aortic aneurysm-localized dilation (ballooning) of the abdominal aorta exceeding the normal diameter by more than 50%, and is the most common form of aortic aneurysm BB ✔✔bundle branch block-refers to a defect of the heart's electrical conduction system that can be seen on an EKG CABG ✔✔coronary artery bypass graft-procedure that returns blood flow to heart by rerouting it through a new artery or vein that is grafted around diseased sections
Echocardiogram ✔✔sonogram of the heart, also called cardiac ultrasound Pericarditis ✔✔inflammation of the pericardium (fluid filled sac that surrounds the heart) Risk factors for heart disease ✔✔1. HTN
- high cholesterol
- tobacco use
- family history
- diabetes
- obesity
- age (elderly) Apnea ✔✔loss of spontaneous respirations Dyspnea ✔✔SOB Hemoptysis ✔✔coughing up blood Orthopnea ✔✔dyspnea upon lying flat Trachea ✔✔airway that connects the lungs and the layrnx/pharynx DOE ✔✔dyspnea on exertion NC ✔✔nasal canula RR ✔✔respiratory rate
SOB ✔✔shortness of breath BS ✔✔breath sounds CTAB ✔✔clear to auscultation bilaterally COPD ✔✔chronic obstructive pulmonary disorder-chronic emphysema and bronchitis (which usually occur together) that causes narrowing of the airway PNA ✔✔pneumonia TB ✔✔tuberculosis-bacterial infection caused by various strains of mycobacteria, usually mycobacterium tuberculosis, that involves the lungs, but may spread to other organs URI ✔✔upper respiratory infection-illnesses caused by an acute infection which involves the upper respiratory tract: nose, sinuses, pharynx or larynx cyanotic ✔✔bluish or slate-like skin color rales ✔✔crackling noises that may be heard Blood clot risk factors ✔✔1. recent long travel
- recent surgery
- cancer
- previous hx
- smoking
- BCP or hormonal replacement therapy
- family history
clonus ✔✔involuntary contraction and relaxation of the muscle, characteristic of some neurologic disorders TM ✔✔tympanic membrane-cone-shaped membrane that separates the internal ear from the middle ear; aka the ear drum MMM ✔✔moist mucous membranes EOMI ✔✔extraocular motion intact PERRL ✔✔pupils equal round reactive to light AMS ✔✔altered mental status ALOC ✔✔altered level of consciousness CVA ✔✔cerebral vascular accident-aka stroke; blood flow to a part of the brain stops; ischemic or hemorrhagic MAE ✔✔moving all extremities A&O ✔✔alert and oriented DTR's ✔✔deep tendon reflexes-reflexes elicited and measured on a scale of 0 - 5+; often patellar reflex tested (Normal: 2+ patellar reflexes) GCS ✔✔Glascow coma scale: test that assesses mental and motor function on a scale of 3 - 15 with 15 indicating the patient is functioning properly
Aphagia ✔✔inability to swallow Epistaxis ✔✔nosebleed Rhinorrhea ✔✔thin, watery discharge from the nose diplopia ✔✔double vision Flurescein ✔✔dye used in eye exam to observe corneal abnormalities sclera ✔✔white outer wall of the eye tinnitus ✔✔ringing in the ears dymentia ✔✔loss of global cognitive ability in a previously unimpaired person, beyond what might be expected from normal aging Hydrocephaly ✔✔build up of fluid inside the skull Tonic clonic (grand mal) ✔✔type of seizure that affects the entire brain Sensation ✔✔Perception of a stimulus Mandible ✔✔lower jaw bone Trismus ✔✔inability to normally open the mouth Tonsillectomy ✔✔removal of one or both tonsils
CN III ✔✔oculomotor CN IV ✔✔trochlear CN V ✔✔trigeminal CN VI ✔✔Abducens CN VII ✔✔Facial CN VIII ✔✔vestibulocochlear CN IX ✔✔glossopharyngeal CN X ✔✔vagus CN XI ✔✔accessory CN XII ✔✔hypoglossal Affect ✔✔experience of feeling and emotion Memory ✔✔ability to store, retain, and recall information and experience Amenorrhea ✔✔having no menstural period Urinary retention ✔✔inability to urinate
Urinary hesitancy ✔✔difficulty in starting the flow of urine Adnexa ✔✔ovaries and fallopian tubes Emesis ✔✔vomiting Hematochezia ✔✔blood in stool ECO ✔✔emergency containment order-patient can be held against his will if the physician deems him a threat ETOH ✔✔alcohol presence or intoxication HI ✔✔homicidal ideations SI ✔✔suicidal ideations TDO ✔✔temporary detaining order-court-ordered, necessary if a physician deems a patient threatening, but that patient refuses to be admitted BCP ✔✔birth control pill LMP ✔✔last menstrual period STD ✔✔sexually transmitted disease BM ✔✔bowel movement BRB ✔✔bright red blood
