SCRIBE AMERICA FINAL EXAM 2 2026 FINAL
ASSESSMENT PAPER HEALTH RECORD
ACCURACY COMPREHENSIVE QUESTIONS
AND ANSWERS VERIFIED A+
◉ distress. Answer: the doctor's judgement of discomfort
◉ baseline. Answer: an individual's normal state of being
◉ Unit Secretary. Answer: places physician's orders, answers calls,
pages for other specialists, organizes pt. paperwork
◉ mid level provider. Answer: LNP or PA; works under supervision
of physician to diagnose and treat patients
◉ ED Nurse. Answer: records medical histories, symptoms, monitors
the pt., starts IVs, administers meds, assists with procedures
◉ ED Flow. Answer: Walk in/EMS, Triage (CC, Vitals, Level of
Acuity), Vital Signs (HR, BP, RR, T, SaO2), Bed Placement, Nurse
Assessment, History and Physical, Physician Orders, Results and ED
Course, Final Dx, Disposition
,◉ Documentation. Answer: HPI, ROS, Past History, PE, ED Course,
Disposition
◉ Hyperlipidemia. Answer: HLD
◉ Episodes of abnormally fast/ racing heartbeat. Answer:
Supraventricular Tachycardia (SVT)
◉ Emphysema/ Chronic Bronchitis. Answer: COPD
◉ Ulcer. Answer: Gastric Ulcer or Peptic Ulcer Disease
◉ Kidney Infection. Answer: Pyelonephritis
◉ I'm on Dialysis. Answer: Chronic Renal Failure (CRF) or End Stage
Renal Disease (ESRD)
◉ Pregnancies, births, and abortions. Answer: Para is number of live
births, Gravida is total number of times pt has been pregnant, a is
the number of miscarriages or elective abortions
◉ Patient says I had a balloon. Answer: Angioplasty, PMHx CAD
,◉ Patient says I have a hole in my neck. Answer: tracheostomy
◉ Part of lung removed. Answer: partial lobectomy
◉ bag to collect stool. Answer: colostomy
◉ hernia repair. Answer: herniorrhaphy
◉ kidney removed. Answer: nephrectomy
◉ ovary removed. Answer: oophorectomy
◉ tubes tied. Answer: tubal ligation (female) or Vasectomy (male)
◉ uterus removed. Answer: hysterectomy
◉ brain surgery. Answer: carniotomy
◉ stents. Answer: coronary stents, PMHx CAD
◉ Social History. Answer: Drug Use, Alcohol Use, Occupation, Living
Circumstances, Smoking
, ◉ Differential Diagnoses. Answer: Diseases being considered
◉ Coronary Artery Disease (CAD). Answer: Chest pain with physical
exertion, improved by rest or NTG, diagnosed by Cardiac
Catheterization or stress test, should be given 324 mg. Aspirin
(Single Greatest risk factor for MI)
◉ Atrial Fibrillation. Answer: Electrical abnormality. CC is
palpitations.
◉ MI. Answer: Chest pressure with diaphoresis, N/V, and SOB,
diagnosed by EKG (Stemi) or Troponin (non Stemi) (STEMI pts must
get to Cath lab within 90 min of arrival)
◉ CHF. Answer: heart becomes enlarged, inefficient, and congested
with excess fluid. CC is SOB with associated pedal edema and
orthopnea. Diagnosed by CXR or elevated BNP. Rales, JVD and edema
seen on PE. Meds are diuretics
◉ Pericarditis. Answer: inflammation of the sac surrounding the
heart causing CP
◉ Angina. Answer: Symptom of CAD. Diagnosed by exertional CP
with history of CAD
ASSESSMENT PAPER HEALTH RECORD
ACCURACY COMPREHENSIVE QUESTIONS
AND ANSWERS VERIFIED A+
◉ distress. Answer: the doctor's judgement of discomfort
◉ baseline. Answer: an individual's normal state of being
◉ Unit Secretary. Answer: places physician's orders, answers calls,
pages for other specialists, organizes pt. paperwork
◉ mid level provider. Answer: LNP or PA; works under supervision
of physician to diagnose and treat patients
◉ ED Nurse. Answer: records medical histories, symptoms, monitors
the pt., starts IVs, administers meds, assists with procedures
◉ ED Flow. Answer: Walk in/EMS, Triage (CC, Vitals, Level of
Acuity), Vital Signs (HR, BP, RR, T, SaO2), Bed Placement, Nurse
Assessment, History and Physical, Physician Orders, Results and ED
Course, Final Dx, Disposition
,◉ Documentation. Answer: HPI, ROS, Past History, PE, ED Course,
Disposition
◉ Hyperlipidemia. Answer: HLD
◉ Episodes of abnormally fast/ racing heartbeat. Answer:
Supraventricular Tachycardia (SVT)
◉ Emphysema/ Chronic Bronchitis. Answer: COPD
◉ Ulcer. Answer: Gastric Ulcer or Peptic Ulcer Disease
◉ Kidney Infection. Answer: Pyelonephritis
◉ I'm on Dialysis. Answer: Chronic Renal Failure (CRF) or End Stage
Renal Disease (ESRD)
◉ Pregnancies, births, and abortions. Answer: Para is number of live
births, Gravida is total number of times pt has been pregnant, a is
the number of miscarriages or elective abortions
◉ Patient says I had a balloon. Answer: Angioplasty, PMHx CAD
,◉ Patient says I have a hole in my neck. Answer: tracheostomy
◉ Part of lung removed. Answer: partial lobectomy
◉ bag to collect stool. Answer: colostomy
◉ hernia repair. Answer: herniorrhaphy
◉ kidney removed. Answer: nephrectomy
◉ ovary removed. Answer: oophorectomy
◉ tubes tied. Answer: tubal ligation (female) or Vasectomy (male)
◉ uterus removed. Answer: hysterectomy
◉ brain surgery. Answer: carniotomy
◉ stents. Answer: coronary stents, PMHx CAD
◉ Social History. Answer: Drug Use, Alcohol Use, Occupation, Living
Circumstances, Smoking
, ◉ Differential Diagnoses. Answer: Diseases being considered
◉ Coronary Artery Disease (CAD). Answer: Chest pain with physical
exertion, improved by rest or NTG, diagnosed by Cardiac
Catheterization or stress test, should be given 324 mg. Aspirin
(Single Greatest risk factor for MI)
◉ Atrial Fibrillation. Answer: Electrical abnormality. CC is
palpitations.
◉ MI. Answer: Chest pressure with diaphoresis, N/V, and SOB,
diagnosed by EKG (Stemi) or Troponin (non Stemi) (STEMI pts must
get to Cath lab within 90 min of arrival)
◉ CHF. Answer: heart becomes enlarged, inefficient, and congested
with excess fluid. CC is SOB with associated pedal edema and
orthopnea. Diagnosed by CXR or elevated BNP. Rales, JVD and edema
seen on PE. Meds are diuretics
◉ Pericarditis. Answer: inflammation of the sac surrounding the
heart causing CP
◉ Angina. Answer: Symptom of CAD. Diagnosed by exertional CP
with history of CAD
