Scribe America 2023 with 100% correct questions and answers

Pain vs. Tenderness Pt feeling vs. Physician assessment Distress Doctor's judgement of discomfort; subjective Auscultation Listening with a stethescope Palpation The pressing on an area Job of the charge nurse Manage the ED flow Triage consists of: chief complaint, vital signs, level of acuity Level of acuity 5 - 1 (low to high; head ache to heart attack) Vital signs RR (respiratory rate), BP, T (temp), SatO2, HR (heart rate in bpm) Nurse assessment consists of: confirm chief complaint, review allergies, brief PMHx Disposition discharge, admit, transfer Where to Document: patient complaint HPI (if pertains to chief complaint) or ROS (everything else) Patient Says/ Scribe Writes: high BP hypertension (HTN) Patient Says/ Scribe Writes: high cholesterol hyperlipidemia (HLD) Patient Says/ Scribe Writes: thyroid problem hypothyroidism (sometimes hyperthyroidism) Patient Says/ Scribe Writes: diabetes diabetes melltus (DM) Patient Says/ Scribe Writes: "I only take pills for my diabetes" Non- Insulin dependent diabetes mellitus (NIDDM) Patient Says/ Scribe Writes: "I take shots/ insulin for my diabetes" Insulin dependent diabetes mellitus (IDDM) Patient Says/ Scribe Writes: heart disease coronary artery disease (CAD) Patient Says/ Scribe Writes: heart attack myocardial infarction (MI) Patient Says/ Scribe Writes: heart failure congestive heart failure (CHF) Patient Says/ Scribe Writes: irregular heart beat arrhythmia Patient Says/ Scribe Writes: murmur heart murmur Patient Says/ Scribe Writes: episodes of abnormally fast/ racing heartbeat arrhythmia Patient Says/ Scribe Writes: asthma asthma Patient Says/ Scribe Writes: emphysema/ chronic bronchitis chronic obstructive pulmonary disease (COPD) Patient Says/ Scribe Writes: blood clot in lung pulmonary embolism (PE) Patient Says/ Scribe Writes: pneumonia pneumonia (PNA) Patient Says/ Scribe Writes: reflux gastroesophangeal reflux disease (GERD) Patient Says/ Scribe Writes: ulcer gastric ulcer or peptic ulcer disease Patient Says/ Scribe Writes: pancreatitis pancreatitis Patient Says/ Scribe Writes: diverticulitis diverticulitis Patient Says/ Scribe Writes: Crohn's/ UC Crohn's disease or ulcerative colilitis Patient Says/ Scribe Writes: irritable bowel irritable bowel syndrome (IBS) Patient Says/ Scribe Writes: bladder infection urinary tract infection (UTI) Patient Says/ Scribe Writes: kidney infection pyelonephritis (pyelo) Patient Says/ Scribe Writes: kidney stones renal calculi Patient Says/ Scribe Writes: "I'm on dialysis" chronic renal failure (CRF) or end stage renal disease (ESRD) on dialysis Patient Says/ Scribe Writes: enlarged prostate benign prostatic hypertrophy (BPH) GPA gravda/para/abortus: total number of pregnancies (twins = 2), pregnancies reaching viable gestational age (23 weeks, #times to hospital, twins =1), total number of miscarriages/elective abortions Patient Says/ Scribe Writes: brain bleed hemorrhagic CVA Patient Says/ Scribe Writes: stroke ischemic cerebrovascular accident (CVA) Patient Says/ Scribe Writes: mini-stroke transient ischemic attach (TIA) Patient Says/ Scribe Writes: seizures history of seizures Patient Says/ Scribe Writes: bipolar bipolar disorder Patient Says/ Scribe Writes: schizophrenia schizophrenia Patient Says/ Scribe Writes: "I drink a lot" ETOH abuse or Alcoholism Patient Says/ Scribe Writes: "I do drugs" substance abuse Patient Says/ Scribe Writes: blood clot in my leg lower extremity deep vein thrombosis (DVT) Patient Says/ Scribe Writes: "bulge in my aorta" aortic aneurysm Patient Says/ Scribe Writes: "bad flow in my legs" peripheral vascular disease (PVD) Patient Says/ Scribe Writes: "numbness in my legs" peripheral neuropathy Patient Says/ Scribe Writes: low back pain chronic low back pain Patient Says/ Scribe Writes: bulging/ herniated disc degenerative disc disease (DDD) Patient Says/ Scribe Writes: weak/ fragile bones Osteoporosis Patient Says/ Scribe Writes: cancer cancer or carcinoma (CA) - add type (breast, colon, prostate, etc.) Patient Says/ Scribe Writes: spread to my... with metastases to the... Patient Says/ Scribe Writes: chemo chemotherapy Patient Says/ Scribe Writes: radiation radiation therapy Patient Says/ Scribe Writes: they cut it out status-post surgical resection Patient Says/ Scribe Writes: it's gone in remission Patient Says/ Scribe Writes: tonsils removed tonsillectomy Patient Says/ Scribe Writes: adenoids removed adenoidectomy Patient Says/ Scribe Writes: ear tubes pressure equalizing (P.E.) tubes Patient Says/ Scribe Writes: heart bypass coronary artery bypass graft (CABG) -- PMHx CAD Patient Says/ Scribe Writes: stents coronary stents -- PMHx CAD Patient Says/ Scribe Writes: heart cath cardiac catherization Patient Says/ Scribe Writes: balloon angioplasty -- PMHx CAD Patient Says/ Scribe Writes: valve surgery valve repair or replacement (bovine vs. mechanical) Patient Says/ Scribe Writes: pacer pacemaker Patient Says/ Scribe Writes: defibrillator automatic implanted cardiac defibrillator (AICD) Patient Says/ Scribe Writes: surgery for Afib Afib s/p cardiac ablation Patient Says/ Scribe Writes: breast removal mastectomy Patient Says/ Scribe Writes: hole in my neck tracheostomy ("trach") Patient Says/ Scribe Writes: part of my lung removed partial lobectomy Patient Says/ Scribe Writes: appendix removed appendectomy Patient Says/ Scribe Writes: gallbladder removed cholecystectomy Patient Says/ Scribe Writes: hernia repair hemiorrhaphy Patient Says/ Scribe Writes: part of my colon removed partial colectomy Patient Says/ Scribe Writes: bag to collect stool colostomy Patient Says/ Scribe Writes: spleen removed splenectomy Patient Says/ Scribe Writes: stomach stapled bariatric surgery Patient Says/ Scribe Writes: exploratory exploratory laparoscopy (ExLap) Patient Says/ Scribe Writes: kidney removed nephrectomy Patient Says/ Scribe Writes: uterus removed hysterectomy (partial vs. total) Patient Says/ Scribe Writes: ovary removed oophorectomy Patient Says/ Scribe Writes: ovary and fallopian tubes removed salpingo-oophorectomy Patient Says/ Scribe Writes: tubes tied tubal litigation (female) or vastectomy (male) Patient Says/ Scribe Writes: c-section cesarean section Patient Says/ Scribe Writes: prostate removed prostatectomy or prostate resection, often transurethral resection of the prostate (TURP) Patient Says/ Scribe Writes: uterine product dilation and curettage (D&C) Patient Says/ Scribe Writes: neck artery cleaned carotid endartectomy Patient Says/ Scribe Writes: shunt cerebral shunt Patient Says/ Scribe Writes: dialysis fistula arteriovenous (AV) fistula Patient Says/ Scribe Writes: dialysis graft AV graft Patient Says/ Scribe Writes: PICC line peripherally inserted central catheter (PICC) Patient Says/ Scribe Writes: port port-a-cath or medi-port Patient Says/ Scribe Writes: clot filter (lower abdomen) IVC (inferior vena cava) filter Patient Says/ Scribe Writes: clot filter (leg) IVC (inferior vena cava) filter Patient Says/ Scribe Writes: leg amputated above knee amputation (AKA), below knee amputation (BKA) Patient Says/ Scribe Writes: joint repair arthroplasty