ScribeAmerica Final Exam 2023 with complete solution questions and answers

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 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 What does AMS stand for? altered mental status What does GCS stand for? glasgow coma scale What does DNR stand for? do not resuscitate What does AAA stand for? abdominal aortic aneurysm What does PE stand for in the diagnosis section of the chart? pulmonary embolism What does DP stand for in "DP pulse"? dorsalis pedis What does DVT stand for? deep vein thrombosis What does NTG stand for? nitroglycerin What does URI stand for? upper respiratory infection What does CHF stand for? congestive heart failure What does s/p stand for? status post What does GERD stand for? gastroesophageal reflux disease What does EOMI stand for? extraocular movements intact What does DOE stand for? dyspnea on exertion What does LBBB stand for? left bundle branch block What does CVA stand for? costovertebral angle What does CSF stand for? cerebrospinal fluid What does PTX stand for? pneumothorax What does COPD stand for? chronic obstructive pulmonary disease What does PNA stand for? pneumonia What does CBC stand for? complete blood count What does IDDM stand for? insulin dependent diabetes mellitus What does TIA stand for? transient ischemic attack 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 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 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 section of the chart would you find AKA? PSHx PE Which of the following would be documented in ED Course? Re-evals Treatments An ROS has marked positive for head trauma with accompanying LOC. What DDx would your provider be concerned about? Hemorrhagic CVA What condition is 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 Certain words or phrases act as "red flags" to grab your providers attention to let them know a patient may require timely and comprehensive medical action. Which of the following words or phrases are NOT considered "red flags"? "nocturne" in a 65 y/o male Match the following Dx with it't patient presentation COPD: SOB + wheezing +SHx of 3 ppd PE: SOB + unilateral pedal edema + pleuritic CP CHF: SOB + bilateral pedal edema + CP asthma: SOB + wheezing on exam What condition correctly describes "Fertilized egg developed outside the uterus"? ectopic pregnancy A patient recently went on a boat trip 2 days ago and developed dizziness which has continued to persist since onset. She describes her dizziness as a room spinning and reports that it is accompanied by tinnitus, nausea, and vomiting. Physical exam is positive for Romberg's and Heat CT is negative. Based on this information which is the most likely final diagnosis for the patient? BPV What condition correctly describes "An immune response that leads to rash, itching, swelling, or difficulty breathing"? allergic reaction What condition describes "translocation of a thrombus leading to dyspnea and hypoxia"? PE Which of the following are not valid DDx for a patient with CC of HA? Syncope Bell's palsy Vertigo What FHx/ SHx information is usually asked for pediatric parents? Immunization status Second hand smoke exposure A 45 year old male presents to the ED with a ripping, tearing pain to his central chest radiating strait to his back with associated nausea and begun 1 hours ago. What emergency conditions from the following list may explain the patients symptoms? MI and Aortic Dissection A female patient has been pregnant four times in the past, is currently pregnant, and has two children at home. Calculate the G, P, and A. 5,2,2 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 For chest pain patients, administering this medication can prevent onset of MI my thinning out the blood and improving blood flow to the heart. Because of this, it is important in the HPI if the patient has received this medication, and if so who gave the medication and what was the dosage of the medication. What medication is important for meeting this core measure? ASA Which of the following are considered to be cardiac risk factors for CP patients? Tobacco use DM CAD Family hx of CAD 55 y/o PSHx of CABG, angioplasty, and stent HTN HLD T/F. All symptoms documented in the HPI are also documented in the ROS. True A patient states she has had a productive cough for 4 days, and yesterday she developed a fever. Would her fever be considered an associates symptom for her productive cough? Why or why not? Yes, because fever started soon after the cough Match location with he corresponding DDx LLQ: diverticulitis RLQ: appendicitis LUQ: pancreatic disease RUQ: gall bladder disease T/F. All symptoms documented in the ROS are also documented in the HPI False Match the following HPI detail with the corresponding DDx PTX: chest pains when taking in a deep breath CAD/ MI: sharp, stabbing pains that alternately becomes a dull heavy pressure like an elephant sitting on the chest, but regardless of quality, pain is always brought on my exertion GERD: burning chest pain 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? 4,3,1 What is the medical term for "coughing up blood"? hemoptysis What is the medical term for painful urination? dysuria What medical term describes "blood present in vomit"? hematemesis What is the medical term for "bright red blood in stools"? hematochezia What medical term describes "noticeable blood in the urine"? hematuria What is the medical term for infection of the gallbladder? cholecystitis What is the medical term for stones in the gallbladder? cholelithiasis What is the medical term for "carotid artery cleaning"? carotid endarterectomy What ROS system would include Dyspepsia, the medical term for indigestion? Gastrointestinal Which of the following would NOT be considered an example of PHI? None of the above 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 are the possible consequences of a HIPAA violations? 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 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 devise and it is not encrypted 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 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 in constant? timing Read through the PE and decide if this meets the Level 5 billing criteria... No, the PE does not meet level 5 billing criteria Fill in the blank: Critical care must be at least a minimum of _______. 30 minutes Among the following diseases listed, select the ones that qualify for CCT. DKA Sepsis PTX ACS Acute MI A-fib with RVR CVA PE 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 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 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 What term describes "the patient destination is home"? discharged What abréviation describes the scenario in which a patient declines a hospital stay and decided to go home instead? AMA 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 What do you need to make sure to document for ever admitted patient? A consultation note indicating the admitting physician 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 You've just caught up on all you're charting. What are some things you can do to increase you providers efficiency? Preparing charts for patients that are assigned to your provider Tracking results Accompanying your provider on reevals Preparing for dispositions 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 You are starting your shirt and you physician immediately picks up 3 patients... PNA, Appendicitis, UTI What does ETT stand for? endotracheal tube Select terms you might find on an x-ray interpretation Infiltrate Pneumothorax Match the oxygen administration route to the corresponding definition Non-rebreather mask: A facial mask with a reservoir bag attached RA: This means the patient is not on oxygen Intubation: An ETT goes through the patient's mouth and down the trachea BVM: A large facial mask held in place by hand and attached to an Ambu-bag used to manually inflate the patient's lungs NC: A plastic tube placed into that patient's nostrils FM: A plastic mask fit over the nose and mouth What is a "GI cocktail"? Liquid consumed by mouth to treat an upset stomach Select the EKG interpretation documentation guidelines. Rate and rhythm 2 positive or negative findings How would you diagnose AFIB? EKG How would you diagnose pneumothorax? CXR Which of the following lab results need to be monitored closely for efficiency? Troponin Creatinine D-dimer How would you diagnose Hemorrhagic CVA? Head CT LP What procedure would be used to diagnose Meningitis? LP Match the following results with the corresponding diagnosis no MI: combination of (-) EKG and (-) blood work NSTEMI: combination of (-) EKG and (+) blood work STEMI: combination of (+) EKG and (+) blood work Which of the following would be ordered to investigate thyroid disease? T3 TSH T4 How would you diagnose an AAA? Ct A/P with IV contrast dye Which of the following diseases may be diagnosed using CXR? Rib fracture PTX PNA CHF Which of the following tests would likely be immediately ordered for a Cardiac Workup in the ED? CBC and BMP Troponin CXR EKG Your physician tells you the patient had a wood's lamp exam to look for fluorescein uptake. In which organ system would you document this physical exam finding? Eyes Match the normal grading scale with the corresponding PE finding Reflexes: 2+ Strength: 5/5 GCS: 15 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 Which of the following would belong in a psychiatric exam? Affect 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