Scribe America Final (2023/2024) Verified Questions and Answers Graded A+

Scribe America Final -What are the 5 vital signs? heart rate, blood pressure, respiratory rate, temperature, oxygen saturation -The HPI and ROS are what type of information? Subjective -The physical exam is what type of information? objective -What is the difference between HPI and ROS? HPI focuses on the details related to their chief complaint. ROS is a head to toe checklist of symptoms, which includes the chief complaint, associated symptom all other complaints the patient might have -What does disposition (dispo) mean? The patients destination after they leave the Emergency Department -What is the abbreviation for a heart attack? MI - Myocardial Infarction -What is the abbreviation for high blood pressure? HTN- Hypertension -What is the medical term for acid reflux? GERD - Gastroesophageal Reflux Disease -What is the medical term for stroke? CVA- cerebrovascular accident -what is the term for gallbladder removal? Cholecystectomy -What does NKDA stand for? No Known Drug allergies -what is the medical term for redness? Erythema -Wat is the medical term for bruising? Ecchymosis -if the doctor says the exam was "benign", what does that mean? normal nothing of concern -Name five elements of HPI Onset, timing, location, quality, severity, modifying factors, associated symptoms, context -8 body systems included in ROS Constitutional, eyes, Ent, CV Resp, GI, GU, MS skin, near, psych, endocrine, heme/lymph, immunological -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 does MOI stand for in a Trauma HPI? Mechanism of Injury -What are the risk factors for an MI? CAD, HTN, DM, hyperlipidemia, smoking, Fox of CAD 55 y/o -What are the risk factors for a PE? Known DVT, PMHx of DVT or PE, Fox of DVT or PE, recent surgery, CA, A Fib, immobility, pregnancy, BCP, smoking -What are the risk factors for CVA? HTN, HLD, DM, hx TIA/CVA, smoking, Fox CVA, Afib -What does PERRL stand for?? Pupils are equal round and reactive to light -What does AT/NC mean?? Atraumatic/ Normocephalic -What does NAD stand for? No acute distress/disease -IF a patient has pale conjunctiva, what does that indicate? anemia -What is scleral icterus, and what does it indicate? yellowing of the eyes, indicates liver failure -In which body system would you document "TM erythema and bulging"/ ears -What is the medical term for nostril? Naris both nares -To describe a "runny nose" what would the doctor use? rhinorrhea -what would dry mucous membranes indicate? dehydration -Why is midline bony tenderness "worse" than paraspinal tenderness? bony tenderness points towards a spinal fracture and therefore concern for spinal cord injury. paraspinal tenderness points toward a muscle sprain or strain -if you saw "RRR" written in the cardiac exam, what do you think it might mean Regular Rate and Rhythm -Name the rhythm that the physician would hear if the patient was in A Fib Irregularly irregular rhythm