Scribe America Final Exam with 100% Correct Answers Verified 2023/2024

What is the standard template for charting? - Correct answer-HPI, ROS, Past History, PE, ED Course, Disposition What are some general PMHx? - Correct answer-Hypertension (HTN), Hyperlipidemia, Cancer, Diabetes Mellitus (IDDM, NIDDM) What are some cardiac PMHx? - Correct answer-Myocardial Infarction, Coronary Artery Disease, Congestive Heart Failure, Atrial Fibrillation What are some pulmonary PMHx? - Correct answer-Pulmonary Embolism, Pneumonia, Chronic Obstructive Pulmonary Disease, Asthma What are some abdominal PMx? - Correct answer-GERD, AAA, Pancreatitis, Hepatitis, Diverticulitis What are some GU PMHx? - Correct answer-UTI, Kidney Stones, Chronic Renal Failure What are some neuro PMHx? - Correct answer-CVA, TIA, Sz What are some psych PMHx? - Correct answer-Bipolar, Schizophrenia What are some "other" PMHx? - Correct answer-DVT, MRSA, RA, CBP, Osteoporosis, DJD, DDD What are some ENT PSHx? - Correct answer-Tonsillectomy, Adenoidectomy, Myringotomy What are some cardiac PSHx? - Correct answer-CABG What are some abd PSHx? - Correct answer-Appendectomy, Cholecystectomy, Colectomy What are some GU PSHx? - Correct answer-Hysterectomy, Salpingo-oophorectomy, Tubal Ligation What are some ortho PSHx? - Correct answer-AKA, BKA What are some neuro PSHx? - Correct answer-Carotid Endarterectomy What are some other PSHx? - Correct answer-Mastectomy True or False: A patient has CAD if they have a PMHx of Angina, MI, CABG, Cardiac Stents, or Angioplasty - Correct answer-True What is CAD? - Correct answer-Narrowing of the coronary arteries limits blood supply to the heart muscle causing angina What is a MI? - Correct answer-Acute blockage of the coronary arteries results in ischemia and infarct of the heart muscle . What is the ScribeAlert for CAD? - Correct answer-MI patients must get to Cath-lab within 90 minutes of arriva l What are the risk factors for MI? - Correct answer-CAD, HTN, DM, Smoker, Hyperlididemia, PHx of CAD 55 yo What is CHF? - Correct answer-The heart becomes enlarged, inefficient, and congested with excess fluid. What are the catch phrases for CHF? - Correct answer-SOB, pedal edema, and orthopnea What are the CC of CHF? - Correct answer-SOB - Orthopnea - Paroxysmal Nocturnal Dyspnea (PND) - Dyspnea on Exertion (DOE) What is the PE of CHF like? - Correct answer-Rales and JVD What is CHF Dx by? - Correct answer-CXR or elevated BNP What is A Fib? - Correct answer-Electrical abnormalities in the wiring of the heart causes the atria to quiver abnormally What is the PE of A Fib like? - Correct answer-Irregularly irregular rhythm, tachycardia What is A Fib Dx by? - Correct answer-EKG What is the ScribeAlert for A Fib? - Correct answer-ED concern is Rapid Ventricular Response. These pts will often be cardioverted which means they are put back into a regular rhythm known as NSR What is MI Dx by? - Correct answer-EKG or elevated troponin What is A Fib Dx by? - Correct answer-EKG What is CHF Dx by? - Correct answer-CXR or BNP What is CAD Dx by? - Correct answer-positive heart cath What is angina Dx by? - Correct answer-Exertional Cp with Hx of CAD What is a PE? - Correct answer-A blood cot becomes lodged in the pulmonary artery and blocks blood flow to the lungs What are the risk factors for PE? - Correct answer-DVT, PMHx of DVT or PE, FHx, Recent Surgery, Cancer, A Fib, Immobility, Pregnancy, BCP, Smoking What is plueritic chest pain? - Correct answer-CP that worsens with deep breaths What is PE diagnosed by? - Correct answer-CTA Chest (CT Chest with IV contrast) or VQ scan D-Dimer aids in detecting clots, but cannot diagnose a PE What is the PE like for PNA? - Correct answer-Rhonchi in the lungs What is PNA Dx by? - Correct answer-CXR What is the scribealert for PNA? - Correct answer-Community Acquired Pneumonia protocol applies to pts with PNA, requires documenting Abx, Vital Signs, SaO2, Mental Status, and blood cultures What is PTX? - Correct answer-Pneumothorax What is PTX Dx by? - Correct answer-CXR What is the scribealert for PTX? - Correct answer-Document percentage of lung collapsed What are the risk factors for COPD? - Correct answer-Smoking What is the CC for COPD? - Correct answer-SOB What is the PE for COPD like? - Correct answer-Decreased breathing sounds, Wheezes, Rales What is Asthma? - Correct answer-Constricting of the airway due to inflammation and muscular contraction of the bronchioles, known as a bronchiospasm What is the CC of asthma? - Correct answer-SOB/Wheezing What is the catch phrase for PE? - Correct answer-Pleuritic chest pain with tachycardia and hypoxia What is PE Dx by? - Correct answer-CT Chest with IV contrast (CTA Chest) What is the catch phrase for PTX? - Correct answer-Unilateral CP and SOB What is PTX Dx by? - Correct answer-CXR What is the catch phrase PNA? - Correct answer-SOB and productive cough What is PNA Dx by? - Correct answer-CXR? What is the catch phrase for COPD? - Correct answer-SOB with Hx of smoking What is COPD Dx by? - Correct answer-CXR with Hx of smoking What is the catch phrase for asthma? - Correct answer-Wheezing with Hx of asthma What is a hemorrhagic CVA? - Correct answer-AKA Brain Bleed, Mini TIA Traumatic or spontaneous rupture of blood vessels in the head leads to bleeding in the brain What are the Associated Symptoms of Hemorrhagic CVA - Correct answer-Changes in speech, Vision, Sensation, motor, AMS, seizur e AKA: FND (Focal Neurological Deficit) What is a Hemorrhagic CVA Dx by? - Correct answer-CT head or lumbar puncture What is an Ischemic CVA? - Correct answer-Blockage of the arteries supplying blood to the brain resulting in permanent brain damage What is the CC for Ischemic CVA? - Correct answer-Unilateral FND, one sided weakness/numbness or changes in speech or vision What are the associated Sx of meningitis? - Correct answer-Fever, neck pain, neck stiffness, AMS What is meningitis Dx by? - Correct answer-Lumbar Puncture What is the ScribeAlert for a spinal cord injury? - Correct answer-Remember that during the physical exam, the spine is often immobilized with a c-collar What is a TIA? - Correct answer-Vascular changes temporarily deprive a part of the brain of oxygen What is the scribealert for TIA? - Correct answer-Document TPA considered and not indicated due to the fact that symptoms are resolved What is the #1 cause for Seizures (Sz) in peds? - Correct answer-Fever What is the PE like for Sz? - Correct answer-Somnolent, Confused (Post-Ictal)