ScribeAmerica Final Exam

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? - ANSWER-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? - ANSWER-Uncomplicated laceration of
the left foot - initial encounter



What does AMS stand for? - ANSWER-altered mental status



What does GCS stand for? - ANSWER-glasgow coma scale



What does DNR stand for? - ANSWER-do not resuscitate



What does AAA stand for? - ANSWER-abdominal aortic aneurysm



What does PE stand for in the diagnosis section of the chart? - ANSWER-pulmonary embolism



What does DP stand for in "DP pulse"? - ANSWER-dorsalis pedis



What does DVT stand for? - ANSWER-deep vein thrombosis



What does NTG stand for? - ANSWER-nitroglycerin



What does URI stand for? - ANSWER-upper respiratory infection



What does CHF stand for? - ANSWER-congestive heart failure



What does s/p stand for? - ANSWER-status post

,What does GERD stand for? - ANSWER-gastroesophageal reflux disease



What does EOMI stand for? - ANSWER-extraocular movements intact



What does DOE stand for? - ANSWER-dyspnea on exertion



What does LBBB stand for? - ANSWER-left bundle branch block



What does CVA stand for? - ANSWER-costovertebral angle



What does CSF stand for? - ANSWER-cerebrospinal fluid



What does PTX stand for? - ANSWER-pneumothorax



What does COPD stand for? - ANSWER-chronic obstructive pulmonary disease



What does PNA stand for? - ANSWER-pneumonia



What does CBC stand for? - ANSWER-complete blood count



What does IDDM stand for? - ANSWER-insulin dependent diabetes mellitus



What does TIA stand for? - ANSWER-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.



5 hours ago, DKA, vomiting, admit, Type II DM, right BKA, hyperglycemia & elevated ketones,



Onset:

, Disposition:

ED Course:

CC:

PMHx:

Diagnosis:

PSHx: - ANSWER-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.



Unit Secretary, ED tech, Scribe, Mid-level Provider, charge nurse, RT, ED nurse



________: Documents the patient's visits on behalf of the physician



________: Answers phone calls, pages other specialists/ doctors, and organizes the patient's
paperwork



________: Records medical histories, symptoms, monitors the patient, starts IVs, administers
mediations, and assists with procedures



________: Helps the nurse and assists with procedures



________: Administers "breathing treatments" and assists with managing a patient's airway



________: NP or PA that works under the supervision of a physician to diagnose and treat patients