Scribe America Final Exam 2023/2024
Updated Questions and Answers (Verified
Answers)
What is the standard template for charting?
HPI, ROS, Past History, PE, ED Course, Disposition
What are some general PMHx?
Hypertension (HTN), Hyperlipidemia, Cancer, Diabetes Mellitus (IDDM, NIDDM)
What are some cardiac PMHx?
Myocardial Infarction, Coronary Artery Disease, Congestive Heart Failure, Atrial Fibrillation
What are some pulmonary PMHx?
Pulmonary Embolism, Pneumonia, Chronic Obstructive Pulmonary Disease, Asthma
What are some abdominal PMx?
GERD, AAA, Pancreatitis, Hepatitis, Diverticulitis
What are some GU PMHx?
UTI, Kidney Stones, Chronic Renal Failure
What are some neuro PMHx?
CVA, TIA, Sz
What are some psych PMHx?
Bipolar, Schizophrenia
What are some "other" PMHx?
DVT, MRSA, RA, CBP, Osteoporosis, DJD, DDD
What are some ENT PSHx?
Tonsillectomy, Adenoidectomy, Myringotomy
What are some cardiac PSHx?
CABG
What are some abd PSHx?
Appendectomy, Cholecystectomy, Colectomy
What are some GU PSHx?
Hysterectomy, Salpingo-oophorectomy, Tubal Ligation
,What are some ortho PSHx?
AKA, BKA
What are some neuro PSHx?
Carotid Endarterectomy
What are some other PSHx?
Mastectomy
True or False: A patient has CAD if they have a PMHx of Angina, MI, CABG, Cardiac Stents, or
Angioplasty
True
What is CAD?
Narrowing of the coronary arteries limits blood supply to the heart muscle causing angina
What is a MI?
Acute blockage of the coronary arteries results in ischemia and infarct of the heart muscle.
What is the ScribeAlert for CAD?
MI patients must get to Cath-lab within 90 minutes of arrival
What are the risk factors for MI?
CAD, HTN, DM, Smoker, Hyperlididemia, PHx of CAD < 55 yo
What is CHF?
The heart becomes enlarged, inefficient, and congested with excess fluid.
What are the catch phrases for CHF?
SOB, pedal edema, and orthopnea
What are the CC of CHF?
SOB
- Orthopnea
- Paroxysmal Nocturnal Dyspnea (PND)
- Dyspnea on Exertion (DOE)
What is the PE of CHF like?
Rales and JVD
What is CHF Dx by?
CXR or elevated BNP
What is A Fib?
, Electrical abnormalities in the wiring of the heart causes the atria to quiver abnormally
What is the PE of A Fib like?
Irregularly irregular rhythm, tachycardia
What is A Fib Dx by?
EKG
What is the ScribeAlert for A Fib?
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?
EKG or elevated troponin
What is A Fib Dx by?
EKG
What is CHF Dx by?
CXR or BNP
What is CAD Dx by?
positive heart cath
What is angina Dx by?
Exertional Cp with Hx of CAD
What is a PE?
A blood cot becomes lodged in the pulmonary artery and blocks blood flow to the lungs
What are the risk factors for PE?
DVT, PMHx of DVT or PE, FHx, Recent Surgery, Cancer, A Fib, Immobility, Pregnancy, BCP, Smoking
What is plueritic chest pain?
CP that worsens with deep breaths
What is PE diagnosed by?
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?
Rhonchi in the lungs
Updated Questions and Answers (Verified
Answers)
What is the standard template for charting?
HPI, ROS, Past History, PE, ED Course, Disposition
What are some general PMHx?
Hypertension (HTN), Hyperlipidemia, Cancer, Diabetes Mellitus (IDDM, NIDDM)
What are some cardiac PMHx?
Myocardial Infarction, Coronary Artery Disease, Congestive Heart Failure, Atrial Fibrillation
What are some pulmonary PMHx?
Pulmonary Embolism, Pneumonia, Chronic Obstructive Pulmonary Disease, Asthma
What are some abdominal PMx?
GERD, AAA, Pancreatitis, Hepatitis, Diverticulitis
What are some GU PMHx?
UTI, Kidney Stones, Chronic Renal Failure
What are some neuro PMHx?
CVA, TIA, Sz
What are some psych PMHx?
Bipolar, Schizophrenia
What are some "other" PMHx?
DVT, MRSA, RA, CBP, Osteoporosis, DJD, DDD
What are some ENT PSHx?
Tonsillectomy, Adenoidectomy, Myringotomy
What are some cardiac PSHx?
CABG
What are some abd PSHx?
Appendectomy, Cholecystectomy, Colectomy
What are some GU PSHx?
Hysterectomy, Salpingo-oophorectomy, Tubal Ligation
,What are some ortho PSHx?
AKA, BKA
What are some neuro PSHx?
Carotid Endarterectomy
What are some other PSHx?
Mastectomy
True or False: A patient has CAD if they have a PMHx of Angina, MI, CABG, Cardiac Stents, or
Angioplasty
True
What is CAD?
Narrowing of the coronary arteries limits blood supply to the heart muscle causing angina
What is a MI?
Acute blockage of the coronary arteries results in ischemia and infarct of the heart muscle.
What is the ScribeAlert for CAD?
MI patients must get to Cath-lab within 90 minutes of arrival
What are the risk factors for MI?
CAD, HTN, DM, Smoker, Hyperlididemia, PHx of CAD < 55 yo
What is CHF?
The heart becomes enlarged, inefficient, and congested with excess fluid.
What are the catch phrases for CHF?
SOB, pedal edema, and orthopnea
What are the CC of CHF?
SOB
- Orthopnea
- Paroxysmal Nocturnal Dyspnea (PND)
- Dyspnea on Exertion (DOE)
What is the PE of CHF like?
Rales and JVD
What is CHF Dx by?
CXR or elevated BNP
What is A Fib?
, Electrical abnormalities in the wiring of the heart causes the atria to quiver abnormally
What is the PE of A Fib like?
Irregularly irregular rhythm, tachycardia
What is A Fib Dx by?
EKG
What is the ScribeAlert for A Fib?
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?
EKG or elevated troponin
What is A Fib Dx by?
EKG
What is CHF Dx by?
CXR or BNP
What is CAD Dx by?
positive heart cath
What is angina Dx by?
Exertional Cp with Hx of CAD
What is a PE?
A blood cot becomes lodged in the pulmonary artery and blocks blood flow to the lungs
What are the risk factors for PE?
DVT, PMHx of DVT or PE, FHx, Recent Surgery, Cancer, A Fib, Immobility, Pregnancy, BCP, Smoking
What is plueritic chest pain?
CP that worsens with deep breaths
What is PE diagnosed by?
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?
Rhonchi in the lungs
