SCRIBEAMERICA OUTPATIENT FINAL EXAM 2 LATEST VERSION
(VERSION A & B) ACTUAL EXAM 300 QUESTIONS AND
CORRECT DETAILE ANSWERS
Uterine product removed - ANSWER: Dilation and Curettage (D and C)
Hip surgery - ANSWER: Open Reduction with Internal Fixation (ORIF)
Stents - ANSWER: Coronary Stents>> PMHx CAD
Brain surgery - ANSWER: Craniotomy (brain bleed vs brain CA)
True allergy - ANSWER: Rash, itching, swelling, or difficulty breathing
Age of Onset that makes it more likely to be environment than genetics? - ANSWER:
50 y/o + (also higher genetic risk if more family members have it)
Age of Onset for CAD? - ANSWER: 54 and younger would be genetic and 55 and
older would be environment.
What are the three common general family histories your physician may ask about? -
ANSWER: Hypertension (HTN)
Diabetes Mellitus (DM)
Cancer (CA)
Two pulmonary FHx - ANSWER: PE and Asthma
Two Gastrointestinal FHx - ANSWER: Crohn's and IBS
Three Neurological FHx - ANSWER: CVA, Aneurysm, Seizures
Two Miscellaneous FHx - ANSWER: Sickle Cell Anemia and DVT
Social History list... - ANSWER: Tobacco use, Drug use, Alcohol use, living
circumstances, occupation
Smoking status (Current) - ANSWER: #ppd or #yr
Smoking status (Former) - ANSWER: year quit
Second hand exposure - ANSWER: (pediatrics)
If Chronic alcoholic need.. - ANSWER: Number of drinks/day and type of alcohol
,Illicit Drug Use need... - ANSWER: Which Drug, Route of Administration, Date of last
use
Social History for pediatrics - ANSWER: Need Caretaker, attends daycare, attends
school, siblings, second hand smoke exposure, immunizations
Why must smoking status be documented on every patient 13 yrs and older? -
ANSWER: Government standard require this
Would PMHx of chronic alcoholism belong in the SHx section as well as the PMHx
section? - ANSWER: Yes
Name the three most common routes of administration of illicit drug use - ANSWER:
Oral, Intravenous, Inhaled
Living Circumstances - ANSWER: Doc will ask if pt: lives alone, with family/friends,
nursing home/assisted living, hospice, homeless/shelter
Occupation - ANSWER: Employed, Unemployed, On disability, Retired
If physician asks specifically about type of work, be sure to document it
Identify ED flow: - ANSWER: Walk-in > Triage > Bed > Physician Assessment >
Lab/Rad/Meds > Results > MDM/ED Course > Diagnosis > Consults > Disposition
What are the 5 vital signs? - ANSWER: Blood Pressure, Respiratory Rate,
Temperature, Heart Rate, Oxygen Saturation
What does disposition (dispo) mean? - ANSWER: Destination of the patient
following the ED evaluation. Admitted to the hospital, discharged or transferred to
another facility.
What subcategories are included in the Past History section of the template? -
ANSWER: PMx: Past Medical History
PSHx: Past Surgical History
FHx: Family History
SHx: Social History
What is the term for gallbladder removal? - ANSWER: Cholesystectomy
What is the medical term for redness? - ANSWER: Erythema/Erythematous
That is the medical term for bruising? - ANSWER: Eccymosis
Pertinent Positives - ANSWER: present symptoms that point to a diagnosis
Catch Phase for CAD - ANSWER: Chest pain with physical exertion
, Nitroglycerin - ANSWER: NTG
sublingual - ANSWER: put meds under tongue
Chief Complaint of CAD - ANSWER: CP (worse with exertion, better with rest/NTG)
CAD diagnosed by.. - ANSWER: Cardiac Catheterization or stress test (not diagnosed
in ED)
PMHx signs for a CAD - ANSWER: MI, Angina, CABG, Cardiac stents, or Angioplasty
Single greatest risk for an MI - ANSWER: CAD
Meds given to patients with CP - ANSWER: 324 mg Aspirin PO
.4 mg NTG SL
Stemi patients must... - ANSWER: go to cath lab within 90 minutes of arrival
CHF - ANSWER: heart becomes enlarged, inefficient, and congested with fluid
Catch phrase for CHF - ANSWER: SOB with pedal edema and orthopnea
Orthopnea - ANSWER: SOB when lying flat
Pedal edema - ANSWER: swelling of ankles and feet
PND - ANSWER: Paroxysmal Nocturnal Dyspnea
DOE - ANSWER: Dyspnea on Exertion
How to diagnose CHF - ANSWER: CXR or elevated BNP
BNP - ANSWER: B type natriuretic peptide
PE of CHF - ANSWER: JVD, Rales in lungs, pedal edema
JVD - ANSWER: Jugular Vein Distention
Atrial Fibrillation - ANSWER: top of heart (atria) quivers abnormally
Atrial Fibrillation diagnosed by... - ANSWER: EKG
Meds for Atrial Fibrillation - ANSWER: Coumadin (blood thinner) or Digoxin (slows
heart rate)
NSR - ANSWER: normal sinus rhythm
(VERSION A & B) ACTUAL EXAM 300 QUESTIONS AND
CORRECT DETAILE ANSWERS
Uterine product removed - ANSWER: Dilation and Curettage (D and C)
Hip surgery - ANSWER: Open Reduction with Internal Fixation (ORIF)
Stents - ANSWER: Coronary Stents>> PMHx CAD
Brain surgery - ANSWER: Craniotomy (brain bleed vs brain CA)
True allergy - ANSWER: Rash, itching, swelling, or difficulty breathing
Age of Onset that makes it more likely to be environment than genetics? - ANSWER:
50 y/o + (also higher genetic risk if more family members have it)
Age of Onset for CAD? - ANSWER: 54 and younger would be genetic and 55 and
older would be environment.
What are the three common general family histories your physician may ask about? -
ANSWER: Hypertension (HTN)
Diabetes Mellitus (DM)
Cancer (CA)
Two pulmonary FHx - ANSWER: PE and Asthma
Two Gastrointestinal FHx - ANSWER: Crohn's and IBS
Three Neurological FHx - ANSWER: CVA, Aneurysm, Seizures
Two Miscellaneous FHx - ANSWER: Sickle Cell Anemia and DVT
Social History list... - ANSWER: Tobacco use, Drug use, Alcohol use, living
circumstances, occupation
Smoking status (Current) - ANSWER: #ppd or #yr
Smoking status (Former) - ANSWER: year quit
Second hand exposure - ANSWER: (pediatrics)
If Chronic alcoholic need.. - ANSWER: Number of drinks/day and type of alcohol
,Illicit Drug Use need... - ANSWER: Which Drug, Route of Administration, Date of last
use
Social History for pediatrics - ANSWER: Need Caretaker, attends daycare, attends
school, siblings, second hand smoke exposure, immunizations
Why must smoking status be documented on every patient 13 yrs and older? -
ANSWER: Government standard require this
Would PMHx of chronic alcoholism belong in the SHx section as well as the PMHx
section? - ANSWER: Yes
Name the three most common routes of administration of illicit drug use - ANSWER:
Oral, Intravenous, Inhaled
Living Circumstances - ANSWER: Doc will ask if pt: lives alone, with family/friends,
nursing home/assisted living, hospice, homeless/shelter
Occupation - ANSWER: Employed, Unemployed, On disability, Retired
If physician asks specifically about type of work, be sure to document it
Identify ED flow: - ANSWER: Walk-in > Triage > Bed > Physician Assessment >
Lab/Rad/Meds > Results > MDM/ED Course > Diagnosis > Consults > Disposition
What are the 5 vital signs? - ANSWER: Blood Pressure, Respiratory Rate,
Temperature, Heart Rate, Oxygen Saturation
What does disposition (dispo) mean? - ANSWER: Destination of the patient
following the ED evaluation. Admitted to the hospital, discharged or transferred to
another facility.
What subcategories are included in the Past History section of the template? -
ANSWER: PMx: Past Medical History
PSHx: Past Surgical History
FHx: Family History
SHx: Social History
What is the term for gallbladder removal? - ANSWER: Cholesystectomy
What is the medical term for redness? - ANSWER: Erythema/Erythematous
That is the medical term for bruising? - ANSWER: Eccymosis
Pertinent Positives - ANSWER: present symptoms that point to a diagnosis
Catch Phase for CAD - ANSWER: Chest pain with physical exertion
, Nitroglycerin - ANSWER: NTG
sublingual - ANSWER: put meds under tongue
Chief Complaint of CAD - ANSWER: CP (worse with exertion, better with rest/NTG)
CAD diagnosed by.. - ANSWER: Cardiac Catheterization or stress test (not diagnosed
in ED)
PMHx signs for a CAD - ANSWER: MI, Angina, CABG, Cardiac stents, or Angioplasty
Single greatest risk for an MI - ANSWER: CAD
Meds given to patients with CP - ANSWER: 324 mg Aspirin PO
.4 mg NTG SL
Stemi patients must... - ANSWER: go to cath lab within 90 minutes of arrival
CHF - ANSWER: heart becomes enlarged, inefficient, and congested with fluid
Catch phrase for CHF - ANSWER: SOB with pedal edema and orthopnea
Orthopnea - ANSWER: SOB when lying flat
Pedal edema - ANSWER: swelling of ankles and feet
PND - ANSWER: Paroxysmal Nocturnal Dyspnea
DOE - ANSWER: Dyspnea on Exertion
How to diagnose CHF - ANSWER: CXR or elevated BNP
BNP - ANSWER: B type natriuretic peptide
PE of CHF - ANSWER: JVD, Rales in lungs, pedal edema
JVD - ANSWER: Jugular Vein Distention
Atrial Fibrillation - ANSWER: top of heart (atria) quivers abnormally
Atrial Fibrillation diagnosed by... - ANSWER: EKG
Meds for Atrial Fibrillation - ANSWER: Coumadin (blood thinner) or Digoxin (slows
heart rate)
NSR - ANSWER: normal sinus rhythm
