scribe America 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? - 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? - Uncomplicated laceration of the left foot - initial encounter
What does AMS stand for? - altered mental status
What does GCS stand for? - Glasgow coma scale
What does DNR stand for? - do not resuscitate
What does AAA stand for? - abdominal aortic aneurysm
What does PE stand for in the diagnosis section of the chart? - pulmonary embolism
What does DP stand for in "DP pulse"? - dorsalis pedis
What does DVT stand for? - deep vein thrombosis
What does NTG stand for? - nitroglycerin
What does URI stand for? - upper respiratory infection
What does CHF stand for? - congestive heart failure
,What does s/p stand for? - status post
What does GERD stand for? - gastroesophageal reflux disease
What does EOMI stand for? - extraocular movements intact
What does DOE stand for? - dyspnea on exertion
What does LBBB stand for? - left bundle branch block
What does CVA stand for? - costovertebral angle
What does CSF stand for? - cerebrospinal fluid
What does PTX stand for? - pneumothorax
What does COPD stand for? - chronic obstructive pulmonary disease
What does PNA stand for? - pneumonia
What does CBC stand for? - complete blood count
What does IDDM stand for? - insulin dependent diabetes mellitus
What does TIA stand for? - 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: - 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
,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? - 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? - Uncomplicated laceration of the left foot - initial encounter
What does AMS stand for? - altered mental status
What does GCS stand for? - Glasgow coma scale
What does DNR stand for? - do not resuscitate
What does AAA stand for? - abdominal aortic aneurysm
What does PE stand for in the diagnosis section of the chart? - pulmonary embolism
What does DP stand for in "DP pulse"? - dorsalis pedis
What does DVT stand for? - deep vein thrombosis
What does NTG stand for? - nitroglycerin
What does URI stand for? - upper respiratory infection
What does CHF stand for? - congestive heart failure
,What does s/p stand for? - status post
What does GERD stand for? - gastroesophageal reflux disease
What does EOMI stand for? - extraocular movements intact
What does DOE stand for? - dyspnea on exertion
What does LBBB stand for? - left bundle branch block
What does CVA stand for? - costovertebral angle
What does CSF stand for? - cerebrospinal fluid
What does PTX stand for? - pneumothorax
What does COPD stand for? - chronic obstructive pulmonary disease
What does PNA stand for? - pneumonia
What does CBC stand for? - complete blood count
What does IDDM stand for? - insulin dependent diabetes mellitus
What does TIA stand for? - 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: - 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
