Medical Scribe America Final Exam,final review and final Study Guide + Scribe America Ou, Exams of Nursing

Download Medical Scribe America Final Exam,final review and final Study Guide + Scribe America Ou and more Exams Nursing in PDF only on Docsity! Medical Scribe America Final Exam,final review and final Study Guide + Scribe America Outpatient Final Exam Scribe America OP Final Exam Questions and Answers (Graded A) * What medical term describes the surgical removal of the gallbladder? - ANSWER- cholecystectomy What does "PHI" stand for? Expand the abbreviation. - ANSWER-Protected Health Information T/F. Sharing information about a case with family is allowed, as long as you are scribing with the physician assigned to the case. - ANSWER-False ** A patient underwent brain surgery to treat bleeding in the brain from a stroke. What PSHx would you record into the chart? - ANSWER-craniotomy A patient's PCP is on vacation. The patient is scheduled to see the NP who is covering for the PCP during this time. The patient has never been seen by the NP before. Is this patient considered a new patient or an established patient? - ANSWER-Established A patient is diagnosed with back strain caused by heavy lifting. As part of the treatment, the physician discusses 4-5 different back stretching exercises that the patient can perform every morning and before doing any heavy lifting. The discussion only takes 10 minutes of a 15 minute Established Patient visit. Would your physician be able to bill counseling time on this patient? - ANSWER-Yes What medical term would best describe "the likely course or outcome of a disease"? - ANSWER-Prognosis Which section of the chart should you document when you hear the following cue "what medical problems do you have"? - ANSWER-PHx You are writing an HPI for a patient who presented for hyperlipidemia management. In the middle of the visit, your patient also reports having recently experienced urinary symptoms. Which HPI structure would be the best to use in this scenario? - ANSWER- Multiple complaints structure Which of the following is NOT a purpose of HITECH? - ANSWER-- To require patient accountability in paying for their health care visit - To require government accountability on health insurance plans available in the market place -To require equal access, opportunity, and affordability for health insurance plans by screening patient health information A patient states that he has been having abdominal pain for the last three days, and it varies between mild and severe. Which of the following would best describe the Timing? - ANSWER-waxing and waning The patient reports a tenderness in their right upper abdomen that began 2 weeks ago. Based on that information, do you document RUQ tenderness under the physical exam? - ANSWER-No * What condition correctly describes "heart attack"? (Use the abbreviated form of the condition) - ANSWER-MI * An elderly male patient has a history of an enlarged prostate and has undergone surgery to treat his condition. What PSHx would you record into the chart? Use the abbreviation form. - ANSWER-TURP What medical term is used to describe the symptom of a patient's heart beating rapidly, irregularly, or forcibly? - ANSWER-palpitations * "Patient is a 56 y/o male with CRF first diagnosed 3 years ago in acute exacerbation today. He reports decreased urinary output that has progressively worsened since onset 5 days ago. Creatinine and BUN elevated and worsening compared to last visit 3 weeks ago. Patient recommended emergency dialysis today and warned that he may be at risk for death and other complications if he does not seek further urgent medical attention. Patient understands and agrees to be transferred to the ED." - ANSWER-- Age and Sex - PHx, if relevant - Diagnosis - Results - HPI ( first two sentences) - Prognosis/Plan T/F. All symptoms documented in the ROS are also documented in the HPI. - ANSWER- F What is the medical term for "open heart surgery"? HINT: expand the abbreviation. - ANSWER-Coronary Artery Bypass Graft Identify which of these PE systems contains contradictory findings: - ANSWER- Respiratory: No respiratory distress, tachypnea, lungs are clear to auscultation bilaterally If a patient signs a waiver giving you permission to capture photo of their unique rash, would you be committing a HIPAA violation by using your cellphone to capture the photo? (Select the best option.) - ANSWER-Yes because the phone is not an approved hospital device and it is not encrypted. What condition correctly describes "Narrowing of the coronary arteries limits blood supply to the heart muscle causing ischemia"? HINT: Use the abbreviation form of the condition. - ANSWER-CAD An elderly female patient has a history of brittle bone disease and is at risk for developing bone fractures. What PMHx would you record into the chart? - ANSWER- osteoporosis What medical term is used to describe the physician examining the patient by touch? - ANSWER-palpation Organize the parts of the chart in order from top (1) to bottom (7). - ANSWER-1. HPI 2. ROS 3. PHx 4. PE 5. Orders/Results 6. Assessment 7. Plan What ROS system would include dysphagia, the medical term for difficult or painful swallowing? - ANSWER-ENT T/F. The ROS does not contain the CC and its associated symptoms because they are already listed in the HPI. - ANSWER-F (bc anything in hpi will be in ros) 48 - ANSWER- * A patient requires a heart bypass to treat a heart attack. What PSHx would you record into the chart? (HINT: Expand the medical abbreviation.) - ANSWER-coronary artery bypass graft A female patient has been pregnant four times in the past, is currently pregnant, and has two children at home. Calculate the G, P and A, respectively. (Type your answer using the following format: "G,P,A" "#,#,#"; so for example you woud type 0,0,0 with no spaces before or after the answer) - ANSWER-5,2,2 What body system would the exam finding PERRL be documented in? - ANSWER-Eyes T/F. It is acceptable to look up your own medical information while working in the clinic. - ANSWER-F * What condition correctly describes "mini-stroke"? (Use the abbreviation form of the condition.) - ANSWER-TIA A patient requires a "balloon" to treat a heart attack. What PSHx would you record into the chart? (HINT: one word only.) - ANSWER-angioplasty Which of the following are considered to be cardiac risk factors for CP patients? (select all that apply) - ANSWER-- HTN - HLD - Family hx of CAD <55 y/o - PSHx of CABG, angioplasty, and stent - DM (can cause severe bleeding. Have to know DM for my clinic) - CAD - tobacco use What is the medical term for "slow heart rate"? (Remember, when typing your answer, do not include any spaces before or after the term/phrase) - ANSWER-bradycaridia What medical term can be used to describe "having multiple chronic conditions"? - ANSWER-comorbidities A patient requires partial removal of the lung to treat lung cancer. What PSHx would you record into the chart? (HINT: two words) - ANSWER-partial lobectomy What can scribes in the clinic do to help accomplish MACRA and MIPS goals? - ANSWER-- Document quality measures that are met by the physician during the visit. - Prompt the provider to perform a quality measure. - Use a trackingsheet to keep a track of patients that meet criteria for quality measures. Determine which structure best fits the following Assessment. "Patient is a 34 y/o female with Acute Pharyngitis. Post nasal drip on exam with no visible signs of tonsilar exudate. Rapid strep negative." - ANSWER-Brief summary You see the physician check the patient's pulses in four places; the right wrist, the top of the right foot, the back of the right foot and the left neck. The doctor states "The pulses are fine". Match the location with the appropriate pulse that you would document in the physical exam? - ANSWER-- wrist 2+ radial pulse - top of foot 2+ DP pulse - neck 2+ carotid pulse - back of foot 2+ PT pulse What condition correctly describes "A blood clot in the extremities"? (HINT: Use the abbreviation form of the condition) - ANSWER-DVT 1) ICD code - MI - CRF - Impaired vision - CAD * What condition correctly describes "A bacterial lung infection"? (HINT: Use the abbreviation form of the condition.) - ANSWER-PNA A female patient underwent surgery to have her uterus removed. What PSHx would you record into the chart? - ANSWER-Hysterectomy T/F. The physician asks Scribe Sally to hold a patient's arm down so that she can finish suturing the patient. Sally is allowed to help because she is not interfering with the procedure. - ANSWER-F 88 - ANSWER- What is the medical term for difficulty breathing? - ANSWER-Dyspnea What ROS system would include menorrhagia, the medical term for "abnormally heavy or prolonged vaginal bleeding"? - ANSWER-Genitourinary Which of the following information should you be including in the plan section when documenting? (Select all that apply.) - ANSWER-- Prescription for medication - Prescription for diagnostic study (referral) - Follow up with PCP - Follow up with specialist - Lifestyle recommendations - Preventative care instructions ** What surgical procedure should be performed to diagnose CAD? - ANSWER-Cardiac catheterization Can you document both "Clear breath sounds bilaterally" and "rhonchi in the right base"? Why or why not? - ANSWER-No, because they contradict each other Murphy's sign is examined in which organ system? - ANSWER-Abdomen A positive straight-leg-raise may indicate herniated discs. Which organ system should this PE finding be documented in - ANSWER-back Identify which of these selections contain contradictory physical exam findings. - ANSWER-Eyes: PERRL, pupils non-reactive with anisocoria. Neuro: Cranial nerves grossly intact. When should the word "lethargy" be documented on the chart? - ANSWER-Only when the physician explicitly tells you to do so Why might it be important to document the presence of tears for pediatric or adult patients? - ANSWER-Indicates that the patient is hydrated 11 Your physician tells you the patient has bibasilar crackles on exam. In which organ system would you document this physical exam finding? - ANSWER-Respiratory Name the section based on the following clues: "This subjective section (from the patient's perspective) is where you document the story of the chief complaint and what brought the patient to see the doctor." (Expand the abbreviation.) - ANSWER-History of Present Illness Scribe america final -What are the 5 vital signs? heart rate, blood pressure, respiratory rate, temperature, oxygen saturation -The HPI and ROS are what type of information? Subjective -The physical exam is what type of information? objective -What is the difference between HPI and ROS? HPI focuses on the details related to their chief complaint. ROS is a head to toe checklist of symptoms, which includes the chief complaint, associated symptom all other complaints the patient might have -What does disposition (dispo) mean? The patients destination after they leave the Emergency Department -What is the abbreviation for a heart attack? MI - Myocardial Infarction -What is the abbreviation for high blood pressure? HTN- Hypertension -What is the medical term for acid reflux? GERD - Gastroesophageal Reflux Disease -What is the medical term for stroke? 12 CVA- cerebrovascular accident -what is the term for gallbladder removal? Cholecystectomy 15 Irregularly irregular rhythm -If the physician checks the pulse on the right wrist and says "the pulse are fine", what would you document in the physical exam? right radial pulse is 2+ -Name two "peritoneal signs" in the abdominal exam? guarding, rebound, tenderness, rigidity -What abdominal sign is indicative of cholecystitis murphy's sign -If the doctor takes 1 finger and presses in a specific spot in the RLQ, what is the name of the finding they are investigating? McBurney's point tenderness -what would a "guaiac positive" stool sample diagnose? GI bleed -What is bony tenderness a sign of? bone deformity, fracture, or injury -What is CVA tenderness? flank tenderness. tenderness over the kidney(s) -What is fluctuance a sign of? abscess -What is the difference between a laceration and abrasion? laceration- incision in the skin that typically need cultures. abrasion- scrape of the skin -what procedure is associated with a laceration, but not an abrasion? laceration repair, sutures -What does DTR stand for? 16 deep tendon reflex -area of the body that cranial nerves control face --in the neurological exam, what does "normal gait" mean? walking normally -In the psychiatric exam, what do SI and HI stand for? Suicidal and Homicidal ideations -What would you guess "TTP" means? Tenderness to palpation -spell the medical term for "hives" urticaria -what is the medical term for "swollen lymph nodes"? lymphadenopathy -CBC Complete Blood Count -CBC contains WBC - high -infections Hgb (Hemoglobin) - low - anemia Hct (hematocrit) - low - anemia Put (platelets) -low - prone to bleeding -Test to identify liver damage AST, ALT, Alk Phos - must rule of PE? D-Dimer 17 -What test is specific to heart damage? Trop - Troponin -three key labs for efficiency d-dimer troponin creatinine (from the bmp) -What rules our meningitis? lumbar puncture -NSR Normal Sinus Rhythm -SB Sinus Bradycardia -St Sinus Tachyardia -A Fib Atrial Fibrillation -A flutter Atrial Flutter -Paced Pacemaker is functioning --SVT Supraventricular Tachycardia -PVC 20 CBC, BMP, (CK, CKMB, MYO, TROP), EKG, CXR -What procedure is performed before CSF can be obtained? Lumbar puncture -What doe "Coag" lab test examine? Blood coagulation (how fast the blood clots)/ coumadin levels -Name one of the three "Coag" lab test. PT, PTT, INR -What does Lipase diagnose? Pancreatitis -What do both "CRP" and "ESR" test for? Inflammation -Will cultures ever result during a patients ED visit? No -What is the difference between a Urine Dip and a Urine Micro. Urine dip- done bedside and detects leuks, nitrite, glucose, blood. Urine Micro- in lab and detects WBC, RBC, bacteria -Name one of three labs that are particularly important to track for efficiency? Troponin, Creatinine, D-Dimer -what type of body structures are XR's best suited to examine? Bones -What is the difference between a CTA and a CT? CTA- CT angiogram looks at the arteries (uses IV contrast), CT - no IV Contrast but may or may not use PO contrast -What does an US of the RUQ rule out or diagnose? Cholelithiasis, Cholecysititis, gallbladder wall thickening, bile sludge, bile duct obstruction -Name one type of Orthopedic Procedure that may be performed by the EP? Splinting, joint, reduction, arthrocentesis 21 -What does I&D stand for> Incision and Drainage -Name two procedures that qualify the patient for Critical Care Cardioversion, central line placement, endotracheal intubation, chest tube placement -What does LAD stand for as EKG abbreviation? Left Axis Deviation -Name two diagnoses that would qualify a patient for critical care time. Afib with RVR, CVA, MI, Sepesis, DKA, CPR, Severe hypotension/hpertension, sever anemia, PTX, PE, Overdose AAA - ANSWER-Abdominal Aortic Aneurysm A Fib - ANSWER-Atrial Fibrillation Abd - ANSWER-Abdomen, Abdominal Abx - ANSWER-Antibiotics AMA - ANSWER-Against Medical Advice AMS - ANSWER-Altered Mental Status ASA - ANSWER-Acetylsalicylic Acid (Aspirin) BID - ANSWER-Twice Daily Bilat LE - ANSWER-Bilateral Lower Extremities BM - ANSWER-Bowel Movement BP - ANSWER-Blood Pressure CA - ANSWER-Cancer, Carcinoma Scribe America Final Exam Review Graded A+ 22 CABG - ANSWER-Coronary Artery Bypass Graft, "open heart surgery" CAD - ANSWER-Coronary Artery Disease, "heart disease" CT or CAT - ANSWER-Computerized Assisted Tomography CHF - ANSWER-Congestive Heart Failure COPD - ANSWER-Chronic Obstructive Pulmonary Disease CP - ANSWER-Chest Pain CPR - ANSWER-Cardiopulmonary Resuscitation C-section - ANSWER-Caesarean Section 25 NKDA - ANSWER-No Known Drug Allergies Nml -or- nl - ANSWER-Normal NSAID - ANSWER-Non-Steroidal Anti-Inflammatory Drug NSR - ANSWER-Normal Sinus Rhythm NTG - ANSWER-Nitroglycerin N/V/D - ANSWER-Nausea/Vomiting/Diarrhea O2 Sat - ANSWER-Oxygen Saturation (a.k.a. SaO2) OD - ANSWER-Overdose PCP - ANSWER-Primary Care Physician (a.k.a. PMD) PE - ANSWER-Pulmonary Embolism -or- Physical Exam PERRL - ANSWER-Pupils are equal, round, and reactive to light PO - ANSWER-Per Os (by mouth) prn - ANSWER-As needed pt - ANSWER-patient PTA - ANSWER-Prior To Arrival PUD - ANSWER-Peptic Ulcer Disease qd - ANSWER-Every Day qh - ANSWER-Every Hour qhs - ANSWER-At Every Bedtime q2h - ANSWER-Every 2 Hours QID - ANSWER-Four Times a Day RLE - ANSWER-Right Lower Extremity RLQ - ANSWER-Right Lower Quadrant 26 ROM - ANSWER-Range of Motion ROS - ANSWER-Review of Systems RUE - ANSWER-Right Upper Extremity RUQ - ANSWER-Right Upper Quadrant Rx - ANSWER-Prescription r/o - ANSWER-Rule Out SOB - ANSWER-Shortness of Breath s/p - ANSWER-Status Post (after) Sx - ANSWER-Symptoms TIA - ANSWER-Transient Ischemic Attack TID - ANSWER-Three Times a Day TM - ANSWER-Tympanic Membrane T-Spine - ANSWER-Thoracic Spine Tx - ANSWER-Treatment UA - ANSWER-Urinalysis URI - ANSWER-Upper Respiratory Infection US - ANSWER-Ultrasound UTD - ANSWER-Up To Date UTI - ANSWER-Urinary Tract Infection WNL - ANSWER-Within Normal Limits AKA - ANSWER-Above The Knee Amputation SBO - ANSWER-Small Bowel Obstruction h/o - ANSWER-history of 27 DFP - ANSWER-Dorsal Fetal Pulse PCN - ANSWER-Penicillin LAD - ANSWER-Left Axis Deviation SVT - ANSWER-Super Ventricular Tachycardia IV - ANSWER-Intravenous IVP - ANSWER-Intravenous Push IVPB - ANSWER-Intravenous Piggy-Back IM - ANSWER-Intramuscular SQ - ANSWER-Subcutaneous PR - ANSWER-Per Rectum SL - ANSWER-Sub-lingual gtt - ANSWER-Drops Drip - ANSWER-Intravenous Drip Neb - ANSWER-Inhaled Nebulizer Patch - ANSWER-Transdermal These 2 lab test,which are part of the 7 basic chemistries, will be high in someone with renal failure. - ANSWER-Urea and creatinine The "H&H" comes back with this lab test. If low it would indicate the patient is anemic. - ANSWER-Hemoglobin and hematocrit. hemoglobin would be low if the patient is anemic. This lab test will be high in patient with pancreatitis. - ANSWER-Lipase This lab test is used to help physicians rule out PE and DVT. - ANSWER-D-dimer This lab test will be elevated in patients with CHF. - ANSWER-BNP This abbreviation is used to describe a heart attack. - ANSWER-MI This abbreviation is used to describe diabetes. - ANSWER-DM 30 Emphysema/Chronic Bronchitis - ANSWER-Chronic Obstructive Pulmonary Disease (COPD) Blood clot in lung - ANSWER-Pulmonary Embolism (PE) Pneumonia - ANSWER-Pneumonia (PNA) Reflux - ANSWER-Gastroesophageal Reflux Disease (GERD) Ulcer - ANSWER-Gastric Ulcer or Peptic Ulcer Disease Pancreatitis - ANSWER-Pancreatitis Hepatitis - ANSWER-Hepatitis A, Hepatitis B, or Hepatitis C Diverticulitis - ANSWER-Diverticulitis Crohn's/UC - ANSWER-Crohn's Disease or Ulcerative Colitis Irritable bowel - ANSWER-Irritable Bowel Syndrome (IBS) Bladder infection - ANSWER-Urinary Tract Infection (UTI) Kidney infection - ANSWER-Pyelonephritis (Pyelo) Kidney stones - ANSWER-Renal calculi "I'm on dialysis" - ANSWER-Chronic Renal Failure (CRF) on dialysis Enlarged prostate - ANSWER-Benign Prostate Hypertrophy (BPH) Stroke - ANSWER-Cerebrovascular Accident (CVA) Mini-stroke - ANSWER-Transient Ischemic Attack (TIA) Seizures - ANSWER-Seizure disorder/Epilepsy Brain bleed - ANSWER-Hemorrhagic CVA Bipolar - ANSWER-Bipolar disorder Schizophrenia - ANSWER-Schizophrenia "I drink a lot" - ANSWER-Alcoholism or EtOH abuse 31 "Blood clot in my leg" - ANSWER-Lower Extremity Deep Vein Thrombosis "Bulge in my aorta" - ANSWER-Abdominal Aortic Aneurysm (AAA) "Bad blood flow in my legs" - ANSWER-Peripheral Vascular Disease (PVD) Low back pain - ANSWER-Chronic Low Back Pain Bulging/herniated disc - ANSWER-Degenerative Disc Disease (DDD) Arthritis - ANSWER-Usually Osteoarthritis (OA) sometimes Rheumatoid Arthritis (RA) Join pain (chronic) - ANSWER-Degenerative Joint Disease (DJD) Weak/fragile bones - ANSWER-Osteoporosis Cancer - ANSWER-Cancer or Carcinoma (CA) Spread to my... - ANSWER-With metastases to the... Chemo - ANSWER-Chemotherapy Radiation - ANSWER-Radiation therapy They cut it out - ANSWER-Status-post surgical resection It's gone - ANSWER-In remission Tonsils removed - ANSWER-Tonsillectomy Adenoids removed - ANSWER-Adenoidectomy Ear tubes - ANSWER-Pressure Equalizer (P.E.) Tubes Heart bypass - ANSWER-Coronary Artery Bypass Graft (CABG) --> PMHx CAD Stents - ANSWER-Coronary Stents --> PMHx CAD Heart cath - ANSWER-Cardiac catheterization Balloon - ANSWER-Angioplasty --> PMHx CAD Valve surgery - ANSWER-Valve repair or replacement (Bovine vs. Mechanical) Pacer - ANSWER-Pacemaker 32 Defibrillator - ANSWER-Automatic Implanted Cardiac Defibrillator (AICD) Surgery for Afib - ANSWER-Afib s/p cardiac ablation Breast removal - ANSWER-Mastectomy hole in my neck - ANSWER-Tracheostomy (commonly called a "trach") Part of my lung removed - ANSWER-Partial lobectomy Appendix removed - ANSWER-Appendectomy Gallbladder removed - ANSWER-Cholecystectomy Hernia repair - ANSWER-Herniorrhaphy Part of my colon removed - ANSWER-Partial colectomy Bag to collect stool - ANSWER-Colostomy Spleen removed - ANSWER-Splenectomy Stomach stapled - ANSWER-Gastric bypass Uterus removed - ANSWER-Hysterectomy Ovary removed - ANSWER-Oophorectomy Ovary and fallopian tubes removed - ANSWER-Salpingo-oophorectomy Tubes tied - ANSWER-Tubal ligation (female) or Vasectomy (male) Prostate removed - ANSWER-Prostatectomy (most often Trans-Urethral Removal of the Prostate, or TURP) Neck artery cleaned - ANSWER-Carotid Endarterectomy Brain surgery - ANSWER-Craniotomy Shunt - ANSWER-Ventriculoperitoneal (VP) Shunt Dialysis fistula - ANSWER-AV (arteriovenous) Fistula Dialysis graft - ANSWER-AV Graft PICC Line - ANSWER-Peripherally Inserted Central Catheter (PICC) 2 What do you do if someone asks for your help with a patient? - ANSWER-We cannot touch patients. Find a nurse, a tech, etc. who can help. If someone comes in complaining about dyspnea, what are the 2 major diseases to worry about? - ANSWER-PE and PNA What is diagnosed when elevated Troponin is present? - ANSWER-MI What is likely the diagnosis of lower abdomen pain? - ANSWER-Appendicitis, ectopic pregnancy What are all of the possible elements of an HPI? - ANSWER-Location, quality, timing, duration, modifying factors, associated signs and symptoms, context, severity final Study Guide Quizzes 1. What does the abbreviation COPD stand for? * Chronic obstructive pulmonary disease. Correct! 2. What does the abbreviation AAA stand for? * Abdominal aortic aneurysm 3. What does the abbreviation HA stand for? * Headache. Correct! 4. What does the abbreviation MOI stand for? * Mechanism of injury. 5. What does the abbreviation EtOH stand for? * Alcohol. (this is often used when describing someone who drinks, ex. Pt admits to daily EtOH consumption) 6. What does the abbreviation PERRL stand for? * Pupils equal, round, and reactive to light. 7. What does the abbreviation NTG stand for? * Nitroglycerin. (this is a medication abbreviation) 8. What does the abbreviation LAD stand for? * Left axis deviation. (this is an EKG abbreviation) 9. What does the abbreviation H&H stand for? * Hemoglobin and hematocrit (this is a lab result abbreviation) 10. What is the name of the surgery of getting your kidneys removed? * Nephrectomy. Correct! 11. What is the medical term for throat redness? * Pharyngeal erythema 12. Describe the medical disease CVA. * CVA, otherwise known as a cerebrovascular accident or stroke, is when an artery to the brain is either blocked or ruptured. This causes a lack of blood flow to the brain which thus means lack of oxygen to the brain causing sudden death of these brain cells. 13. What study would you use to diagnose meningitis? * Lumbar puncture 14. What are 5 coding elements of an HPI? 3 * Correct! All eight coding elements of an HPI = onset, timing, location, associated symptoms, modifying factors, severity, quality, context 15. What study would you use to diagnosed a pneumothorax? * Chest x-ray (abbreviation = CXR) 1. What does the abbreviation DKA stand for? - Diabetic keto-acidosis 2. What does the abbreviation DNR stand for? - Do not resuscitate. Correct! 3. What does the abbreviation DOE stand for? - Dyspnea on exertion 4. What does the abbreviation DP pulse stand for? - Dorsalis pedis pulse. Make sure you know the different kinds of pulses the physicians normally document in the room and how to properly document them!!!!! (Usually they use a numeric scale, ex; 2+) 5. What does the abbreviation ASA stand for? - Aspirin. Correct! 6. What does the abbreviation LBBB stand for? - Left bundle branch block. Make sure you know your EKG abbreviations!!!! 7. What surgery would you call getting your stomach stapled? - Gastric bypass. Correct! 8. What is the medical term for fast breathing rate? - Tachypnea. Correct! 9. Provide the definition of STEMI. - You have the definition correct, but not the abbreviation. STEMI stands for ST elevation myocardial infarction. It is when a heart artery is blocked, causing death of cells. AKA ischemia and infarct. 10. How would one diagnose CHF? - The diagnostic procedure I am looking for is a Chest XR. (Elevated BNP is another accepted answer). Definitely KNOW BOTH! 11. How would one diagnosed pancreatitis? - Elevated lipase. 12. What are 3 cardiac risk factors? Correct! Those three are cardiac risk factors. Three others are hyperlipidemia, hypertension, and coronary artery disease (CAD) 13. What are 4 important things to document when a patient comes in with syncope? 4 - Correct! It is important how the pt feels before, during, after, and currently! 14. What is the abbreviation for BM? - Correct! Bowel movement. WorkBook Highlights 1. Level of Acuity (5 low to 1 high)- During Triage. Triage has 3 parts: chief complaint, vital signs, and LOA 2. Past History: PMHx, PSHx, SHx, FHx Patient Complaint HPI or ROS Past Diagnosis or Surgery Past History Physician’s Observations Physical Exam Objective Study Results/ED Re-Evaluation ED Course Where They Will Go Disposition 3. GPA Gravida, Para, Abortion (# of times of pregnancy, # of viable offspring, # of miscarriages or abortions 4. Coronary Artery Disease CAD a. Associated Medication: i. Aspirin (ASA) ii. Nitroglycerin (NTG) 5. Risk Factors of Myocardial Infarction a. CAD, HTN, HLD, DM, Smoker, FHx of CAD <55 y.o 6. Congestive Heart Failure (CHF) is Diagnosed By: a. Chest X-Ray: CXR b. Elevated BNP (B-type Natriuretic Peptide) 7. AFIB: Atrial Fibrillation a. Diagnosed by: EKG (Electocardiogam) 8. DOE (Dyspnea on Exertion) a. One main chief complaint of CHF 9. Pleural Effusion: Non-Cardiac Chest Pain Example a. Fluid collecting around the lungs causing SOB or CP Diagnosis What is it? Diagnosed By MI Heart Attack EKG (STEMI) or Elevated Troponin Non- STEMI AFIB Electrical Problem EKD CHF Congestive Heart Failure CXR or Elevated BNP CAD Major Risk Factor for MI Positive cardiac catherization (not in ED) Angina Symptom of CAD Exceptional CP with Hx of CAD 10. Pulmonary Embolism a. Etiology: A blood clot becomes lodged in the pulmonary artery and blocks blood flow to the lungs b. Diagnosed by: CTA i. CTA Chest or VQ scan ii. D-Dimer 11. Pneumonia (PNA) 7 a. Associated Symptom: Fever, Sore Throat, Headache, Myalgias 26. Deep Vein Thrombosis (DVT) a. Diagnosed by: US/ Doppler of the extremity 27. HPI Elements: 4 Elements Required Element Description Onset When did the complaint begin? Timing Constant, Intermittent, or Waxing and Waning? Location Where is the discomfort? 8 Quality Does it feel sharp, dull, aching, cramping? Severity How bad is it? Mild, mod, severe or 0-10 Modifying Factors What makes it better? What makes it worse? Associated Symptoms Do any other symptoms accompany the complaint? Context Is there anything else that’s important? 28. ROS: Review of Symptoms System Examples Constitutional Fever, Weight loss, Sweats Eyes Change in vision, eye pain, double vision Ear/Nose/Throat Ear ache, Nose bleed, Congestion, sore throat Cardiovascular Chest Pain, palpitations, leg swelling Respiratory SOB, Cough, Sputum, Wheezing Gastrointestinal Abdominal pain, N/V/D, Black or body stools Genitourinary Dysuria, Frequency, Urgency, Hematuria Musculoskeletal Joint pain, muscle pain Integumentary Rash/Itching/Abrasion/Laceration Neurological Headache, Syncope, Seizure, Numbness, Focal Weakness Psychiatric Anxiety/Depression Endocrine Polyuria/ Polydipsia Hematologic/Lymph Bleeding gums, easy bruising, swollen lymph nodes Immunologic HIV/AIDS, Splenectomy 29. Syncope: Tongue bite wound DDx: Seizure (Sz) 30. A complete physical exam requires 8 elements. 31. Head PE: Normal Exam Atraumatic/Normocephalic (AT/NC) 32. Eyes PE: Normal Exam Pupils Equal, Round, Reactive to Light (PERRL) & Extra Ocular Movements Intact (EOMI) 33. Moist Mucous Membranes a. Dry Mucous Membranes: (DMM) b. Peritonsillar Abscess (PTA) 34. Cardiovascular a. Tachycardia (>100bpm)/ Brachycardia (<60bpm) b. Irregularly Irregular Rhythm 35. Perfusion a. Pulses Equal and Symmetric, Capillary Refill less than 2 seconds i. Normal 2+ = Easily Palpable 36. Signs of Appendicitis a. Murphy’s sign and McBurney’s point tenderness 37. Muscuskeletal/Extremities a. Normal No Edema b. Abnormal Pitting Pedal Edema (Trace to 4+) 38. Skin Infection a. Fluctuance (Abscess) 39. Skin Trauma a. Ecchymyosis 40. Neurological LOC a. Alert, A&0x4 ideal/normal 9 41. Neurological a. Normal Motor and Sensation: Motor Strength 5/5 Symmetric 42. Neurological: Reflexes a. Normal 2+ 12 b. Blood Pressure (BP): Normal: 90/60 and 140/90 c. Oxygen Saturation (SaO2): Normal: 96% or above on room air d. Temperature (T): Normal: 97 to 99 degrees F. Fever is greater than 100.4 degrees F 57. Common Oxygen Routes a. Nasal Cannula (NC): a plastic tube placed into the patient’s nostrils. It typically delivers oxygen at 2 LPM, although it may be set from 1-6 liters per minute. Ex: 100% on 2L NC 58. Normal NI 59. Walk In/EMS -> Triage -> Bed -> Nurse Assessment -> H&P 60. Differential DX -> Lab, Imaging, Procedures, Meds -> Results -> Final Dx -> Disposition subjective vs objective - ANSWER-feeling vs fact pain vs tenderness - ANSWER-patients feeling vs physicians assessment benign - ANSWER-normal, nothing of concern acute vs chronic - ANSWER-new onset vs long standing baseline - ANSWER-an individuals normal state of being ausculation - ANSWER-listening to sound with a stethoscope palpation - ANSWER-act of pressing on an area (by the physician) inpatient - ANSWER-admitted to the hospital overnight outpatient - ANSWER-seen and sent home the same day chief complaint - ANSWER-main reason for the patients visit meaningful use - ANSWER-set of government mandated criteria that must be obtained for every patient medical decision making - ANSWER-physicians though process Scribes can... - ANSWER-document history, physician exam, results, procedures. access and document laboratory and radiology findings. locate and obtain PMHx, previous charts, past results. Medical Scribe America Outpatient Final Exam with Complete Solutions 13 Scribes cannot... - ANSWER-partake in any activity that may affect patient health, touch patients, handle bodily fluids, sign any charts, give verbal orders or submit electronic orders. are physician assistants and nurse practitioners considered medical providers? - ANSWER-YES T/F: The scribe can listen to a patient's heart and lungs as long as it is for learning purposes and under the supervision of the physician. - ANSWER-False 14 Lucy has been seen by Dr. Heart for the past 2 years. She is here today for a routine appointment with Dr. Heart. Is Lucy a new or established patient? - ANSWER- Established a patient made an appointment because she developed a rash a few days ago. what type of visit would this be? - ANSWER-diagnostic diagnostic visits consist of - ANSWER-new problems, new symptoms health management visits consist of - ANSWER-check-ups, management visits a patient has an appointment for management of her diabetes. what type of visit would this be? - ANSWER-health management who is the first person to speak with the patient after he/she is place in a room? - ANSWER-Nurse/MA What are the meaningful use requirements the nurse/MA will obtain? - ANSWER-Chief complaint; Vital signs (HR, BP, T, RR), Height, weight, BMI; Smoking status What does H&P abbreviate and who performs this evaluation? - ANSWER-history and physical, performed by the provider Is a differential diagnosis necessary for a health maintenance visit? - ANSWER-nope. what information will be included in the patient's plan? give 3 examples. - ANSWER-F/U for specialist, instructions for lifestyle, F/U for next routine appointment name the 8 elements of the HPI - ANSWER-Location, Quality, Severity, Context, Timing, Duration, Associated signs and symptoms, Modifying factors polydipsia - ANSWER-excessive thirst paresthesia - ANSWER-sensation of tingling or numbness anticoagulant - ANSWER-a drug that prevents blood clotting chronic illness - ANSWER-longer than 3 months if a patient has had respiratory symptoms for the past 5 weeks, are the symptoms considered chronic? - ANSWER-No Having multiple comorbidities increases the of patient care - ANSWER- complexity 17 T/F: Abbreviations are permitted in the HPI as long as they are approved medical abbreviations - ANSWER-True T/F: It is okay for scribes to misspell words because doctors do it all the time - ANSWER-False How would you document the onset of symptoms that began on Wednesday? - ANSWER-x days ago If the patient says, "It hurts when I touch it," what would you write in the HPI? - ANSWER-Symptoms worsened by palpation of the area. thyroid problem - ANSWER-hypothyroidism or hyperthyroidism it only take pills for my diabetes - ANSWER-non-insulin dependent diabetes mellitus (NIDDM) heart disease - ANSWER-Usually Coronary Artery Disease (CAD) heart attack - ANSWER-Myocardial Infarction (MI) and CAD heart failure - ANSWER-Congestive Heart Failure (CHF) irregular heartbeat - ANSWER-Atrial Fibrillation (A-Fib) Episodes of abnormally fast/racing heartbeat - ANSWER-Supraventricular Tachycardia (SVT) emphysema/chronic bronchitis - ANSWER-Chronic Obstructive Pulmonary Disease (COPD) blood clot in the lung - ANSWER-Pulmonary Embolism (PE) reflux - ANSWER-Gastroesophageal Reflux Disease (GERD) ulcer - ANSWER-Gastric Ulcer or Peptic Ulcer Disease (PUD) kidney infection - ANSWER-Pyelonephritis (Pyelo) "I'm on dialysis" means... - ANSWER-Chronic Renal Failure (CRF) on dialysis How would you document the past history for a patient who is currently pregnant, has been pregnant 3 times in the past, and has 2 kids at home? - ANSWER-G: 4, P: 2, A: 1 stroke - ANSWER-Cerebrovascular Accident (CVA) 18 minor-stroke - ANSWER-Transient Ischemic Attack (TIA) brain bleed - ANSWER-Hemorrhagic CVA "Blood clot in my leg" - ANSWER-Lower Extremity Deep Vein Thrombosis (DVT) "bulge in my aorta" - ANSWER-Abdominal Aortic Aneurysm (AAA) "bad blood flow to my legs" - ANSWER-Peripheral Vascular Disease (PVD) bulging disc - ANSWER-Herniated Disk [Note: Patient may also have Degenerative Disc Disease (DDD)] arthritis - ANSWER-Usually Osteoarthritis (OA) sometimes Rheumatoid Arthritis (RA) joint pain (chronic) - ANSWER-Degenerative Joint Disease (DJD) weak/fragile bones - ANSWER-osteoporosis A & T - ANSWER-adenoidectomy & tonsillectomy heart bypass - ANSWER-Coronary Artery Bypass Graft (CABG) --> PMHx CAD stents - ANSWER-Coronary Stents --> PMHx CAD heart cath - ANSWER-cardiac catheterization balloon - ANSWER-Angioplasty --> PMHx CAD valve surgery - ANSWER-Valve repair or replacement (Bovine vs. Mechanical) defibrillator - ANSWER-Automatic Implanted Cardiac Defibrillator (AICD) surgery for Afib - ANSWER-Afib s/p cardiac ablation breast removal - ANSWER-mastectomy hole in the neck - ANSWER-tracheostomy (trach) part of my lung removed - ANSWER-Partial lobectomy gallbladder removed - ANSWER-cholecystectomy hernia repair - ANSWER-herniorrhaphy 19 part of my colon removed - ANSWER-partial colectomy bag to collect stool - ANSWER-colostomy spleen removed - ANSWER-splenectomy stomach stapled - ANSWER-gastric bypass uterus removed - ANSWER-Hysterectomy (partial vs. total) ovary removed - ANSWER-oophorectomy Ovary and fallopian tubes removed - ANSWER-Salpingo-oophorectomy tubes tied - ANSWER-Tubal ligation (female) or Vasectomy (male) prostate removed - ANSWER-prostatectomy shunt - ANSWER-VP shunt neck artery cleaned - ANSWER-carotid endarterectomy dialysis fistula - ANSWER-AV fistula dialysis graft - ANSWER-AV graft PICC Line - ANSWER-Peripherally Inserted Central Catheter (PICC) port - ANSWER-Port-a-cath or Medi-Port clot filter - ANSWER-IVC filter leg amputated - ANSWER-Above Knee Amputation (AKA) Below Knee Amputation (BKA) joint repair - ANSWER-arthroplasty metal plates/pins - ANSWER-hardware neck fused - ANSWER-Cervical spinal fusion back fused - ANSWER-Lumbar spinal fusion At what age would a family member's cardiac disease indicate an increased risk for similar heart disease in the patient? - ANSWER-55 + y/o 22 Auscultating the heart and lungs Palpating the abdomen Palpating the patient's legs If the physician listens to the patient's chest, what is he looking for? - ANSWER-heart rate, rhythm, murmur. If the doctor palpates the patient's lower extremities, what is he looking for? - ANSWER- edema give an example of a detailed exam system that is not typically included in a basic exam - ANSWER-detailed eye exam, hearing/vision assessment, neurologicla, GYN. normal exam, constitutional (and an abnormal finding) - ANSWER-well-developed, well- nourished, no acute distress (NAD vs. Mild/moderate/severe distress) normal exam, eyes (and an abnormal finding) - ANSWER-PERRL, EOMI (EOMI vs EOM entrapment) normal exam, ENT (and an abnormal finding) - ANSWER-moist mucous membranes (normal nares vs rhinorrhea) (moist mucous membranes vs dry mucous membranes) normal exam, Neck (and an abnormal finding) - ANSWER-supple, no lymphadenopathy (supple vs cervical lymphadenopathy, swollen lymph nodes) normal exam, cardiovascular (and an abnormal finding) - ANSWER-RRR. no murmurs, rubs or gallops. Distal pulses intact. (regular rate vs tachycardia, regular rhythm vs irregularly irregular rhythm) normal exam, respiratory (and an abnormal finding) - ANSWER-no respiratory distress. clear to auscultation bilaterally. no wheezes, rales, or rhonchi. (normal respiratory rate vs tachypnea) normal exam, abdominal (and an abnormal finding) - ANSWER-soft. non-tender. no guarding, rebound, or rigidity. (soft vs rigid) normal exam, extremities (and an abnormal finding) - ANSWER-no edema, full ROM (full ROM vs decreased ROM 2º pain) normal exam, skin (and an abnormal finding) - ANSWER-warm, dry (warm vs cool or hot to the touch, dry vs diaphoretic) 23 normal exam, neurological (and an abnormal finding) - ANSWER-alert and oriented. normal speech. (alert vs somnolent) (motor strength 5/5 and symmetric vs extremity weakness) normal exam, psychiatric - ANSWER-normal affect Review, Normal Pediatric Physical Exam - ANSWER-general? playful, smiling, crying with tears, interactive head? flat fontanel ears? normal TMA neck? supple, no meningismus abdominal? soft, no crying or grimacing with palpation genital? nml external, testicles descended extremities? FROM What does PERRLA stand for and in which body system does it belong? - ANSWER- Pupils are equal round and reactive to light and accomodation, eyes If the doctor says, "positive Murphy's sign," which area of the abdomen is he palpating and which disease(s) could this indicate? - ANSWER-RUQ, cholecystitis Why is it important that the patient is producing tears if crying? - ANSWER-dehydration why is it incorrect to write A&Ox3 on an infant neurological exam? - ANSWER-they aren't able to communicate awareness of people, place, or time Name 2 signs of respiratory distress in a peds patient - ANSWER-wheezing, retractions, nasal flaring risk factors for CAD - ANSWER-HTN, HLD, DM, smoking, FHx <55 y/o cheif complaint for CAD - ANSWER-CP, worse with exertion CAD associated medications - ANSWER-ASA, NTG (anticoagulants - blood thinning medications) CAD Dx by - ANSWER-Cardiac catheterization by cardiologist A cardiologist does a cardiac cath and decides the pt is at risk of MI due to CAD. What is the least invasive procedure the cardiologist can perform? - ANSWER-Angioplasty ICD - ANSWER-international classification of diseases CPT - ANSWER-Current Procedural Terminology 24 E&M - ANSWER-Evaluation and Management LOS - ANSWER-level of service problem-focused - ANSWER-A visit, history, or exam that focuses solely on the chief complaint in-house study - ANSWER-A study (usually a lab test) that can be done in the clinic, during an appointment - typically results in a few minutes (strep throat swab, UA, blood glucose) New vs Established Patient - ANSWER-new had no care by any member of the practice within 3 years, established has been seen in the clinic within the last 3 years Alice has an orthopedic visit with Dr. Smith whose partner, Dr. Roy, saw Alice 18 months ago for a wrist sprain. Is Alice considered a new patient during her appointment with Dr. Smith? - ANSWER-No, she's established Which type of patients (new or established) typically have a longer and more detailed visit? - ANSWER-new What is the cutoff for a patient to be considered established at a particular clinic? - ANSWER-3 years What are the five E&M levels? - ANSWER-Level 1: Minimal, Level 2: Problem-focused visit, Level 3: Expanded problem-focused, Level 4: Detailed, Level 5: Comprehensive Which level of E&M do we use? - ANSWER-Level 4, this is typically more than one chronic illness Level 4 new patient numbers - ANSWER-HPI elements: 4, ROS elements: 10, PMHx: 3, PE: 9 (but 18 bullets from 9 systems), Assessment/Plan: 1 Level 4 established patient numbers - ANSWER-HPI elements: 2, ROS elements:2, PMHx: 1, PE: 2 (but 12 bullets from 2 systems), Assessment/Plan:2 T/F: Every patient whether new or established must have a complete 10-system ROS - ANSWER-No Based on what you have learned so far, how many systems need to be documented on the physical exam for a new patient? established patient? - ANSWER-new, 9. established, 2. Your provider chose a clinical impression that is unsupported by your documentation. What is the correct way to address this discrepancy? - ANSWER-Consult the provider outside of the room. 27 What are 2 classes of medications that are used to treat CHF? - ANSWER-ACE- Inhibitors, Beta-Blockers, Diuretics, Anticoagulants QD - ANSWER-once daily QOD - ANSWER-Every other day QD-AC - ANSWER-Once daily with meal Subq - ANSWER-Medication injected just under the skin (abbreviation for subcutaneous) prognosis - ANSWER-a forecast of the likely course of a disease or ailment follow-up - ANSWER-ongoing contact with healthcare providers in order to address a health concern T/F: When reviewing a previous visit, the physician is more likely to review the HPI than the assessment because the HPI is more comprehensive. - ANSWER-False T/F: A diagnosis or differential diagnosis will always be listed in the assessment - ANSWER-True What are 3 items besides the diagnosis that may be documented in the assessment? - ANSWER-Summary of the HPI, Summary of the PE, summary of the labs/imaging results, Prognosis 3 assessment structures - ANSWER-simple statement, brief summary, comprehensive summary T/F: The assessment is typically written in complete sentences - ANSWER-True Does the assessment always begin with the age and sex of the patient? - ANSWER-Yes What is the structure of a "simple statement" assessment? - ANSWER-Age and sex of patient PMHx of patient Diagnoses Name four items, besides the diagnosis, that are typically included in a comprehensive summary assessment. - ANSWER-Age and sex of patient. PMHx HPI summary PE Summary Results summary RTC (So follow-up, return to clinic) 28 T/F: The scribe should only include results that are new since the last visit. - ANSWER- true A patient visits the clinic with a chief complaint of ankle pain. An XR of the painful ankle is negative for fracture. Does the XR result belong in the assessment? Why or why not? - ANSWER-Yes, these are negative results, there is no fracture, so it rules it out. A patient with HTN visits the clinic for routine follow-up and routine blood-work. The physician tells you his diagnosis is "chronic hypertension, well-controlled." Which of the following results belong in his assessment? Normal CBC, Normal Blood Chemistry, Normal Lipid Panel, Normal BP? - ANSWER-Normal BP and the Lipid Panel, these are pertinent What four items should you include when summarizing a test result? - ANSWER-Name of the test Result of the test Why it was ordered (the differential the test is ruling out or confirming) Date of order The plan includes this information: (5) - ANSWER-Recommended treatment(s) for each diagnosis prescriptions ordered today studies or tests ordered today Follow-up with other healthcare professionals Follow-up here: when should the patient return for next appt.? T/F: Each diagnosis should be followed-up with at least one line-item in the plan. - ANSWER-True How is the plan formatted? - ANSWER-- each item should appear on a separate line - bulleted or numbered list - at least one bullet to address each diagnosis - last bullet should always be timeline for follow-up in the office The last bullet in the plan should always be ? - ANSWER-Follow up List three items you may be asked to document in the plan for a patient with a diagnosis of hypertension. - ANSWER-continue medication continue to keep BP log low sodium diet