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Medical Scribe > Review Questions > Flashcards

Review Questions Flashcards

1
Q

What does HIPAA stand for?

A

Health Insurance Portability

and Accountability Act,

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2
Q

What does PHI stand for ?

A

protected health information and it refers to ANY
type of information that can be directly or indirectly tied to a

particular patient or visit:

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3
Q

T/F : It’s okay to email yourself a patient’s chart for HPI practice as
long as you delete it within 48 hours.

A

F

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4
Q

Fill in the blanks for ED Flow:

Walk –in →_______→ Bed → Physician Assessment →Lab/Rad/Meds → Results → MDM → Diagnosis → Consults →_________

A

1) Triage

2) Disposition: 1. Discharge 2. Admit 3. Transfer 4. AMA 5. Death

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5
Q

What are the 4 types of histories?

A

Medical Hx, Surgical Hx, Family Hx, Social Hx

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6
Q

The HPI and ROS are what type of information (subjective or objective)?

A

Subjective

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7
Q

The Physical Exam is what type of information (subjective or objective)?

A

Objective

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8
Q

While evaluating a patient complaining of chest pain, your physician tells you
that the heart sounds are normal. Would you document it in the HPI, ROS, or
PE?

A

PE

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9
Q
  1. Would you be contradicting yourself if you wrote “The patient has abdominal pain” in the HPI, but
    then later in the physical exam documented “The abdomen is nontender.” Why or why not?
A

No,
because the patient stating they have abdominal pain is a subjective complaint. A non-tender abdomen is an objective finding.

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10
Q

What does disposition (dispo) mean?

A

The patient’s destination after they leave the Emergency

Department.

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11
Q

What is the abbreviation for a heart attack?

A

MI- Myocardial Infarction

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12
Q

What is the abbreviation for high blood pressure?

A

HTN- Hypertension

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13
Q

What is the medical term for acid reflux?

A

GERD- Gastroesophageal Reflux Disease

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14
Q

What is the medical term for stroke?

A

CVA- Cerebrovascular Accident

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15
Q

What is the term for gallbladder removal?

A

Cholecystectomy

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16
Q

What does NKDA stand for?

A

No Known Drug Allergies

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17
Q

What is the medical term for redness?

A

Erythema

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18
Q

What is the medical term for bruising?

A

Ecchymosis

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19
Q

If the doctor says the exam was “benign”, what does that mean?

A

Normal- Nothing of

concern

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20
Q

What is CAD?

A

Coronary Artery Disease.

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21
Q

What other past surgical and medical histories would suggest that a patient has CAD?

A

MI, Angina, CABG, Stent,

Angioplasty

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22
Q

Does a PMHx of CVA mean the patient has CAD?

A

No

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23
Q

Does a surgical history of angioplasty mean the patient has CAD?

A

Yes

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24
Q

Explain the difference between CAD and an MI.

A

CAD is a broad term for heart disease. MI is

included in CAD. It’s an active heart attack.

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25
Q

If someone has a PMHx of A-Fib or CHF, do they also have CAD?

A

No

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26
Q

What are the “cardiac risk factors?”

A

HTN, DM, HLD, CAD, Smoking, FHx CAD < 55 y/o

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27
Q

How is CAD diagnosed?

A

By a cardiologist during a cardiac catheterization. Not done in the
ED.

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28
Q

Name two ways that an MI can be diagnosed?

A

STEMI- EKG, Non-STEMI- Troponin

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29
Q

What are some associated symptoms of an MI other than CP?

A

N/V, SOB, Diaphoresis

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30
Q

What are some associated symptoms for CHF?

A

SOB (Orthopnea, PND, DOE), pedal edema

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31
Q

What 2 studies would diagnose CHF?

A

CXR or elevated BNP

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32
Q

What is A-Fib?

A

Electrical abnormality of the heart causing the top of the heart to quiver

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33
Q

What might someone feel with A-Fib?

A

Palpitations, fast, pounding, irregular heartbeat

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34
Q

How is A-Fib diagnosed?

A

EKG

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35
Q

What could be the CC of someone with a PE?

A

Pleuritic CP or SOB

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36
Q

What are risk factors for a PE?

A

Known DVT, PMHx of DVT or PE, FHx of DVT or PE, recent

surgery, CA, Afib, immobility, pregnancy, BCP, smoking

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37
Q

What study would diagnose a PE?

A

CTA Chest/VQ Scan. D-Dimer can only rule it out

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38
Q

What part of the heart does CAD affect; Arteries, Veins, or Nerves?

A

Arteries

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39
Q

Can a CT Chest without IV contrast diagnose a PE? Why or why not?

A

No. Contrast in the

vessels(IV) helps clearly see a blockage.

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40
Q

What is a PTX?

A

Pneumothorax, “collapsed lung”

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41
Q

What is the most common cause of a PTX?

A

Trauma

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42
Q

How is a PTX diagnosed?

A

CXR

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43
Q

What social history will most COPD patients also have?

A

Smoking

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44
Q

What is the difference between an inhaler and a nebulizer for asthma?

A

An inhaler is portable
and gives a one time dose and provides a rapid release of medication. A nebulizer is a home
machine that delivers continuous treatment over a period of time.

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45
Q

What is asthma?

A

Constricting of the airway due to inflammation and muscular contraction of the
bronchioles. Also called Reactive Airway Disease

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46
Q

What physical exam finding is closely associated with asthma?

A

Wheezes/ing

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47
Q

What is PNA?

A

Pneumonia. Usually a bacterial infection (infiltrates) and inflammation inside the
lung

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48
Q

What might a person with PNA complain of?

A

Productive cough and fever

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49
Q

How is PNA diagnosed?

A

CXR

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50
Q

Name all 7 areas of the abdomen.

A

Epigastric, RUQ, LUQ, RLQ, LLQ, Suprapubic, Periumbilical

Right/ Left flank

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51
Q

What is the layman’s name for GERD?

A

“Heartburn” or Acid Reflux

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52
Q

What might someone with GERD complain of?

A

Epigastric pain “burning”

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53
Q

For older patients with GERD symptoms, what life-threatening disease may also need to be ruled
out?

A

MI

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54
Q

What does bile do? Where is it stored?

A

Bile emulsifies the fats in foods. It is stored in the

gallbladder and made in the liver

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55
Q

What is the difference between Cholelithiasis and Cholecystitis?

A

Cholelithiasis is gallstones.

Cholecystitis is acute gallbladder inflammation/infection.

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56
Q

What might be the chief complaint of a person with gallstones?

A

RUQ abdominal pain

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57
Q

What physical exam finding is closely associated with Cholecystitis?

A

Murphy’s Signs

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58
Q

How are gallstones diagnosed?

A

Abdominal Ultrasound of the RUQ

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59
Q

Name associated symptoms of appendicitis.

A

Fever, N/V, decreased appetite (anorexia) Note:

RLQ pain- gradual, constant, worse w/ movements is the CC (not associated sx)

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60
Q

How is appendicitis diagnosed?

A

CT A/P with PO contrast

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61
Q

What might a person with a SBO complain of?

A

Abd pain/bloating, vomiting, abdominal

distention, no BM’s, constipation

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62
Q

What would someone with pancreatitis c/o?

A

LUQ or epigastric abdominal pain, N/V, fever

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63
Q

How is pancreatitis diagnosed?

A

Elevated Lipase (or Amylase which is less specific)

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64
Q

Name four possible CC’s for a GI bleed pt.

A

Hematemesis, coffee ground emesis, hematochezia,

melena

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65
Q

How is a GI bleed diagnosed in the ED?

A

Guaiac positive or heme + stool, gastroccult

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66
Q

What are we worried about for someone with a GI bleed?

A

Too much blood loss, Anemia

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67
Q

What is the pre-existing condition you must have before you can get diverticulitis?

A

Diverticulosis

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68
Q

What will be the CC for someone with diverticulitis?

A

LLQ abdominal pain

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69
Q

What studies would diagnose diverticulitis?

A

CT A/P with PO contrast

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70
Q

How is an SBO diagnosed?

A

CT A/P w/ PO contrast or AAS (acute abd series) X-ray

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71
Q

What is a UTI?

A

Urinary tract infection

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72
Q

What is pyelo?

A

Pyelonephritis, Kidney infection (different and worse than a UTI), usually spread
from an UTI

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73
Q

What will be the CC of someone with a UTI?

A 
Painful urination (dysuria), frequency, burning,
hesitancy, malodorous urine
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74
Q

Where would a patient feel pain if they had pyelo?

A

Flank pain, fever and dysuria

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75
Q

How is a UTI diagnosed?

A

Urine dip or urinalysis (UA) showing white blood cells, bacteria and
nitrites

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76
Q

What might a person with kidney stones c/o?

A

Flank pain, sudden onset, radiating to groin

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77
Q

How are kidney stones diagnosed?

A

CT A/P or RBC in UA

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78
Q

What is an ectopic pregnancy?

A

Tubal pregnancy, when a fertilized egg develops outside the

uterus (usually in the fallopian tube). High risk for rupture and death.

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79
Q

How is an ectopic pregnancy diagnosed?

A

US of the pelvis

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80
Q

What is ovarian torsion?

A

Twisting of the ovarian artery, which reduces the blood flow to the
ovary. Could result in infarct of the ovary.

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81
Q

How is ovarian torsion diagnosed?

A

US Pelvis

82
Q

Name the 2 types of CVA’s (strokes).

A

Hemorrhagic CVA. Ischemic CVA. (TIA is not a type of a

stroke)

83
Q

What sx might a person with a brain bleed c/o?

A

HA- sudden (“thunderclap”) onset, worst HA of

their life, changes in speech, vision, motor (weakness), sensation (numbness), AMS

84
Q

What study would diagnose a brain bleed?

A

CT Head or Lumbar Puncture

85
Q

What sx might a person with an ischemic CVA c/o?

A

Focal Neurological Deficit: changes in
speech, changes in vision, one-sided motor changes (weakness), one-sided sensation changes
(numbness)

86
Q

How is an ischemic CVA diagnosed?

A

Clinically, potentially normal CT head

87
Q

What is a TIA?

A

Transient Ischemic Attack. Mini-stroke. Temporary loss of blood supply to the
brain

88
Q

How does a TIA differ from a CVA?

A

TIA - mini stroke, symptoms usually resolve in less than a

hour. CVA - Stroke, symptoms last longer, and potentially may not go away

89
Q

What is a common cause for seizures in children?

A

Fevers

90
Q

What is the name of the state after a seizure?

A

Post-ictal

91
Q

What are 3 symptoms of meningitis?

A

Fever, neck pain/stiffness, headache

92
Q

What study would diagnose meningitis?

A

LP- Lumbar puncture

93
Q

What are 4 important things to document for syncopal episodes?

A

How they felt before, during,

after, and how they currently feel

94
Q

Name 4 causes of altered mental status.

A

Hypoglycemia, infection, intoxication, neurological

95
Q

How is AMS different from a focal neuro deficit?

A

AMS is generalized and typically caused by
something that can affect the whole brain (drugs, low BS). FND are localized (weakness/
numbness/speech/vision) to one specific area and corresponds with damage to specific spot in the
brain

96
Q

What is a DVT?

A

Deep venous thrombosis

97
Q

What are the risk factors that cause DVT?

A

Known DVT, PMHx of DVT or PE, FHx of DVT or PE,

recent surgery, CA, Afib, immobility, pregnancy, BCP, smoking

98
Q

What are common signs of a DVT?

A

Extremity pain, swelling (atraumatic)

99
Q

What is an AAA?

A

Abdominal aortic aneurysm

100
Q

What is an aortic dissection?

A

The separation of the muscular wall from the membrane of the

artery, putting the pt at risk for aortic rupture and death

101
Q

What are 3 symptoms of cellulitis?

A

Redness, swelling, and pain to an area of the skin

102
Q

How is an abscess different from cellulitis?

A

Abscess is cellulitis with fluctuance (pus pocket)

103
Q

What procedure will be performed for every abscess?

A

Incision and drainage

104
Q

What is the main concern with an allergic reaction?

A

Anaphylaxis or respiratory failure

105
Q

What are the ONLY three symptoms of a true allergic reaction?

A

Rash, itching, swelling, SOB

due to airway swelling

106
Q

How can Diabetic Ketoacidosis (DKA) be diagnosed?

A

Arterial Blood Gas showing low pH or

Positive Serum Ketones

107
Q

What is the Emergency Physician’s main responsibility for psychiatric patients?

A

Medical

clearance

108
Q

Name three important things to document for any trauma patient.

A

LOC, head injury, neck pain,

back pain, numbness, weakness

109
Q

In your own words, describe the significance of an HPI.

A

The HPI is the story of the
symptoms and events that led to the patient’s ED visit. It includes the CC and the associated
sx

110
Q

How is the HPI different from the ROS?

A

HPI focuses is a story about the chief complaint
and its associated symptoms. ROS is a checklist of symptoms. It includes the chief
complaint, associated symptoms, and all other complaints the pt may have.

111
Q

Name five “elements” of the HPI.

A

Onset, timing, location, quality, severity, modifying

factors, associated symptoms, context

112
Q

Name eight of the body systems included in the ROS.

A

Constitutional, eyes, ENT, CV,

Resp, GI, GU, MS, skin, neuro, psych, endocrine, heme/lymph, immunological

113
Q

Can the symptoms listed in the ROS ever contradict the symptoms described in the HPI?
Why or why not?

A

No. Symptoms that are documented in the HPI also need to be documented
in the ROS.

114
Q

What do you need to remember to document in the HPI and ROS for any patient that is
unconscious or incapable of providing information?

A

“HPI/ROS limited by…”

115
Q

Identify the error in this sentence from an example HPI: “Patient states the CP has been
intermittent since Thursday.”

A

We do not document days of the week in the HPI. Instead, we

would count back the number of days and document this numerically.

116
Q

Why is it important to remember to document if the patient has had similar symptoms in
the past?

A

Because it is less likely that their current symptoms are life threatening if they have
survived similar symptoms in the past.

117
Q

Name one detail that is important to document if the patient has been evaluated in the
past for a similar complaint.

A

What symptoms prompted the prior evaluation? How long ago
did the prior evaluation occur? Who did they see? (Name and specialty) What treatment did
they receive? Did it help What diagnosis was given? Any prior test results?

118
Q

What should you focus on when writing an HPI (choose one).

a) Capturing everything that is said by the patient
b) Documenting the answers to every question asked by the doctor

A

b) Documenting the answers to every question asked by the doctor

119
Q

Which is the first item in the formula for writing an HPI?

a) Pertinent negatives
b) Timing, quality, and location
c) Chief complaint and onset
d) Associated symptoms

A

c) Chief complaint and onset

120
Q

What does MOI stand for in a Trauma HPI?

A

Mechanism of Injury

121
Q

True or False: In the ROS, you should document “All other systems negative except as marked”
for every patient.

A

F

122
Q

Based on your knowledge from Day 2, why should you always pay special attention to the
complaints of Chest Pain and SOB?

A

Direct concern for MI

123
Q

Name three past surgical histories that indicate that the patient has a history of CAD.

A

Angioplasty, CABG, stents

124
Q

What is the difference between a cardiac stress test and a cardiac catheterization?

A

Cardiac
catheterization - insertion of a catheter with injection of dye into the coronary artery, used to
diagnose CAD. Stress test - measures the heart’s ability to respond to physical stress to determine if
there is adequate blood flow to your heart during increasing levels of activity. There are two different
types of stress tests. Exercise (treadmill) stress test. Nuclear stress test is for patients with a
medical problem (e.g. arthritis) that prevents you from exercising. They use a medication to stresses
the heart (mimicking exercise)

125
Q

What are the risk factors for an MI?

A

CAD, HTN, DM, hyperlipidemia, smoking, FHx of CAD < 55

y/o

126
Q

What are the risk factors for a PE?

A

Known DVT, PMHx of DVT or PE, FHx of DVT or PE, recent

surgery, CA, Afib, immobility, pregnancy, BCP, smoking

127
Q

What are the risk factors for a CVA?

A

HTN, HLD, DM, hx TIA/CVA, Smoking, FHx CVA, AFIB

128
Q

Do any patient complaints belong in the physical exam?

A

No

129
Q

If a patient says their abdomen feels very painful, can you automatically document
“abdominal tenderness” in the physical exam? Why or why not?

A

No. Subjective vs Objective

130
Q

Which of these two physical exam findings could a physician appreciate without
auscultating the patient’s lungs:
A. No respiratory distress
B. No rales

A

A. No respiratory distress

131
Q

What does PERRL stand for?

A

Pupils are equal round and reactive to light

132
Q
  1. What does AT/NC mean?
A

Atraumatic/Normocephalic

133
Q

What does NAD stand for?

A

No acute distress/disease

134
Q
  1. If a patient has pale conjunctiva, what does that indicate?
A

Anemia

135
Q

What is scleral icterus, and what does it indicate?

A

Yellowing of the eyes, indicates

liver failure

136
Q

In which body system would you document “TM erythema and bulging”?

A

Ears

137
Q

What is the medical term for a nostril?

A

Naris (both nostrils is nares)

138
Q

To describe a “runny nose” would the doctor use the word “epistaxis” or
“rhinorrhea”?

A

Rhinorrhea

139
Q

What would dry mucous membranes indicate?

A

Dehydration

140
Q

Why is midline bony tenderness “worse” than paraspinal tenderness?

A

Bony
tenderness (aka vertebral point tenderness) points towards a spinal fracture and
therefore concern for spinal cord injury. Paraspinal tenderness points toward a muscle
sprain or strain

141
Q

Name an instrument a physician may use to closely investigate the eyes?

A

Slit lamp, wood lamp, Opthalmoscope (aka fundoscopic exam)

142
Q
  1. If you saw “RRR” written in the cardiac exam, what do you think it might mean?
    (Hint: It is a normal cardiac finding)
A

Regular Rate and Rhythm

143
Q

Name the rhythm that the physician would hear if the patient was in Afib.

A

Irregularly

irregular rhythm

144
Q

If the physician checks the pulse on the right wrist and says “The pulses are fine”,
what would you document in the physical exam:
a) Wrist pulse 5/5, right
b) Radial pulse OK
c) Right wrist pulse is fine
d) Right radial pulse is 2+

A

d) Right radial pulse is 2+

145
Q

Name two “Peritoneal signs” in the abdominal exam?

A

Name two “Peritoneal signs” in the abdominal exam? Guarding,

146
Q

What abdominal exam sign is indicative of Cholecystitis?

A

Murphy’s Sign

147
Q
  1. 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?
A

McBurney’s point

tenderness

148
Q

Which of these findings is NOT a peritoneal sign:

Guarding, Rebound, Tenderness, Rigidity

A

Tenderness,

149
Q

What would a “Guaiac positive” stool sample diagnose?

A

GI Bleed

150
Q
  1. What phrase do you have to document in the GU exam for every female
    pelvic exam performed by a male physician?
A

Female Chaperone present

151
Q

What is bony tenderness a sign of?

A

Bone deformity, fracture, or injury

152
Q

What is CVA tenderness?

A 
Flank tenderness (costovertebral angle
tenderness). Tenderness over the kidney(s)
153
Q

What is fluctuance a sign of?

A

Abscess

154
Q

What is the difference between a laceration and abrasion?

A

Laceration –

incision in the skin that typically need sutures. Abrasion- scrape of the skin

155
Q

What procedure is associated with a laceration, but not an abrasion?

A

Laceration Repair, Sutures

156
Q

What does A&Ox3 mean?

A

Alert and oriented to person, place, time

157
Q

What section of the neurological exam would you document “Normal
Finger-Nose-Finger test” and “Normal Heel-to-Shin”?

A

Cerebellar/ Coordination

158
Q

What does DTR stand for?

A

Deep tendon reflex

159
Q

Point to the general area of your body that Cranial Nerves (CN) control.

A

Face

160
Q
  1. In the neurological exam, what does “Normal gait” mean?
A

Walking normally

161
Q

In the psychiatric exam, what do SI and HI stand for?

A

Suicidal and Homicidal

ideations

162
Q

Is the Glascow Coma Scale (GCS) associated with Trauma pts or Medical
patients?

A

Trauma

163
Q

Would you document “RUE strength 3/5” under the “Neurological” or
“Extremities” section of the exam?

A

“Neurological”

164
Q

What would you guess “TTP” means? (e.g. “TTP in the RUQ”)

A

Tender to

palpation

165
Q

A mother states her child has been extremely tired and drowsy recently; based
on that, can you document “Lethargic” in the child’s physical exam?

A

No!

166
Q

Spell the medical term for “Hives” (allergic reaction rash)

A

Urticaria

167
Q

What is the medical term for “Swollen lymph nodes?”

A

Lymphadenopathy

168
Q

If you document “There is right pronator drift” in the neurological exam, can you
also document “No focal neurological deficits”?

A

No, contradiction

169
Q

If you documented “NAD” in the constitutional section, would you be
contradicting yourself if you wrote “There is mild respiratory distress” in the
pulmonary exam?

A

Yes

170
Q
  1. What lab order contains the “H&H” (hemoglobin and hematocrit)?
A

CBC- Complete Blood Count

171
Q

What is the difference between a BMP and a CMP?

A

BMP- Basic metabolic panel. Contains
electrolytes, kidney function, and glucose levels. CMP- comprehensive metabolic panel. BMP in
addition to LFTs (liver function tests)

172
Q

What part of the CBC does a “Differential” further characterize, RBC or WBC?

A

WBC?

173
Q

What does Creatinine test?

A

Renal function

174
Q

Is a high potassium level called “hyperkalemia” or “hypernatremia”?

A

“hyperkalemia”

175
Q

What body organ do “LFT’s” investigate?

A

Liver

176
Q

Would “Aspartate Transaminase” be documented as “AST” or “ALT”?

A

AST

177
Q

Which cardiac enzyme is more specific to heart damage, Troponin or CK-MB?

A

Troponin

178
Q

What does a negative D-Dimer mean?

A

No evidence of a Pulmonary Embolism

179
Q

What does a positive D-Dimer mean?

A

Possible PE, must order a CTA Chest or VQ Scan

180
Q

What does an elevated BNP diagnose?

A

Congestive Heart Failure

181
Q

Does the blood sample for an ABG come from a vein or an artery?

A

Artery

182
Q

Name two parts of the “Cardiac Order Set.”

A

CBC, BMP, (CK, CKMB, MYO, TROP), EKG, CXR

183
Q

What procedure must first be performed before CSF can be obtained?

A

Lumbar Puncture

184
Q

What do “Coag” lab tests examine?

A

Blood coagulation (how fast the blood clots) / Coumadin levels

185
Q

Name one of the three “Coag” lab tests.

A

PT, PTT, INR

186
Q

What does Lipase diagnose?

A

Pancreatitis

187
Q

What do both “CRP” and “ESR” test for?

A

Inflammation. CRP- C-Reactive Protein. ESR- Erythrocyte

Sedimentation Rate

188
Q

Will culture’s ever result during a patient’s ED visit?

A

No

189
Q

What is the difference between a Urine Dip and a Urine Micro.

A

Urine Dip- done bedside and detects leuks,

nitrite, glucose, blood. Urine Micro- in lab and detects WBC, RBC, bacteria

190
Q

Name one of three labs that are particularly important to track for efficiency.

A

Troponin, Creatinine, D-Dimer

191
Q

What type of body structures are XR’s best suited to examine?

A

Bones

192
Q

Do emergency physicians interpret XR’s or CT’s?

A

XR’s

193
Q

What is the difference between a CTA and a CT?

A

CTA - CT angiogram looks at the arteries

(uses IV contrast). CT - no IV contrast but may or may not use PO contrast

194
Q

What does an US of the RUQ rule out or diagnose?

A

Cholelithiasis, cholecystitis, Gallbladder wall

thickening, bile sludge, bile duct obstruction

195
Q

Name one type of Orthopedic Procedure that may be performed by the EP.

A

Splinting, joint

reduction, arthrocentesis

196
Q

What does I&D stand for?

A

Incision and Drainage

197
Q

Name two procedures that qualify the patient for critical care.

A

Cardioversion, central line

placement, endotracheal intubation, chest tube placement

198
Q

What does LAD stand for as an EKG abbreviation?

A

Left Axis Deviation

199
Q

Name two diagnoses that would qualify a patient for critical care time.

A

AFIB with RVR, CVA, MI,

SEPSIS, DKA, CPR, Severe hypotension/hypertension, Severe anemia, PTX, PE, Overdose

200
Q

When might an ER doctor obtain a Physician Consult?

A

Regarding admission, advice over

treatment plan, inform primary physician of results, etc.

Medical Scribe (9 decks)

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