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Scribe America Final Exam > scribe america final > Flashcards

scribe america final Flashcards

1
Q

Scribes cannot

A

touch patients
write prescriptions
give orders
handle bodily fluids

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1
Q

components of HPI

A

CC,

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2
Q

Diagnostic

A

new sympotms

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3
Q

health management

A

check up

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4
Q

new paitent

A

no previous records

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5
Q

established

A

previous records

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6
Q

Clinic Flow

A

CC, History, Orders, Assessment, Check out

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7
Q

Sa02

A

Oxygen saturation

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8
Q

ROS

A

Review of systems

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9
Q

PE

A

Physical Exam

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10
Q

DDx

A

Diagnostic

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11
Q

SOAP

A

Subjective Complaints, Objective Evaluation, Assessment, Plan

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12
Q

S

A

HPI and ROS

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13
Q

O

A

PE and orders

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14
Q

PMHx

A

Past medical history

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15
Q

HTN

A

Hypertension and High blood pressure

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16
Q

HLD

A

Hyperlipidemia and High cholesterol

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17
Q

DM

A

Diabetes Mellitus

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18
Q

NIDDM

A

Non insulin dependent diabetes mellitus

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19
Q

IDDM

A

Insulin Dependent diabetes mellitus

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20
Q

CAD

A

Coronary artery disease and Heart disease

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21
Q

MI

A

Myocardial Infarction or heart attack

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22
Q

CHF

A

Congestive Heart Failure or Heart failure

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23
Q

PE

A

Pulmonary Embolism or blood clot in lung

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24
Q

PNA

A

Pneumonia or lung infection

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25
Q

GERD

A

gastroesophageal reflux disease or Reflux

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26
Q

PUD

A

Peptic ulcer disease or Ulcers

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27
Q

IBS

A

Irritable bowel syndrome or Irritable bowel

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28
Q

UTI

A

Urinary tract infection or Bladder infection

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29
Q

Pyelonephritis

A

Kidney infection

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30
Q

CKD

A

Chronic kidney disease or on dialysis

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31
Q

BPH

A

Benign Prostatic Hyperplasia

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32
Q

CVA

A

Cerebrovascular accident or stroke

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33
Q

Ischemic CVA

A

Blood clot in brain

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34
Q

Hemorrhagic CVA

A

Brain bleed

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35
Q

TIA

A

Transient Ischemic attack or mini stroke

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36
Q

DVT

A

Deep vein thrombosis or blood clot in leg

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37
Q

PVD

A

Peripheral vascular disease

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38
Q

CA

A

Caner or carcinoma

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39
Q

True allergy

A

rash itching swelling or difficulty breathing

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40
Q

ectomy

A

removal

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41
Q

AKA

A

above knee amputation

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42
Q

BKA

A

below knee amputation

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43
Q

Angioplasty

A

Balloon in my heart

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44
Q

Coronary stents

A

Stents in heart

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45
Q

FHx

A

Family history

46
Q

SHx

A

Social history

47
Q

increased risk in cardiac disease (age)

48
Q

Chronic disease

A

more than 3 months

49
Q

more than one chronic diseases

A

comorbidities

50
Q

Comorbidities are said to be

51
Q

HTN

A

obesity high sodium diet smoking and ETOH

52
Q

Systolic

A

pressure in arteries when heart contracts

53
Q

Diastolic

A

pressure in arteries when heart relaxes

54
Q

Hypotensive

A

sys less than 90
Dia less than 60

55
Q

Normal BP

A

Sys 90-120
Dia 60-80

56
Q

Prehypertensive

A

Sys 121-140
Dia 81-90

57
Q

Hypertensive

A

Sys more than 140
Dia more than 90

58
Q

Hypertension can lead to

A

CVA, CHF, CAD, MI, Renal failure, impaired vision

59
Q

HTN drugs

A

Lisinopril, Lotensin (ACE inhibitors) Norvasc CA channel blockers, DIurectics, ARBs

60
Q

Type 1 DM

A

treated with insulin, diagnosed early in life

61
Q

Type 2 DM

A

common, high glucose levels, oral meds

62
Q

DM can lead to what else

A

Retinopathy, CAD, CHF, PVD, Renal failure, Neuropathy

63
Q

DM injector drugs

A

Humalog, Lantus, Sliding scale

64
Q

DM oral drugs

A

Metformin, Glyburide

65
Q

HLD

A

Obesity, high fat diet, ETOH, physical inactivity

66
Q

LDL

67
Q

HDL

68
Q

HLD can lead to what

A

CVA, CAD, pancreas

69
Q

CAD

A

risk factors are HLD, DM, HTN

70
Q

Management of CAD

A

cardiac catheterization, angiopasty, coronary stent, CABG

71
Q

HPI elements

A

Onset, timing, location, quality, severity, modifying factors, Associated sx, context

72
Q

Palpation

73
Q

inspection

74
Q

auscultation

75
Q

RUQ

A

Right upper quadrant

76
Q

Belongs in PE

A

Saw, Heard, Felt, Smelled

77
Q

RLE

A

Right lower extremities

78
Q

Anterior

79
Q

Posterior

80
Q

Proximal

A

near point of attachment

81
Q

Distal

A

far point of attachment

82
Q

Medial

A

near midline

83
Q

Lateral

A

far from midline

84
Q

superior

85
Q

inferior

86
Q

diffuse

A

widespread

87
Q

focal

88
Q

Bradycardic

89
Q

Tachycardic

A

high pulse

90
Q

Hypotensive

91
Q

Hypertensive

92
Q

bradypneic

93
Q

RR

A

Respiratory rate

94
Q

Tachypneic

95
Q

Febrile

96
Q

Constitutional

A

general appearance of patient without touching

97
Q

Nose no discharge

A

yellow or clear discharge

98
Q

Normal nasal mucosa

A

Boggy turbinates

99
Q

No active bleeding

A

site bleeding identified

100
Q

appendicitis

A

positive McBurneys point RLQ

101
Q

cholecysititis

A

positive Murphy’s sign RUQ

102
Q

what is the assessment

A

diagnoses and summary of visit

103
Q

assessment must include

A

age and sex, DDx

104
Q

two requirements for result to be included in assessment

A

new or relevant (history)

105
Q

summarizing a test

A

name of test
result of test
why it was ordered

106
Q

ICD code

A

the codes for billing that link with the diagnosis

107
Q

Open heart surgery

108
Q

A and P

A

Assessment and plan

109
Q

If there is no definitive diagnosis

A

the assessment will typically include a list of differential diagnoses

110
Q

Pale Conjunctiva

111
Q

Scleral Icterus

A

Liver failure

Scribe America Final Exam (1 decks)

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