Scribe America Final Exam Study Guide Latest 2022 Graded A+

Document Content and Description Below

Scribe America Final Exam Study Guide Latest 2022 Graded A+ What does ROS stand for? ✔✔Review of symptoms, head to toe checklist of symptoms The HPI and ROS are considered what type of informat... ion? ✔✔Subjective The physical exam is what type of information? ✔✔Objective If a physician told you a patients abdomen was nontender or the patients skin was plale, where would you document this information ✔✔Physical Exam (PE) What section focuses directly on the chief complaint? ✔✔HPI (History of present illness) What are the 5 vital signs? ✔✔1. Heart rate (HR) 2. Respiratory rate (RR) 3. Blood pressure (BP) 4. Temperature (T) 5. Oxygen Saturation (SpO2) Surgical Hx example ✔✔CABG (Coronary artery bypass graft) Social Hx example ✔✔Smoker 1 ppd Family Hx example ✔✔Brother diagnosed with CAD < 55 y/o Removal of appendix ✔✔Appendectomy Removal of gallbladder ✔✔Cholecystectomy Removal of uterus ✔✔Hysterectomy Removal of tonsils ✔✔Tonsillectomy What are the 2 types of heart attacks and how are they diagnosed? ✔✔STEMI - EKG Non-STEMI - Troponin What are 3 cardiac risk factors? ✔✔HTN, HLD, Smoking, CAD, DM, FHx CAD < 55 y/o Chest pain, dyspnea, cough and fever correlated to which DDx? What study would be ordered? ✔✔PNA (Pneumonia) CXR What are 3 symptoms a patient with an Ischemic CVA would present with? ✔✔Unilateral weakness/numbness, slurred speech, vision changes What heart rhythm would a physician hear if the patient were in atrial fibrillation and how is the disease diagnosed? ✔✔Irregularly irregular rhythm (A-Fib) EKG Name 2 risk factors to hemorrhagic CVA ✔✔Head Trauma, anticoagulants (blood thinner medication), uncontrolled HTN How is AMS different from a focal neurological deficit? What is the major cause of AMS in the elderly? ✔✔AMS (confusion, lethargy, unresponsiveness) affects the whole brain (drugs, EtOH) and FND (one sided weakness/numbness, speech changes, vision changes) affects a small portion/localized of the brain AMS in elderly - UTI Layman's term for GERD ✔✔Heartburn, Indigestion, Acid Reflux Most common cause for seizures in children? ✔✔Fever Which drug causes smooth muscle relaxation, causing vasodilation and increase blood supply to heart muscle? ✔✔NTG (Nitroglycerin) Describe the significance of an HPI ✔✔Explains patients CC and answers "Why did the patient seek treatment?" CC of a headache, name 5 elements of the HPI and provide an applicable example of each element ✔✔Onset - 3 weeks ago Timing - intermittent Quality - pressure Severity - 9/10 location - frontal/forehead Modifying factors - worse with light, better after Excedrin Context - does not take a blood thinner, no recent head injuries, Hx of similar HA True or False: Patients entire ED visit is based on their answers to the questions asked during the interview? ✔✔True True or False: Accurate chronology is not important in an HPI ✔✔False What is the main different between HPI and ROS? ✔✔HPI - story of the CC ROS - head-to-toe checklist of subjective Sx True or False: Symptoms listed in ROS can contradict the Sx discussed in the HPI ✔✔False How would you document GPA for a patient who is currently pregnant, has been pregnant 4 time in the past, and has one child at home? ✔✔G - 5 P - 1 A - 3 List 5 body systems found in the ROS and provide 2 symptoms for each system. ✔✔Skin - Rashes, itching, redness General - fever, chills, weight loss Cardio - Chest pain,Palpitations Pulmonary - shortness of breath, dyspnea, cough, wheezing GI - abdominal pain, acid reflux Neuro - headache, seizures, uni [Show More]

Last updated: 1 year ago

Preview 1 out of 47 pages