ED Scribe - Final Exam Questions with 100% Correct Answers | Verified | Updated 2024, Exams of Advanced Education

Download ED Scribe - Final Exam Questions with 100% Correct Answers | Verified | Updated 2024 and more Exams Advanced Education in PDF only on Docsity! ED Scribe - Final Exam Questions with 100% Correct Answers | Verified | Updated 2024 Medical Decision Making (MDM) - Correct Answer-The physician's thought process Pain vs. Tenderness - Correct Answer-Patient's feeling vs. physician's assessment What does distress mean? - Correct Answer-The doctor's judgment of discomfort Baseline - Correct Answer-An individual's normal state of being What does Auscultation mean? - Correct Answer-Listening with a stethoscope Palpation - Correct Answer-The act of pressing on an area by the doctor pg. 1 professoraxe l Inpatient - Correct Answer-Admitted to the hospital overnight Outpatient - Correct Answer-Seen and sent home the same day What is the ED flow (overview)? - Correct Answer-1. Check in and Chief Complaint 2. Physician assessment 3. Objective orders and results 4. Medical Decision Making 5. Disposition What is the ED flow before orders are made? - Correct Answer-1. Arrival 2. Triage 3. Vital Signs / Bed Placement 4. Nurse Assessment 5. HPI, ROS, Hx, PE What is the ED flow after orders are made? - Correct Answer- 1. Differential Dx 2. Physician orders > labs, imaging, procedures, medications 3. Results and ED course 4. Final Dx 5. Disposition What is the general documentation template? - Correct Answer-HPI > ROS > PHx > PE > ED course > Disposition Thyroid problem means.. - Correct Answer-Usually Hypothyroidism, sometimes hyperthyroidism pg. 2 professoraxe l "I'm on dialysis" means.. - Correct Answer-Chronic Renal Failure - CRF or End Stage Renal Disease - ESRD on dialysis Enlarged prostate means.. - Correct Answer-Benign Prostate Hypertrophy - BPH What is the convention for documenting gynecological PMHx? - Correct Answer-G: P: A: Stroke means.. - Correct Answer-Ischemic Cerebrovascular Accident - CVA Mini-stroke means.. - Correct Answer-Transient Ischemic Attack - TIA Seizures means.. - Correct Answer-Seizure disorder/Epilepsy Brain bleed means.. - Correct Answer-Hemorrhagic CVA "I drink a lot" means.. - Correct Answer-ETOH abuse or Alcoholism pg. 5 professoraxe l "I do drugs" means.. - Correct Answer-Substance abuse "Blood clot in my leg" means.. - Correct Answer-DVT "Bulge in my aorta" or "Triple A" - Correct Answer-Abdominal Aortic Aneurysm "Bad blood flow to my legs" means.. - Correct Answer- Peripheral Vascular Disease - PVD "Numbness in my legs" means.. - Correct Answer-Peripheral Neuropathy Bulging/Herniated disc means.. - Correct Answer- Degenerative Disc Disease - DDD What does Arthritis mean? - Correct Answer-Osteoarthritis, Rheumatoid Arthritis Joint pain (chronic) means.. - Correct Answer-Degenerative Joint Disease -DJD pg. 6 professoraxe l Weak/fragile bones means.. - Correct Answer-Osteoporosis Spread to my means.. - Correct Answer-With metastases to the.. "They cut it out" (in regards to cancer) means.. - Correct Answer-Status-post surgical resection "It's gone" (in regards to cancer) means.. - Correct Answer-In remission Tonsils removed means.. - Correct Answer-Tonsillectomy Adenoids removed means.. - Correct Answer-Adenoidectomy Ear tubes means.. - Correct Answer-Pressure Equalizer Tubes Heart bypass means.. - Correct Answer-Coronary Artery Bypass Graft - CABG > PMHx CAD pg. 7 professoraxe l Kidney removed means.. - Correct Answer-Nephrectomy Ovary removed means.. - Correct Answer-Oophorectomy Ovary and fallopian tubes removed means.. - Correct Answer- Salpingo-oophorectomy Tube tied means.. - Correct Answer-Tubal ligation - female or Vasectomy - male C-Section means.. - Correct Answer-Cesarean Section Prostate removed means.. - Correct Answer-Prostatectomy, most often Trans-Urethral Removal of the Prostate - TURP Uterine product removed means.. - Correct Answer-Dilation and Curettage - D&C Neck artery cleaned means.. - Correct Answer-Carotid Endarterectomy pg. 10 professoraxe l Brain surgery means.. - Correct Answer-Craniotomy - brain bleed vs. brain CA Shunt means.. - Correct Answer-Ventriculoperitoneal Shunt - VP Shunt Dialysis fistula means.. - Correct Answer-Arteriovenous (AV) Fistula Dialysis graft means.. - Correct Answer-Arteriovenous (AV) Graft PICC Line means.. - Correct Answer-Peripherally Inserted Central Catheter - PICC Port means.. - Correct Answer-Port-a-cath or Medi-Port Clot filter (lower abdomen) means.. - Correct Answer- Greenfield Filter Leg amputated means.. - Correct Answer-AKA/BKA pg. 11 professoraxe l Joint repair means.. - Correct Answer-Arthroplasty Metal plates/pins means.. - Correct Answer-Hardware Neck fused means.. - Correct Answer-Cervical spine fusion Back fused means.. - Correct Answer-Lumbar spine fusion Hip surgery means.. - Correct Answer-Open Reduction with Internal Fixation - ORIF What are the only Sx of a true allergic reaction? - Correct Answer-rash, itching, swelling What are the 5 vital signs? - Correct Answer-Heart Rate, Blood Pressure, Respiratory Rate, Temperature, Oxygen Saturation What type of information are the HPI and ROS? - Correct Answer-Subjective pg. 12 professoraxe l What is Chest Wall Pain? - Correct Answer-Costochondritis - Irritation of the chest wall causing pain with palpation of the chest What is Pleural Effusion? - Correct Answer-Fluid collecting around the lungs causing SOB or CP How is MI diagnosed? - Correct Answer-EKG for STEMI -or- Elevated Troponin for Non-STEMI How is A Fib (electrical problem) diagnosed? - Correct Answer- EKG How is CHF (fluid traffic jam) diagnosed? - Correct Answer-CXR or Elevated BNP How is CAD (major risk factor for MI) diagnosed? - Correct Answer-Positive cardiac catheterization - not done in the ED How is Angina (Sx of CAD) diagnosed? - Correct Answer- Exertional CP w/ Hx of CAD pg. 15 professoraxe l What are the risk factors associated with Pulmonary Embolism? - Correct Answer-Known DVT, PMHx DVT or PE, FHx, recent surgery, cancer, A Fib, immobility, pregnancy, BCP, smoking What is the chief complaint of someone with Pneumonia? - Correct Answer-SOB or productive cough What are the risk factors associated with Pneumonia? - Correct Answer-Elderly, bedridden, recent chest injury, recent surgery What is Pneumothorax (PTX)? - Correct Answer-Collapsed lung do to trauma or a spontaneous small rupture of the lung What must you document when dealing with a PTX pt? - Correct Answer-The percentage of lung collapsed What is known as the "smoker's disease"? - Correct Answer- Chronic Obstructive Pulmonary Disease - COPD pg. 16 professoraxe l What are the risk factors associated with COPD? - Correct Answer-Smoking What is the chief complaint of someone with COPD? - Correct Answer-SOB How is COPD diagnosed? - Correct Answer-CXR and Hx of smoking What is another way to say asthma? - Correct Answer- Reactive Airway Disease - RAD How is Pulmonary Embolism diagnosed? - Correct Answer-CTA Chest - CT Chest with IV Contrast What is the catch phrase for PTX? - Correct Answer-Unilateral CP and SOB What are the risk factors associated with Ischemic Cerebral Vascular Accident (CVA)? - Correct Answer-HTN, HLD, DM, Hx TIA/CVA, smoking, FHx CVA, A Fib pg. 17 professoraxe l What is an important thing to document for Bell's Palsy? - Correct Answer-Absence of other FND What are the associated diseases of the Epigastric region? - Correct Answer-GERD, MI What are the associated diseases of the RUQ? - Correct Answer-Cholecystitis, Cholelithiasis What are the associated diseases of the LUQ? - Correct Answer-Pancreatitis What are the associated diseases of the Periumbilical region? - Correct Answer-SBO - Small Bowel Obstruction What are the associated diseases of the RLQ? - Correct Answer-Appendicitis What are the associated diseases of the LLQ? - Correct Answer-Diverticulitis pg. 20 professoraxe l What are the associated diseases of the Suprapubic region? - Correct Answer-Ovarian Torsion, Ovarian Cyst, UTI What are the associated diseases of the Flanks? - Correct Answer-Pyelonephritis, Renal Calculi What is/are the chief complaints of Appendicitis? - Correct Answer-RLQ pain, gradual onset, constant, worsened with movement How is Appendicitis diagnosed? - Correct Answer-CT A/P with PO contrast What is/are the chief complaints of Small Bowel Obstruction? - Correct Answer-Abdominal pain, bright green emesis, constipation How is Small Bowel Obstruction (SBO) diagnosed? - Correct Answer-CT A/P with PO Contrast, Acute Abdominal Series (AAS) pg. 21 professoraxe l What is the difference between Cholelithiasis and Cholecystitis? - Correct Answer-Cholelithiasis = Gallstones, Cholecystitis = Gallbladder infection What is/are the chief complaint(s) of Cholelithiasis and Cholecystitis? - Correct Answer-RUQ pain; sharp, worsened with eating, deep breaths, and palpation How is Cholelithiasis and Cholecystitis diagnosed? - Correct Answer-Abdominal US, RUQ What condition is Pancreatitis tied to? - Correct Answer- Cholecystitis What needs to happen with patients who have both cardiac risk factors and epigastric pain? - Correct Answer-They will need to get a cardiac workup What is Pyelonephritis? - Correct Answer-Kidney infection How is Pyelonephritis diagnosed? - Correct Answer-CT A/P or confirmed UTI with CVA tenderness on exam pg. 22 professoraxe l How is DVT diagnosed? - Correct Answer-US/Doppler of the extremity What is Cellutitis? - Correct Answer-Infection of the skin cells What does induration mean? - Correct Answer-Firm, hard What is an Abscess? - Correct Answer-Cellulitis with fluctuance; skin infection with an underlying collection of pus How are abscesses treated? - Correct Answer-The pus-pocket is drained - Incision and Drainage - I&D What is the main concern with an allergic reaction? - Correct Answer-Anaphylaxis or respiratory failure What is the difference between an allergic reaction and an adverse reaction? - Correct Answer-Allergic reaction can only be these 3 things: rash, itching, swelling. Adverse reactions are anything else. pg. 25 professoraxe l What is Diabetic Ketoacidosis (DKA)? - Correct Answer- Shortage of insulin resulting in hyperglycemia and production of ketones How is DKA diagnosed? - Correct Answer-Arterial Blood Gas (ABG or VBG) showing low pH (acidosis) or Positive Serum Ketones What must always be documented with a trauma patient? - Correct Answer-MOI, How it occurred, when it occurred, and what surface did they land on. What does Mechanism of Injury (MOI) mean? - Correct Answer-How a trauma patient became injured What is a STEMI (ST Elevation Myocardial Infarction)? - Correct Answer-It is when the EKG shows "ST segment elevation" it indicates an acute heart attack How is STEMI diagnosed? - Correct Answer-EKG How is Non-STEMI diagnosed? - Correct Answer-Troponin pg. 26 professoraxe l What are some other associated Sx of an MI other than CP? - Correct Answer-N/V, SOB, Diaphoresis What are some associated SX for CHF? - Correct Answer-SOB (Orthopnea, PND, DOE), pedal edema What part of the heart does CAD affect? - Correct Answer- Arteries Name all 7 areas of the abdomen? - Correct Answer- Epigastrium, RUQ, LUQ, RLQ, LLQ, Suprapubic, Periumbilical, Right/Left Flanks What might someone with GERD c/o? - Correct Answer- Epigastric pain - burning What does bile do? Where is it stored? - Correct Answer-Bile emulsifies the fats in foods. It is stored in the gallbladder and made in the liver pg. 27 professoraxe l How is an abscess different from cellulitis? - Correct Answer- An abscess IS cellulitis with fluctuance - pus pocket What is the emergency physician's main responsibility for psychiatric patients? - Correct Answer-Medical clearance Name 3 important things to document for any trauma patient. - Correct Answer-LOC, head injury, neck pain, back pain, numbness, weakness What is the significance of an HPI? - Correct Answer-It is the story of the Sx and events that led to the patient's ED visit. It includes the CC and the associated Sx Name 5 elements of the HPI. - Correct Answer-Chief complaint, onset, timing, location, quality, severity, modifying factors, associated Sx, context Name 8 of the body systems included in the ROS. - Correct Answer-Constitutional, eyes, ENT, CV, Res, GI, GU, MS, skin, neuro, psych, endocrine, heme/lymph, immunological pg. 30 professoraxe l What do you need to remember to document in the HPI and ROS for any patient that is unconscious or incapable of providing information? - Correct Answer-"HPI/ROS is limited by..." Identify the error in this sentence from an example HPI: "Patient states the CP has been intermittent since Thursday." - Correct Answer-We do not document days of the week in the HPI. Instead, we would count back the number of days and document this numerically Why is it important to remember to document if the patient has had similar Sx in the past? - Correct Answer-Because it is less likely that their current Sx are life threatening if they have survived similar Sx in the past 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 - Correct Answer-b) Documenting the answers to every question asked by the doctor Which is the first item in the formula for writing an HPI? pg. 31 professoraxe l a) Pertinent negatives b) Timing, quality, and location c) Chief complaint and onset d) Associated Symptoms - Correct Answer-c) Chief complaint and onset Why should you always pay special attention to the complaints of Chest Pain and SOB? - Correct Answer-Direct concern for MI Name 3 past surgical histories that indicate that the patient has a history of CAD. - Correct Answer-Angioplasty, CABG, stents What are the risk factors of MI? - Correct Answer-CAD, HTN, DM, HLD, smoking, FHx CAD <55 y/o What are the risk factors for PE? - Correct Answer-Known DVT, PMHx DVT or PE, FHx DVT or PE, recent surgery, CA, A Fib, immobility, pregnancy, BCP, smoking pg. 32 professoraxe l CHEST PAIN: "Pleuritic pain" is a red flag for.. - Correct Answer-PE, PTX, Pleurisy CHEST PAIN: "Calf pain" is a red flag for.. - Correct Answer- DVT SOB: "Productive cough" is a red flag for.. - Correct Answer- Pneumonia - PNA SOB: "Orthopnea/Dyspnea on Exertion (DOE)" is a red flag for.. - Correct Answer-Congestive Heart Failure - CHF SOB: "Bilateral leg swelling" is a red flag for.. - Correct Answer-Congestive Heart Failure - CHF SOB: "Hemoptysis" is a red flag for.. - Correct Answer-PE SOB: "Unilateral leg swelling" is a red flag for.. - Correct Answer-DVT causing a PE SOB: "Wheezing" is a red flag for.. - Correct Answer-Asthma pg. 35 professoraxe l SOB: "Hx of tobacco abuse" is a red flag for.. - Correct Answer- COPD SOB: "Chest Pain" is a red flag for.. - Correct Answer-MI, PE, PNA ABD PAIN: "RLQ pain" is a red flag for.. - Correct Answer- Appendicitis ABD PAIN: "RUQ pain" is a red flag for.. - Correct Answer- Cholecystitis ABD PAIN: "LLQ pain" is red flag for.. - Correct Answer- Diverticulitis ABD PAIN: "LUQ pain" is a red flag for.. - Correct Answer- Pancreatitis ABD PAIN: "Fever" is a red flag for.. - Correct Answer- Appendicitis, Cholecystitis, Diverticulitis pg. 36 professoraxe l ABD PAIN: "Blood in vomit or stool" is a red flag for.. - Correct Answer-GI bleed ABD PAIN: "Melena" is a red flag for.. - Correct Answer-GI bleed ABD PAIN: "Dizziness" is a red flag for.. - Correct Answer-GI bleed, Abdominal Aortic Aneurysm - AAA FEMALE LOWER ABD PAIN: "Suprapubic pain" is a red flag for.. - Correct Answer-Ovarian Torsion FEMALE LOWER ABD PAIN: "Pregnancy" is a red flag for.. - Correct Answer-Ectopic pregnancy FEMALE LOWER ABD PAIN: "Fever, RLQ pain" is a red flag for.. - Correct Answer-Appendicitis LOW BACK PAIN: "Weakness/Numbness in lower extremities" is a red flag for.. - Correct Answer-Spinal cord injury pg. 37 professoraxe l SYNCOPE: "Numbness/Weakness/Tingling" is a red flag for.. - Correct Answer-Cerebral Vascular Accident - CVA SYNCOPE: "Changes in speech or vision" is a red flag for.. - Correct Answer-Cerebral Vascular Accident - CVA SYNCOPE: "Chest pain" is a red flag for.. - Correct Answer- Myocardial Infarction - MI SYNCOPE: "Shortness of Breath - SOB" is a red flag for.. - Correct Answer-Pulmonary Embolism - PE SYNCOPE: "Palpitations" is a red flag for.. - Correct Answer- Arrhythmia AMS: "Fever" is a red flag for.. - Correct Answer-Sepsis AMS: "Numbness/Weakness/Tingling" is a red flag for.. - Correct Answer-CVA AMS: "Changes in speech or vision" is a red flag for.. - Correct Answer-CVA pg. 40 professoraxe l AMS: "Headache" is a red flag for.. - Correct Answer- Hemorrhagic CVA AMS: "Hx of depression or drug abuse" is a red flag for.. - Correct Answer-Drug overdose AMS: "Hx of Diabetes" is a red flag for.. - Correct Answer- Hypoglycemia TRAUMA: "Loss of Consciousness - LOC" is a red flag for.. - Correct Answer-Hemorrhagic CVA, Subdural Hematoma TRAUMA: "Unilateral Numbness/Weakness/Tingling" is a red flag for.. - Correct Answer-Hemorrhagic CVA, Subdural Hematoma TRAUMA: "Bilateral Numbness/Weakness/Tingling" is a red flag for.. - Correct Answer-Spinal cord injury TRAUMA: "Neck pain or back pain" is a red flag for.. - Correct Answer-Spinal cord injury pg. 41 professoraxe l TRAUMA: "Shortness of Breath - SOB or Chest Pain - CP" is a red flag for.. - Correct Answer-Pneumothorax - PTX, Cardiac Contusion TRAUMA: "Abdominal pain" is a red flag for.. - Correct Answer-Splenic or liver laceration What are the common general PMHx? - Correct Answer-HTN, HLD, CA, DM - IDDM/NIDDM What are the common cardiovascular PMHx? - Correct Answer-MI, CAD, Angina, CHF, AFIB What are the common pulmonary PMHx? - Correct Answer- PE, PNA, COPD, Asthma What are the common GI PMHx? - Correct Answer-GERD, AAA, Pancreatitis, Hepatitis, Deveticulitis What are the common GU PMHx? - Correct Answer-Kidney stones, UTI, Renal insufficiency/failure pg. 42 professoraxe l What is a Carotid Endarterectomy? - Correct Answer-a surgical procedure used to reduce the risk of stroke by correcting stenosis (narrowing) in the common carotid artery or internal carotid artery What does PICC line mean? - Correct Answer-Peripherally Inserted Central Catheter - is a thin, soft, flexible tube - an IV line What does "waxing and waining" mean? - Correct Answer- Always present but changing in intensity What does "icterus" mean? - Correct Answer-Yellowing, also known as jaundice What does "Organomegaly" mean? - Correct Answer-Organ enlargement What does "Perfusion" mean? - Correct Answer-The flow of blood through the body's blood vessels pg. 45 professoraxe l What does "GCS" mean? - Correct Answer-Glasgow Coma Scale, used to assess level of consciousness in trauma patients Which of these 2 physical exam findings could a physician appreciate without auscultating the patient's lungs? A. No respiratory distress B. No rales - Correct Answer-A. No respiratory distress What does PERRL stand for? - Correct Answer-Pupils are Equal Round and Reactive to Light What does AT/NC mean? - Correct Answer-Atraumatic/Normocephalic What does NAD stand for? - Correct Answer-No Acute Distress/Disease What does it indicate if the pt has pale conjunctiva? - Correct Answer-Anemia What is scleral icterus, and what does it indicate? - Correct Answer-Yellowing of the eyes, indicates liver failure pg. 46 professoraxe l Name an instrument a physician would use to closely investigate the eyes? - Correct Answer-Slit lamp, Woods lamp, ophthalmoscope In what body system would you document "TM erythema and bulging"? - Correct Answer-Ears What is the medical term for nostril? - Correct Answer-Naris; both nostrils is nares What medical term would you use to describe a "runny nose"? - Correct Answer-Rhinorrhea What would dry mucous membranes indicate? - Correct Answer-Dehydration, DKA If you saw "RRR" written in the cardiac exam, what do you think it might mean? - Correct Answer-Regular Rate and Rhythm pg. 47 professoraxe l What does DTR stand for? - Correct Answer-Deep tendon reflex What general area of the body does Cranial Nerves (CN) control? - Correct Answer-Face In the neurological exam, what does "normal gait" mean? - Correct Answer-Walking normally In the psychiatric exam, what do SI and HI stand for? - Correct Answer-Suicidal and Homicidal Ideations What type of patient is the Glasgow Coma Scale (GCS) associated with? - Correct Answer-Trauma What section of the physical exam would you document "RUE strength 3/5" under? - Correct Answer-Neurological In a physical exam, what does "TTP" mean? - Correct Answer- Tender to Palpation pg. 50 professoraxe l What is the medical term for "Hives"? - Correct Answer- Urticaria What is the medical term for "Swollen lymph nodes"? - Correct Answer-Lymphadenopathy What is the benign "no touch" exam for the general system? - Correct Answer-Well developed, Well nourished, No acute distress What is the benign "no touch" exam for the eyes system? - Correct Answer-PERRL What is the benign "no touch" exam for the ENT system? - Correct Answer-Moist mucosa What is the benign "no touch" exam for the Neck system? - Correct Answer-Supple What is the benign "no touch" exam for the Cardiovascular system? - Correct Answer-Well perfused pg. 51 professoraxe l What is the benign "no touch" exam for the Respiratory system? - Correct Answer-No respiratory distress What is the benign "no touch" exam for the GI system? - Correct Answer-Non-distended What is the benign "no touch" exam for the Extremities system? - Correct Answer-No edema What is the benign "no touch" exam for the Skin system? - Correct Answer-Dry, No rashes What is the benign "no touch" exam for the Neurological system? - Correct Answer-Alert and Oriented, Normal speech What is the benign "no touch" exam for the Psychiatric system? - Correct Answer-Normal affect What is the benign "touch" exam for the Eyes system? - Correct Answer-EOMI pg. 52 professoraxe l What does "hyphema" mean in a physical exam? - Correct Answer-An accumulation of blood in the anterior chamber of the eye. What is the medical term for "ear drum"? - Correct Answer- Tympanic Membrane What is the medical term for "middle ear infection"? - Correct Answer-Otitis Media What is the medical term for "Cavities"? - Correct Answer- Dental Caries What does Edentulous mean? - Correct Answer-Toothless What is the medical term for "pus in tonsils"? - Correct Answer-Tonsillar Exudate What is the medical term for "Enlarged Tonsils"? - Correct Answer-Tonsillar Hypertrophy pg. 55 professoraxe l What does PTA (infection) stand for and what is it? - Correct Answer-Peritonsillar Abscess, forms in the tissues of the throat next to one of the tonsils What does JVD stand for? - Correct Answer-Jugular Venous Distension What is the medical term for "swollen lymph nodes"? - Correct Answer-Cervical lymphadenopathy What does "carotid bruit" mean? - Correct Answer-a systolic sound (abnormal) heard over the carotid artery area during auscultation What is the medical term for "enlarged thyroid"? - Correct Answer-Thyromegaly What is the medical term for "extra beats"? - Correct Answer- Extrasystoles What are the 6 different types of pulses? - Correct Answer- Brachial pulse, Radial pulse, Carotid pulse, Femoral pulse, Dorsalis Pedis pulse, Posterior Tibialis pulse pg. 56 professoraxe l What is a "normal" pulse? - Correct Answer-2+ = Easily palpable Other than McBurney's Point Tenderness, what is another sign to check for Appendicitis? - Correct Answer-Psoas, Obturator, Rovsing's What is the medical term/system for "skin"? - Correct Answer-Integumentary What is a medical term for "sweating heavily"? - Correct Answer-Diaphoretic What does "cyanotic" mean? - Correct Answer-Blue What does lymphangitis mean? - Correct Answer- Inflammation of the walls of the lymphatic vessels What does avulsion mean? - Correct Answer-The separation of any part of the body from the whole pg. 57 professoraxe l What does "Coag" lab tests examine? - Correct Answer-Blood coagulation / Coumadin levels Name all of the "Coag" lab tests. - Correct Answer-PT- prothrombin time, PTT-partial thromboplastin time, INR- international normalized ratio What does Lipase diagnose? - Correct Answer-Pancreatitis What do "CRP" and "ESR" mean and what do they test for? - Correct Answer-CRP- C-Reactive Protein. ESR- Erythrocyte Sedimentation Rate. Both test for inflammation. What does a Urine Dip detect? - Correct Answer-Leuks, nitrite, glucose, blood What does a Urine Micro (Urinalysis) detect? - Correct Answer-WBC, RBC, bacteria What is one test/lab that will never result during a patient's ED visit? - Correct Answer-Cultures pg. 60 professoraxe l What are the 3 labs that are important to track for efficiency? - Correct Answer-Troponin, Creatinine, D-Dimer What type of image do ED physicians interpret? - Correct Answer-XR's What is the difference between a CTA and a CT? - Correct Answer-CTA- CT Angiogram looks at the arteries and uses IV contrast. CT does not use IV contrast but may or may not use PO contrast What does a US of the RUQ rule out or diagnose? - Correct Answer-Cholelithiasis, Cholecystitis, Gallbladder wall thickening, bile sludge, bile duct obstruction Name a type of Orthopedic procedure that may be performed by the EP? - Correct Answer-Splinting, joint reduction, Arthrocentesis What does Arthrocentesis mean? - Correct Answer-Procedure of using a syringe to collect synovial fluid from a joint capsule. pg. 61 professoraxe l Name some procedures that qualify the patient for critical care. - Correct Answer-Cardioversion, central line placement, endotracheal intubation, chest tube placement What does LAD stand for as an EKG abbreviation? - Correct Answer-Left Axis Deviation Name some diagnoses that would qualify the patient for critical care time. - Correct Answer-AFIB with RVR, CVA, MI, Sepsis, DKA, CPR, Severe hypotension/hypertension, severe anemia, PTX, PE, overdose When might an ER doctor obtain a physician consult? - Correct Answer-Regarding admission, advice over treatment plan, inform PCP of results In a CBC, what does high WBC's tell us? - Correct Answer- There is an infection In a CBC, what does "low platelets" (Thrombocytopenia) tell us? - Correct Answer-The patient is prone to bleeding pg. 62 professoraxe l What is the medical term for "high chloride"? - Correct Answer-Hyperchloremia What does BNP stand for and what does it test for? - Correct Answer-B-type Natriuretic Peptide What is all included in the Cardiac Enzyme Panel (CEP)? - Correct Answer-Trop, CK, CK-MB, CK-RI, Myo What tests will almost always be placed for every adult patient complaining of chest pain? - Correct Answer-Cardiac Order Set How many tubes of CSF are typically obtained during a Lumbar Puncture? - Correct Answer-4 tubes What is the normal INR for a patient that is on blood thinners? - Correct Answer-INR = 2.0-3.0 What is the normal INR for patients NOT on blood thinners? - Correct Answer-INR = 1.0 pg. 65 professoraxe l What is prothrombin time? - Correct Answer-The time it takes for blood to clot What is the medical term for a "cold"? - Correct Answer- Respiratory Syncytial Virus - RSV Name 2 pancreatic enzymes. - Correct Answer-Lip- Lipase and Amy- Amylase What does Lipase do in the body? - Correct Answer-Breaks down fats What does Amylase do in the body? - Correct Answer-Breaks down sugars What lab must always be ran first before doing a CTA? - Correct Answer-Creatinine must always be done first due to IV contrast in the CTA stressing the kidneys What is AAS/KUB and what does it entail? - Correct Answer- Acute Abdominal Series/Kidneys Ureters Bladder - series of 3 XR's taken to check for Free air- rupture, SBO, constipation, large kidney stones pg. 66 professoraxe l If a doctor says "Normal EKG at 80 (bpm)" what do you write? - Correct Answer-NSR at a rate of 80bpm, no acute ST/T changes If a doctor says "Sinus at 72 (between 60 and 100bpm)" what do you write? - Correct Answer-Normal Sinus Rhythm at a rate of 72bpm If a doctor says "Sinus at 114 (greater than 100bpm)" what do you write? - Correct Answer-Sinus tachycardia at a rate of 114bpm If a doctor says "Sinus at 56 (less than 60bpm)" what do you write? - Correct Answer-Sinus bradycardia at a rate of 56 bpm If a doctor says "Sinus Brady" what do you write? - Correct Answer-Sinus Bradycardia If a doctor says "Sinus Tachy" what do you write? - Correct Answer-Sinus Tachycardia pg. 67 professoraxe l What is anesthesia? - Correct Answer-Medication that suppresses the CNS that results in unconsciousness and lack of sensation What does POC stand for? - Correct Answer-Point of Care What are cultures? - Correct Answer-The propagation of microorganisms or of living tissue cells in media conducive to their growth When documenting the diagnoses, what question must you always ask the physician? - Correct Answer-Which diagnosis is the primary? What are you looking for when double checking your chart? - Correct Answer-That all final diagnoses are based off of documentation somewhere else in your chart What is the very last part of a chart? - Correct Answer- Disposition What must you remember to document if a patient is discharged home? - Correct Answer-Follow up, Time period in pg. 70 professoraxe l which to follow up, Specific conditions for return to ED, Condition: stable for discharge, Time of disposition What does AMA stand for? - Correct Answer-Against Medical Advice What does it mean when a chart is "Down-coded"? - Correct Answer-The ED chart is incomplete and does not accurately reflect the level of care provided What is my main goal as a scribe? - Correct Answer-To eliminate all down coded charts How to make sure the HPI is coded at a "level 5"? - Correct Answer-Make sure the HPI has at least 4 elements How to make sure the ROS is coded at a "level 5"? - Correct Answer-Make sure the ROS has at least 10 elements or 2 elements and the - All systems negative box checked How to make sure the PMHx is coded at a "level 5"? - Correct Answer-Make sure the PMHx has at least 2 elements. PMHx and PSHx count as 1 element pg. 71 professoraxe l How to make sure the Physical Exam is coded at a "level 5"? - Correct Answer-Must have at least 8 elements What is the coding "level 5" summary? - Correct Answer-HPI: 4, ROS: 10 or 2 "All systems negative", PHx: 2, PE: 8 What must you document to any caveat to the level 5 elements? - Correct Answer-"Unable to obtain a complete ___ due to ___" in each section independently What additional documental may the physician be reimbursed for? - Correct Answer-Critical care time, Pulse Ox interpretation, X-ray interpretation, EKG interpretation, ED procedures What is the normal Heart Rate range? - Correct Answer-60- 100 bpm What is the normal Blood Pressure range? - Correct Answer- Between 90/60 and 140/90 pg. 72 professoraxe l