ScribeAmerica Final Exam -with 100% verified solutions-2024-2025 .docx, Exams of Advanced Education

Download ScribeAmerica Final Exam -with 100% verified solutions-2024-2025 .docx and more Exams Advanced Education in PDF only on Docsity! ScribeAmerica Final Exam -with 100% verified solutions-2024- 2025 A patient is seen in the emergency department complaining of dysuria and tells you that she is 23 weeks pregnant. Your doctor diagnoses her with a UTI. Which of the following would be the best diagnosis? acute urinary tract infection in pregnancy, 2nd trimester A patient cut his left foot on a piece of glass two hours ago and is seen in the emergency department to have sutures placed. The doctor tells you there is no tendon injury and circulatory, sensory and motor is intact. What is the best diagnosis for his complaint? Uncomplicated laceration of the left foot - initial encounter What does AMS stand for? altered mental status What does GCS stand for? glasgow coma scale What does DNR stand for? do not resuscitate What does AAA stand for? abdominal aortic aneurysm What does PE stand for in the diagnosis section of the chart? pulmonary embolism What does DP stand for in "DP pulse"? dorsalis pedis What does DVT stand for? deep vein thrombosis What does NTG stand for? nitroglycerin What does URI stand for? upper respiratory infection What does CHF stand for? congestive heart failure What does s/p stand for? status post What does GERD stand for? gastroesophageal reflux disease What does EOMI stand for? extraocular movements intact What does DOE stand for? dyspnea on exertion What does LBBB stand for? left bundle branch block What does CVA stand for? costovertebral angle What does CSF stand for? cerebrospinal fluid What does PTX stand for? pneumothorax What does COPD stand for? chronic obstructive pulmonary disease What does PNA stand for? pneumonia What does CBC stand for? complete blood count What does IDDM stand for? insulin dependent diabetes mellitus What does TIA stand for? transient ischemic attack A 43 y/o male presents to the ED with vomiting that began 5 hours ago. He has a history of Type II DM and is s/p right BKA. On objective evaluation it is found that he is hyperglycemic and has elevated ketones and so he will be admitted for DKA. Match the details to the correct section of the chart. Onset: 5 hours ago Disposition: admit ED Course: hyperglycemia and elevated ketones CC: vomiting PMHx: Type II DM Diagnosis: DKA PSHx: right BKA Match the following description to the appropriate team member. Scribe: Documents the patient's visits on behalf of the physician Unit Secretary: Answers phone calls, pages other specialists/ doctors, and organizes the patient's paperwork ED Nurse: Records medical histories, symptoms, monitors the patient, starts IVs, administers mediations, and assists with procedures ED Tech: Helps the nurse and assists with procedures RT: Administers "breathing treatments" and assists with managing a patient's airway Mis-Level Provider: NP or PA that works under the supervision of a physician to diagnose and treat patients Charge Nurse: Manages the ED patient flow T/F. It is the middle of the day. Your provider is busy dealing with a critical ill patient and during this time the ED Strats to pick up tase as more patients arrive. While your provider is prepping the critical patient for a procedure, she asks you to look up the CBC result on another patient. You quickly look up the information on your laptop and tell the physician that the labs came back normal except for a blood glucose level of 356, so your provider subsequently asks you to tell the nurse to start that hematochezia What medical term describes "noticeable blood in the urine"? hematuria What is the medical term for infection of the gallbladder? cholecystitis What is the medical term for stones in the gallbladder? cholelithiasis What is the medical term for "carotid artery cleaning"? carotid endarterectomy What ROS system would include Dyspepsia, the medical term for indigestion? Gastrointestinal Which of the following would NOT be considered an example of PHI? None of the above George is employed with SA as a scribe. He was off today and accidentally cut his cheek while practicing his sward swallowing skills. He goes to the emergency department and is seen by a doctor and another scribe. The emergency department is extremely busy, and so George decides to help out the doctor by scribing his own note using the computer in the room. Has George taken appropriate steps in this situation? No, because George accessed his own medical record using his EMR login What are the possible consequences of a HIPAA violations? Monetary fines to you and the hospital Scribe program cancellation Violator is blacklisted from medical programs Lawsuit against you and the hospital Prison time Termination 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? Yes because the phone is not an approved hospital devise and it is not encrypted A patient has the following history: breast CA s/p chemoradiation therapy and mastectomy. Based on this, does the patient meet level 5 billing criteria for this scenario of the chart? Yes, the PHx meets level 5 billing criteria A 45 year old male presents to the ED with a constant ripping, tearing pain to his central chest radiating strait to his back with associated nausea that began 1 hour ago. What element in constant? timing Read through the PE and decide if this meets the Level 5 billing criteria... No, the PE does not meet level 5 billing criteria Fill in the blank: Critical care must be at least a minimum of _______. 30 minutes Among the following diseases listed, select the ones that qualify for CCT. DKA Sepsis PTX ACS Acute MI A-fib with RVR CVA PE Match each critical care dx with it's associated procedure PTX: chest tube Sepsis: central line placement Cardiac arrest: CPR Respiratory failure: Intubation Acute exacerbation CHF/ COPD (severe): CPAP/ BiPAP Abnormal heart rhythm: cardioversion Which of these procedures qualify as critical care procedures and would indicate that critical care time must be documented on a patient? CPAP/ BiPAP Central line placement CPR Chest tube Intubation Cardioversion Which of the following would need to go into a consult note for a patient that will be admitted to the hospital for treatment of bacterial meningitis? Name of the accepting physician Location in the hospital Condition at time of admission Timing of admission consultation note with accepting physician What term describes "the patient destination is home"? discharged What abréviation describes the scenario in which a patient declines a hospital stay and decided to go home instead? AMA A 13 y/o male patient was riding his bike earlier today and accidentally fell off after traveling on an uneven patch of sidewalk. He landed on to his outstretched right hand and subsequently experienced localized pains and swelling to his right wrist. An x-ray of the right wrist shows a distal radial fracture. Now that results are back, the physician will be ready to discharge the patient home. Which of the following would need to go into this patient's disposition note? F/u with specialist or PCP Condition at time of disposition Timing of disposition Time period for f/u Specific conditions for return to the ED What do you need to make sure to document for ever admitted patient? A consultation note indicating the admitting physician An ED technician informs the provider that they have just finished applying a splint and sling for the patient with the wrist fracture. What PE finding is important for your provider to assess and include in the procedure note before the patient can be discharged home? CSMT You've just caught up on all you're charting. What are some things you can do to increase you providers efficiency? Preparing charts for patients that are assigned to your provider Tracking results Accompanying your provider on reevals Preparing for dispositions Consent should be documented any time a procedure is preformed, but there are maybe certain situations in which consent is unobtainable. In that case, consent is precluded by clinical urgency. During which of the following procedures would consent usually be unobtainable? CPR You are starting your shirt and you physician immediately picks up 3 patients... PNA, Appendicitis, UTI What does ETT stand for? endotracheal tube Select terms you might find on an x-ray interpretation Infiltrate Pneumothorax Match the oxygen administration route to the corresponding definition Non-rebreather mask: A facial mask with a reservoir bag attached RA: This means the patient is not on oxygen Intubation: An ETT goes through the patient's mouth and down the trachea BVM: A large facial mask held in place by hand and attached to an Ambu-bag used to manually inflate the patient's lungs NC: A plastic tube placed into that patient's nostrils FM: A plastic mask fit over the nose and mouth What is a "GI cocktail"? Liquid consumed by mouth to treat an upset stomach Select the EKG interpretation documentation guidelines. Rate and rhythm 2 positive or negative findings How would you diagnose AFIB? EKG How would you diagnose pneumothorax? CXR Which of the following lab results need to be monitored closely for efficiency? Troponin Creatinine D-dimer How would you diagnose Hemorrhagic CVA? Head CT LP What procedure would be used to diagnose Meningitis? LP Match the following results with the corresponding diagnosis no MI: combination of (-) EKG and (-) blood work