ScribeAmerica Scribe Test / Revised Questions and Answers / Sure A+
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ScribeAmerica Scribe
Institution
ScribeAmerica Scribe
"Heart Disease" is also known as: - Coronary Artery Disease
A 92 year old male presented to the ED without a heart rate and not breathing. He was successfully
resuscitated in the Emergency Department, but he required a breathing tube (intubation) and is
receiving oxygen through a ventilator. Whe...
ScribeAmerica Scribe Test / Revised
Questions and Answers / Sure A+
"Heart Disease" is also known as: - Coronary Artery Disease
A 92 year old male presented to the ED without a heart rate and not breathing. He was successfully
resuscitated in the Emergency Department, but he required a breathing tube (intubation) and is
receiving oxygen through a ventilator. Where do you think he will go next? - Inpatient
A gastrointestinal perforation (also known as ruptured bowel) is a highly emergent condition that occurs
when there is a hole in the wall of part of the GI tract. What test would be best to evaluate this
condition? - CT A/P
A person who is very stressed while watching a scary movie is MOST likely: - Tachycardic
A sick child who has had a fever for 2 hours most likely has which temperature? - 102.5
A UTI that is unresolved and goes to the kidneys is known as: - Pyelonephritis
Abdominal tenderness belongs in which part of the chart - PE
An 11 year old patient fell off a trampoline earlier today, and presents with right wrist pain. Which test is
your provider likely to order, to evaluate the patient's pain? - X-ray of the right wrist
An 8 year old patient comes in for follow up on their Diabetes, what type of Diabetes do they most likely
have? - Type I
Blood pressure is defined as: - The pressure at which blood is being pumped throughout your
body
cc - chief complaint
, Components of MDM - procedures
rechecks on patients
medication reactions
case summary
consultation with other physicians
discussions with family
lab interpretations
EKG interpretations
radiology interpretations
*if it affected decision making it should be included*
Consultation - physician talks to/references a specialist
write: timestamp
full name of consultant
what specialty service
DDx - Differential Diagnosis; best guess as to what is the cause
(what was investigated and how? history, lab, procedure findings? how did this rule out certain
diagnoses? discuss why the physician chose a certain diagnosis?)
Discharge - physician goes in to discharge the patient home
write: guidelines for return (symptoms/concerns)
follow up (who/when/for what)
medicolegal (is the patient aware and understanding instructions?)
Each diagnosis becomes a permanent part of the patient's medical record. - True
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