SCRIBEAMERICA FINAL EXAM ED WITH VERIFIED ANSWERS GRADED A+
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SCRIBEAMERICA
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SCRIBEAMERICA
SCRIBEAMERICA FINAL EXAM ED WITH VERIFIED ANSWERS GRADED A+
1. What are the 3 types of dispositions? Discharge, Admit, Transfer
2. What does HPI stand for? history of present illness
3. What does ROS stand for? review of systems
4. The HPI and ROS are considered
what type of information?
5. T...
SCRIBEAMERICA FINAL EXAM ED WITH VERIFIED ANSWERS GRADED A+
1. What are the 3 types of dispositions? Discharge, Admit, Transfer
2. What does HPI stand for? history of present illness
3. What does ROS stand for? review of systems
4. The HPI and ROS are considered subjective
what type of information?
5. The physical exam is what type of objective
information?
6. If a physician told you a patient's ab- PE
domen was non tender, where would
you document this?
7. What section focuses directly on the HPI
chief complaint?
8. If someone has a hx of CABG or MI, CAD
what is something you can also al-
ways document in the PMHx section
of the chart?
9. Name an example of something you smokes 1 pack/day
may write in the Social Hx portion of
the chart.
10. Name an example of something you Mother had Hx of CAD at age 46
may write in the Family Hx portion of
the chart.
11. What are the abbreviations for the fol- HTN
lowing past medical history terms? CVA (cerebrovascular accident)
Hypertension DM
Stroke MI
Diabetes HLD
Heart Attack
High Cholesterol
,SCRIBEAMERICA FINAL EXAM ED WITH VERIFIED ANSWERS GRADED A+
12. What are the medical terms for the appendectomy
following past surgical terms? cholecystectomy
Removal of the appendix hysterectomy
Removal of the gallbladder Salpingo-oophorectomy
Removal of the uterus tonsillectomy
Removal of a fallopian tube mastectomy
Removal of the tonsils
Removal of the breast
13. What are the five vital signs? Blood pressure (BP), heart rate
(HR), oxygen saturation (SaO2),
respiratory rate (RR), temperature
(C or F)
14. What does NKDA stand for? no known drug allergies
15. What does LNMP stand for? Last Normal Menstrual Period
16. If the doctor said the exam was "be- this means that the exam was nor-
nign", what does this mean? mal and of no concern
17. Explain acute vs chronic. acute: serious, new condition, that
could potentially be life-threatening
chronic: not of much concern,
long-lasting condition, typically not
a death threat
18. What are the medical terms for the coronary artery disease
following pathophysiology abbrevia- abdominal aortic aneurysm
tions? chronic obstructive pulmonary dis-
CAD ease
AAA pneumonia
COPD upper respiratory disease
PNA
URI
19. How are the following diseases diag- -chest x-ray, bnp (b-type natriuretic
nosed? peptide)
-CHF (two answers) -CT chest with IV contrast (CTA
, SCRIBEAMERICA FINAL EXAM ED WITH VERIFIED ANSWERS GRADED A+
-PE (three answers) chest), VQ scan, D-dimer
-Cholecystitis -abdominal ultrasound (US) of RUQ
-Pancreatitis -elevated lipase lab test
-Appendicitis -CT AP w/ PO
-Hemorrhagic CVA (two answers) -CTA w/ IV contrast, LP (lumbar
-DVT puncture)
-ultrasound (US)
20. What are the two types of heart at- STEMI (ST elevation myocardial in-
tacks and how are they diagnosed? farction) and NSTEMI (non ST ele-
vation myocardial infarction)
STEMI: EKG
NSTEMI: troponin
21. What are three cardiac risk factors? HTN, DM, HLD, CAD, Smoking,
FHx CAD < 55 y/o
22. What are four associated symptoms Chest pressure with diaphoresis,
of an MI other than CP? (Hint: catch N/V (nausea and vomiting), and
phrase) SOB
23. What are three symptoms a patient Unilateral focal neurological
with an Ischemic CVA might present deficits: One-sided weakness,
with? one-sided numbness or changes in
speech/vision
24. What are the only three symptoms of SOB (difficulty breathing), rash,
a true allergic reaction? itching/swelling
25. What heart rhythm would a physician an irregularly irregular rhythm, this
hear if the patient were in atrial fibril- is diagnosed by and EKG
lation and how is this disease diag-
nosed?
26. What physical exam finding is asso- wheezes (while inspiring or expir-
ciated with asthma? ing)
27. How is altered mental status different AMS is very different than a focal
from a focal neurological deficit? neurological deficit. AMS is gener-
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