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final

Terms in this set (101)

What abbreviation describes the scenario in which a patient declines a hospital stay and decides to go home instead?
AMA
test
...
What is a "GI cocktail"?
Liquid consumed by mouth to treat an upset stomach
Medical Terminology: Expand the following medical abbreviation into the full medical term. Remember, do not include any spaces before or after the term/phrase.e.g. Correct way "Good luck" vs incorrect " good luck ".What does "DOE" stand for?
Dyspnea on exertion
You see the physician check the patient's pulses in four places; the right wrist, the top of the right foot, the back of the right foot and the left neck. The doctor states "The pulses are fine". Match the location with the appropriate pulse that you would document in the physical exam?
wrist - 2+ radial pulse
neck- 2+ carotid
top of foot- 2+ DDP
Back of foot- 2+ PTP
Medical Terminology: Expand the following medical abbreviation into the full medical term. Remember, do not include any spaces before or after the term/phrase.e.g. Correct way "Good luck" vs incorrect " good luck ".What does "CVA" stand for in the PE section?
costovertebral angle
You've just caught up on all of your charting. What are some things you can do to increase your providers efficiency?
-accompanying your provider on reevals
-tracking results
-preparing for dispositions
-preparing charts for patients that are assigned to your provider
Which of the following are not valid DDx for a patient with CC of HA?
Bell's Palsy
Vertigo
Medical Terminology: Expand the following medical abbreviation into the full medical term. Remember, do not include any spaces before or after the term/phrase.e.g. Correct way "Good luck" vs incorrect " good luck ".What does "CSF" stand for?
Cerebrospinal fluid
Expand the following medical abbreviation. Remember, do not include any spaces before or after the term/phrase.e.g. Correct way "Good luck" vs incorrect " good luck ".What does "CHF" stand for?
congestive heart failure
How would you diagnose Hemorrhagic CVA?
LP
Head CT
How would you diagnose AFIB? Use the abbreviation to answer the question. (Remember, do not include any spaces before or after the term/phrase. e.g. Correct way "Good luck" vs incorrect " good luck ".)
EKG
Quality is an important descriptor that can paint a picture for concerning DDx. Match the following HPI detail with the corresponding DDx.
PTX: chest pains when taking in a deep breath
CAD/ MI: sharp, stabbing pains that alternately becomes a dull heavy pressure like an elephant sitting on the chest, but regardless of quality, pain is always brought on my exertion
GERD: burning chest pain
What do you need to make sure to document for every admitted patient?
a consultation note idicating the admitting physician
How would you document GPA for a patient who has previously been pregnant four times in the past, has three children at home, and is NOT currently pregnant? (Type your answer using the following format: "G,P,A" "#,#,#"; so for example you woud type 0,0,0 with no spaces before or after the answer)
4,3,1
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
Medical Terminology: Expand the following medical abbreviation into the full medical term. Remember, do not include any spaces before or after the term/phrase.e.g. Correct way "Good luck" vs incorrect " good luck ".What does "DVT" stand for?
deep vein thrombosis
Diagnosis: What condition correctly describes "An immune response that leads to rash, itching, swelling, or difficulty breathing"? Hint: 2 words.
allergic reaction
Among the following diseases listed, select the ones that qualify for CCT.
ACS
CVA
Afib
acute MI
DKA
PTX
PE
sepsis
What condition correctly describes "translocation of a thrombus leading to dyspnea and hypoxia"? Use the abbreviation form of the condition. (Remember, do not include any spaces before or after the term/phrase.)
PE
Expand the following medical abbreviation. Remember, do not include any spaces before or after the term/phrase.e.g. Correct way "Good luck" vs incorrect " good luck ".What does "s/p" stand for?
status post
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? (Select the best option.)
Yes because the phone is not an approved hospital device and it is not encrypted.
A patient states she has had a productive cough for 4 days, and yesterday she developed a fever. Would her fever be considered an associated symptom for her productive cough? Why or why not?
Yes, because the fever started soon after the cough
T/F. All symptoms documented in the HPI are also documented in the ROS.
True
You are starting your shift and your physician immediately picks up 3 patients. The first patient is presenting with a productive cough steadily worsening since onset 4 weeks ago. The second patient has had abdominal discomfort slowly localizing into the right lower abdomen with accompanying fever over the last 6 hours and on PE, the patient has RLQ tenderness on palpation. The third patient has urinary sx and urinedip has already resulted and is positive for leukocytes and bacteria. Given the information, what might the most likely diagnoses' end up being for these patients?
pna, appendicitis, uti
Read through the PE and decide if this meets Level 5 billing criteria.
Genera/Constitutional: NC, AT
Eyes: PERRL, EOMI
ENT: moist oral mucosa
Cardiac: irregularly irregular rhythm, tachycardic, no murmurs, no rubs, no gallops
Respiratory: Lungs clear, no respiratory distress, no wheezing, no rales, no rhonchi
Neurological: A&O x 4
Psychiatric: normal affect
No, the PE does not meet Level 5 billing criteria.
Expand the following medical abbreviation. Remember, do not include any spaces before or after the term/phrase.e.g. Correct way "Good luck" vs incorrect " good luck ".What does "EOMI" stand for?
extraocular movements intact
What FHx/SHx information is usually asked for pediatric patients?
Second hand smoke exposure
Immunization status
Which of the following are considered to be cardiac risk factors for CP patients?
All
An 23-year-old female is brought in by EMS for a motor vehicle crash. Your physician verbalizes outloud that the patient appears to be on a backboard and her cervical spine is stabilized
with a hard collar. The patient also appears to be lethargic with obvious lacerations above her right eyebrow, left hand, and left thigh. Match the following exam findings with the appropriate organ system.
-patient back-boarded: back
-patient with a c-collar: neck
-patient lethargic: neurological
-lacerations to the right eyebrow, left hand, and left thigh: integumentary
Expand the following medical abbreviation. Remember, do not include any spaces before or after the term/phrase.e.g. Correct way "Good luck" vs incorrect " good luck ".What does "TIA" stand for?
transient ischemic attack
Expand the following medical abbreviation. Remember, do not include any spaces before or after the term/phrase.e.g. Correct way "Good luck" vs incorrect " good luck ".What does "IDDM" stand for? Do not include any hyphenations for your answer.
insulin dependent diabetes mellitus
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 onto his outstretched right hand and subsequently experienced localized pain and swelling to the his right wrist. An x-ray of the right wrist shows a distal radial fracture. Now that the 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? (Select all that apply.)
F/u with specialist or PCP
Specific conditions for return to the ED
Condition at time of disposition
Time period for f/u
Timing of disposition
Which of the following would belong in a psychiatric exam? (Select all that apply.)
Affect
Which of the following would NOT be considered an example of PHI? (select all that apply.)
None of the above
Consent should be documented any time a procedure is performed, but there 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? (Select the best response.)
CPR
Expand the following medical abbreviation. Remember, do not include any spaces before or after the term/phrase.e.g. Correct way "Good luck" vs incorrect " good luck ".What does "PNA" stand for?
pneumonia
You are writing an HPI for a very complex patient who has had multiple recent hospital admissions and several significant complaints; what is the best way to organize the information in your HPI?
Chronological order
Expand the following medical abbreviation. Remember, do not include any spaces before or after the term/phrase.e.g. Correct way "Good luck" vs incorrect " good luck ".What does "COPD" stand for?
chronic obstructive pulmonary disease
Expand the following medical abbreviation. Remember, do not include any spaces before or after the term/phrase.e.g. Correct way "Good luck" vs incorrect " good luck ".What does "DNR" stand for?
do not resuscitate
Medical Terminology: What is the medical term for "carotid artery cleaning"? (Remember, when typing your answer, do not include any spaces before or after the term/phrase. e.g. Correct way "Good luck" vs incorrect " good luck ".)
carotid endarterectomy
Expand the following medical abbreviation. Remember, do not include any spaces before or after the term/phrase.e.g. Correct way "Good luck" vs incorrect " good luck ".What does "NTG" stand for?
nitroglycerin
Which of these procedures qualify as critical care procedures and would indicate that critical care time must be documented on a patient? (select all that apply)
Sedation
LP
Cardioversion
Central line placement
Chest tube
CPR
Intubation
CPAP/BiPAP
T/F. It's the middle of the day. Your provider is busy dealing with a crtically ill patient and during this time the ED starts to pick up pace 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 patient on an insulin drip. You locate the nurse and relay the message. This scenario is acceptable and within the bounds of your scribe scope.
False
Expand the following medical abbreviation. Remember, do not include any spaces before or after the term/phrase.e.g. Correct way "Good luck" vs incorrect " good luck ".What does "GERD" stand for? (Hint: three words.)
gastroesophageal reflux disease
Fill in the blank: Critical care must be at least a minimum of
30 minutes
Which of the following diseases may be diagnosed using a CXR? (select all that apply.)
CHF
PTX
Rib fracture
PNA
What medical term describes "blood present in vomit"? (Remember, when typing your answer, do not include any spaces before or after the term/phrase. e.g. Correct way "Good luck" vs incorrect " good luck ".)
hematemesis
Expand the following medical abbreviation. Remember, do not include any spaces before or after the term/phrase.e.g. Correct way "Good luck" vs incorrect " good luck ".What does "LBBB" stand for?
left bundle branch block
What ROS system would include Dyspepsia, the medical term for indigestion?
Gastrointestinal
Your physician tells you the patient had a wood's lamp exam to look for fluorescein uptake. In which organ system would you document this physical exam finding?
Eyes
A 43-year-old 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.
PSHx: right BKA
ED Course: hyperglycemia and elevated ketones???Onset: 5 hrs ago
Disposition: admit
PMHx: type II
DMCC: Vomiting
Diagnosis: DKA
Expand the following medical abbreviation. Remember, do not include any spaces before or after the term/phrase.e.g. Correct way "Good luck" vs incorrect " good luck ".What does "GCS" stand for?
glasgow coma scale
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?
Location in the hospital
Consultation note with accepting physician
Condition at time of admission
Timing of admission
Name of the accepting physician
Match the normal grading scale with the corresponding PE finding.
reflexes: 2+
gcs: 15
strength: 5/5
Match each critical care dx with it's associated procedure.
Respiratory Failure: Intubation
Acute exacerbation: CPAP/BiPAP
Cardiac arrest: CPR
PTX: Chest Tube
Sepsis: central line placement
Abnormal heart rhythm: cardioversion
Expand the following medical abbreviation. Remember, do not include any spaces before or after the term/phrase.e.g. Correct way "Good luck" vs incorrect " good luck ".What does "CBC" stand for?
complete blood count
What is the medical term for "coughing up blood"? (Remember, when typing your answer, do not include any spaces before or after the term/phrase. e.g. Correct way "Good luck" vs incorrect " good luck ".)
hemoptysis
Diagnosis: Expand the following medical abbreviation into the full medical term. Remember, do not include any spaces before or after the term/phrase.e.g. Correct way "Good luck" vs incorrect " good luck ".What does "PE" stand for in the Diagnosis section of the chart?
pulmonary embolism
Select terms you might find on an x-ray interpretation
Pneumothorax
Infiltrate
A patient recently went on a boat trip 2 days ago and developed dizziness which has continued to persist since onset. She describes her dizziness as a room spinning and reports that it is accompanied by tinnitus, nausea, and vomiting. Physical exam is positive for Romberg's and Head CT is negative. Based on this information which is the most likely final diagnosis for the patient?
BPV
For chest pain patients, administering this medication can prevent onset of MI by thinning out the blood and improving blood flow to the heart. Because of this, it is important to document in the HPI if the patient received this medication, and if so who gave the medication and what was the dosage of the medication. What medication is important for meeting this core measure?
ASA
Diagnosis: What condition correctly describes "Fertilized egg develops outside the uterus"?
ectopic pregnancy
Which of the following tests would likely be immediately ordered for a Cardiac Workup in the ED?
CBC and BMP
Troponin
EKG
CXR
Which of the following would be ordered to investigate thyroid disease?
TSH
T3
T4
An ROS has marked positive for head trauma with accompanying LOC. What DDx would your provider be concerned about?
Hemorrhagic CVA
Match the following results with the corresponding diagnosis.
combination of (+) EKG and (+) blood work
STEMI
combination of (-) EKG and (+) blood work
NSTEMI
combination of (-) EKG and (-) blood work
no MI
What does ETT stand for? Fully expand the abbreviation. (Remember, do not include any spaces before or after the term/phrase. e.g. Correct way "Good luck" vs incorrect " good luck ".)
endotracheal tube
Match the oxygen administration route to the corresponding definition.
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 the patient's nostrils.
FM-A plastic mask fit over the nose and mouth.
Intubation-An ETT goes through the patient's mouth and down the trachea.
non-rebreather mask-A facial mask with a reservoir bag attached.
What procedure would be used to diagnose Meningitis? Expand the medical abbreviation into the full medical term. (Remember, do not include any spaces before or after the term/phrase. e.g. Correct way "Good luck" vs incorrect " good luck ".)
lumbar puncture
T/F. All symptoms documented in the ROS are also documented in the HPI.
False
A patient is seen in the emergency department complaining of dysuria and tells you that she is 23 weeks pregnant. Â Your doctor diagnoses her with a UTI. Â Which of the following would be the best diagnosis?
Acute urinary tract infection in pregnancy, 2nd trimester
Expand the following medical abbreviation. Remember, do not include any spaces before or after the term/phrase.e.g. Correct way "Good luck" vs incorrect " good luck ".What does "AMS" stand for?
altered mental status
What are the possible consequences of a HIPAA violation? (select all that apply)
ALL
Match the following Dx with it's patient presentation.
CHF-SOB + bilateral pedal edema + CP
asthma-SOB + wheezing on exam
PE-SOB + unilateral pedal edema + pleuritic CP
COPD-SOB + wheezing on exam + Shx of 3 ppd
Which of the following lab results need to be monitored closely for efficiency?
Creatinine
D-dimer
Troponin
Expand the following medical abbreviation. Remember, do not include any spaces before or after the term/phrase.e.g. Correct way "Good luck" vs incorrect " good luck ".What does "URI" stand for?
upper respiratory infection
How would you diagnose a pneumothorax? Hint: use abbreviation. (Remember, do not include any spaces before or after the term/phrase. e.g. Correct way "Good luck" vs incorrect " good luck ".)
CXR
A 45 year old male presents to the ED with a constant, ripping, tearing pain to his central chest radiating straight to his back with associated nausea that began 1 hour ago. What element is constant?
timing
What term describes "the patient destination is home"? (Remember, do not include any spaces before or after the term/phrase. e.g. Correct way "Good luck" vs incorrect " good luck ".)
discharged
Medical terminology. What is the medical term for infection of the gall bladder? (Remember, when typing your answer, do not include any spaces before or after the term/phrase. e.g. Correct way "Good luck" vs incorrect " good luck ".)
Cholecystitis
Medical terminology. What is the medical term for stones in the gallbladder? (Remember, when typing your answer, do not include any spaces before or after the term/phrase. e.g. Correct way "Good luck" vs incorrect " good luck ".)
cholelithiasis
How would you diagnose an AAA?
CT A/P with IV contrast
Which of the following would be documented in ED Course? (select all that apply.)
Orders
Interpretations
Re-evals
Treatments
What condition correctly describes "A vascular change that temporarily deprives a part of the brain of oxygen but does not result in any long lasting deficits"? Use the abbreviation form of the condition. (Remember, do not include any spaces before or after the term/phrase.)
TIA
What is the medical term for "bright red blood in stools"? (Remember, when typing your answer, do not include any spaces before or after the term/phrase. e.g. Correct way "Good luck" vs incorrect " good luck ".)
hematochezia
A 45 year old male presents to the ED with a ripping, tearing pain to his central chest radiating straight to his back with associated nausea that began 1 hour ago. What emergency conditions (ideally from what you have learned in CRT) from the following list may explain the patient's symptoms?
MI and Aortic Dissection
Select the EKG interpretation documentation guidelines. (select all that apply.)
Rate and rhythm
2 positive or negative findings
Location is an important element that can paint a picture for concerning DDx. Match location with the corresponding DDx.
LLQ-diverticulitis
RUQ-gall bladder disease
LUQ-pancreatic disease
RLQ-appendicitis
George is employed with SA as a scribe. He was off today and accidentally cut his cheek while practicing his sword 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 the appropriate steps in this situation?
No, because George accessed his own medical record using his EMR login.
Expand the following medical abbreviation. Remember, do not include any spaces before or after the term/phrase.e.g. Correct way "Good luck" vs incorrect " good luck ".What does "AAA" stand for?
abdominal aortic aneurysm
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 section of the chart?
No, the PHx does not meet Level 5 billing criteria.
Medical Terminology: Expand the following medical abbreviation into the full medical term. Remember, do not include any spaces before or after the term/phrase.e.g. Correct way "Good luck" vs incorrect " good luck ".What does the DP stand for in "DP pulse"?
dorsalis pedis
A female patient has been pregnant four times in the past, is currently pregnant, and has two children at home. Calculate the G, P and A, respectively. (Type your answer using the following format: "G,P,A" "#,#,#"; so for example you woud type 0,0,0 with no spaces before or after the answer)
5,2,2
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? HINT: it's an abbreviation. (Remember, do not include any spaces before or after the term/phrase. e.g. Correct way "Good luck" vs incorrect " good luck ".)
csmt
Match the following description to the appropriate team member. Do not change the positioning of an answer after it is placed.
??
What medical term describes "noticeable blood in the urine"? (Remember, when typing your answer, do not include any spaces before or after the term/phrase. e.g. Correct way "Good luck" vs incorrect " good luck ".)
hematuria
Medical Terminology: Expand the following medical abbreviation into the full medical term. Remember, do not include any spaces before or after the term/phrase.e.g. Correct way "Good luck" vs incorrect " good luck ".What does "PTX" stand for?
pneumothorax
Certain words or phrases act as "red flags" to grab your provider's attention to let let them know that a patient may require timely and comprehensive medical action. Which of the following words or phrases are NOT considered a "red flag?"
"nocturia" in a 65 y/o male
What is the medical term for painful urination? (Remember, when typing your answer, do not include any spaces before or after the term/phrase. e.g. Correct way "Good luck" vs incorrect " good luck ".)
dysuria
Which section of the chart would you find AKA?
PSHx
PE
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