Nicolette Natale is a dedicated healthcare professional with a diverse background in medicine and education. She holds a Doctor of Osteopathic Medicine degree from Nova Southeastern University, as well as Bachelor's degrees in English Literature and Psychology from the University of Miami. With over 6 years of experience, Nicolette is a physician, research coordinator, and medical writer who is committed to advancing medical research and providing quality patient care.
, DO (Medicine)
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Welcome to the Medical Scribe test questions Quiz! This engaging quiz will test your knowledge and skills as a medical scribe. Get ready to answer questions about charting, patient encounters, coding, and ensuring accurate and comprehensive medical records. This quiz will challenge your ability to prioritize information, understand physician instructions, and maintain confidentiality. Whether you're a seasoned medical scribe or looking to enhance your knowledge in the field, this quiz will provide an interactive learning experience. Let's see how well you can document and support healthcare professionals effectively! If you like this quiz, share it with your friends.
Questions and Answers
1.
Provide the proper medical term:
Removal of appendix: ____________________________________________________________
Explanation The proper medical term for the removal of the appendix is appendectomy.
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2.
Provide the proper medical term:
Removal of tonsils: ______________________________________________________________
Explanation Tonsillectomy is the correct medical term for the removal of tonsils. This surgical procedure involves the complete removal of the tonsils, which are located at the back of the throat. Tonsillectomy is often performed to treat chronic or recurrent tonsillitis, sleep apnea, or other conditions that affect the tonsils. It is a common procedure, especially in children, and can help alleviate symptoms and improve overall health.
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3.
Provide the proper medical term:
Placement of ear tubes: __________________________________________________________
Explanation The proper medical term for the placement of ear tubes is myringotomy or tympanostomy. This procedure involves making a small incision in the eardrum to drain fluid and relieve pressure in the middle ear. Ear tubes are then inserted into the incision to allow for proper ventilation and drainage. This procedure is commonly performed to treat recurrent ear infections or persistent fluid buildup in the middle ear.
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4.
Provide the proper medical term:
Removal of gallbladder: __________________________________________________________
Explanation Cholecystectomy is the medical term used to describe the surgical removal of the gallbladder. This procedure is often performed to treat conditions such as gallstones, inflammation of the gallbladder, or gallbladder cancer. During a cholecystectomy, the gallbladder is carefully dissected and removed, either through traditional open surgery or minimally invasive laparoscopic techniques. After the gallbladder is removed, bile flows directly from the liver into the small intestine, bypassing the gallbladder. This procedure is considered safe and effective in relieving symptoms and preventing complications associated with gallbladder diseases.
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5.
Provide the proper medical term:
Removal of kidney: ______________________________________________________________
Explanation The proper medical term for the removal of a kidney is nephrectomy. This term is derived from the Greek word "nephros" meaning kidney and "ektomē" meaning removal. Nephrectomy is a surgical procedure that is performed for various reasons, such as treating kidney cancer, removing a non-functioning or diseased kidney, or for kidney donation. During a nephrectomy, the surgeon removes the entire kidney or a portion of it, depending on the specific condition and the patient's needs.
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6.
Provide the proper medical term:
Removal of colon: _______________________________________________________________
Explanation Colectomy refers to the surgical procedure of removing the colon. It is commonly performed to treat conditions such as colon cancer, diverticulitis, inflammatory bowel disease, or severe constipation. During a colectomy, the diseased or damaged part of the colon is removed, and the remaining healthy sections are reconnected. In some cases, a colostomy or ileostomy may be created to allow waste to exit the body through an opening in the abdomen.
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7.
Provide the proper medical term:
Removal of uterus: ______________________________________________________________
Explanation Hysterectomy is the medical term for the surgical removal of the uterus. It is a common procedure performed for various reasons, such as treating uterine fibroids, endometriosis, or certain types of cancer. Hysterectomy can be performed through different methods, including abdominal, vaginal, or laparoscopic approaches. After the uterus is removed, a woman will no longer be able to conceive or carry a pregnancy.
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8.
Provide the proper medical term:
"Tubes tied": ___________________________________________________________________
Explanation "Tubes tied" is a colloquial term used to describe the medical procedure called tubal ligation. This procedure involves the surgical blocking or sealing of the fallopian tubes to prevent eggs from traveling from the ovaries to the uterus, thus preventing pregnancy. It is a permanent form of contraception and is commonly chosen by individuals who do not wish to have any more children.
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9.
Provide the proper medical term:
Removal of fallopian tubes and ovaries: ______________________________________________
Explanation Salpingo-oophorectomy is the medical term used to describe the surgical removal of both the fallopian tubes and ovaries. This procedure is often performed for various reasons, including the prevention or treatment of certain gynecological conditions such as ovarian cancer, pelvic inflammatory disease, or severe endometriosis. By removing the fallopian tubes and ovaries, hormonal production and fertility are affected, and the patient may experience menopause-like symptoms if not already in menopause.
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10.
Provide the proper medical term:
Hernia Repair: __________________________________________________________________
Explanation Herniorrhaphy is the correct medical term for hernia repair. It is a surgical procedure that involves closing the defect or weakness in the abdominal wall through sutures or mesh. This procedure helps to prevent the protrusion of organs or tissues through the weakened area, reducing pain and discomfort caused by the hernia.
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11.
Provide the proper medical term:
High Cholesterol: ________________________________________________________________
Explanation High cholesterol refers to the presence of elevated levels of cholesterol in the blood. Cholesterol is a type of lipid, hence the term "hyperlipidemia." Additionally, high cholesterol specifically refers to elevated levels of LDL cholesterol, often referred to as "bad" cholesterol, which can lead to the buildup of plaque in the arteries. Therefore, the term "hypercholesterolemia" is also appropriate, as it specifically refers to the presence of high levels of cholesterol in the blood.
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12.
Provide the proper medical term:
High Blood Pressure: _____________________________________________________________
Explanation High blood pressure is commonly referred to as hypertension in medical terminology.
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13.
Define the acronym:
AKA: __________________________________________________________________________
Explanation The acronym AKA stands for "above the knee amputation." This refers to a surgical procedure in which a patient's leg is amputated above the knee joint. This procedure is typically done to remove a diseased or damaged limb, often due to trauma or a medical condition. The amputation allows for the use of a prosthetic limb to aid in mobility and functionality.
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14.
Define the acronym:
BKA: __________________________________________________________________________
Explanation The acronym BKA stands for below the knee amputation. This refers to a surgical procedure where a person's leg is amputated below the knee joint. This may be necessary due to various reasons such as severe trauma, infection, or disease. By removing the leg below the knee, individuals can be fitted with a prosthetic limb to regain mobility and functionality.
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15.
Define the acronym:
Sz: ____________________________________________________________________________
Explanation The acronym "Sz" stands for seizure. A seizure is a sudden and uncontrolled electrical disturbance in the brain that can cause changes in behavior, movements, or feelings. It is often associated with conditions such as epilepsy.
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16.
Define the acronym:
ExLap: _________________________________________________________________________
Explanation ExLap is an acronym that stands for exploratory laparotomy. This surgical procedure involves making an incision in the abdomen to visually inspect and examine the organs and tissues inside. It is typically performed when the cause of a patient's symptoms or condition cannot be determined through non-invasive diagnostic tests. During an exploratory laparotomy, the surgeon can identify and potentially treat any abnormalities or issues found, such as tumors, infections, or internal bleeding. This procedure allows for a more accurate diagnosis and can guide further treatment options.
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17.
Define the acronym:
HTN: __________________________________________________________________________
Explanation The acronym HTN stands for hypertension. Hypertension is a medical condition characterized by high blood pressure. It is a chronic condition that can lead to serious health complications if left untreated. Hypertension is often referred to as the "silent killer" because it typically does not cause noticeable symptoms until it has reached an advanced stage. It is important to manage and control hypertension through lifestyle changes and medication to reduce the risk of heart disease, stroke, and other related complications.
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18.
Define the acronym:
CA: ___________________________________________________________________________
Explanation The acronym CA stands for cancer.
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19.
Define the acronym:
IDDM: _________________________________________________________________________
Explanation IDDM stands for Insulin Dependent Diabetes Mellitus. This acronym is used to define a type of diabetes in which the body is unable to produce enough insulin to regulate blood sugar levels effectively. People with IDDM require regular insulin injections to manage their blood sugar levels and prevent complications associated with diabetes.
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20.
Define the acronym:
NIDDM: _______________________________________________________________________
Explanation NIDDM stands for Non-Insulin Dependent Diabetes Mellitus. This acronym is used to describe a type of diabetes where the body is unable to effectively use insulin, resulting in high blood sugar levels. Unlike insulin-dependent diabetes, individuals with NIDDM do not require insulin injections for survival. Instead, they can often manage their condition through lifestyle changes such as diet and exercise, as well as oral medications that help control blood sugar levels.
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21.
Define the acronym:
MI: ___________________________________________________________________________
Explanation MI stands for myocardial infarction, which refers to a medical condition commonly known as a heart attack. It occurs when there is a blockage in the blood flow to the heart, leading to the death of heart muscle cells due to lack of oxygen. This can result in severe chest pain, shortness of breath, and potential damage to the heart. Immediate medical attention is crucial to prevent further complications and potentially save a person's life.
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22.
Define the acronym:
CAD: __________________________________________________________________________
Explanation CAD stands for Coronary Artery Disease. This is a medical condition that occurs when the blood vessels that supply oxygen and nutrients to the heart become narrow or blocked due to the buildup of plaque. This can lead to chest pain, shortness of breath, and even heart attacks. Managing CAD involves lifestyle changes, medications, and sometimes medical procedures to improve blood flow to the heart.
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23.
Define the acronym:
CHF: __________________________________________________________________________
Explanation The acronym CHF stands for congestive heart failure. Congestive heart failure is a medical condition in which the heart is unable to pump enough blood to meet the body's needs. This can lead to symptoms such as shortness of breath, fatigue, and fluid retention. It is a serious condition that requires medical intervention and management.
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24.
Define the acronym:
Afib: __________________________________________________________________________
Explanation Afib is an acronym that stands for atrial fibrillation. Atrial fibrillation is a heart condition characterized by irregular and often rapid heart rate. It occurs when the electrical signals in the upper chambers of the heart (atria) are chaotic, causing them to quiver instead of contracting normally. This can lead to poor blood flow, increased risk of blood clots, and other complications. Treatment options for atrial fibrillation include medication, lifestyle changes, and procedures like cardioversion or ablation.
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25.
Define the acronym:
PE: ___________________________________________________________________________
Explanation PE stands for pulmonary embolism, which is a potentially life-threatening condition where a blood clot blocks one of the arteries in the lungs. This can lead to symptoms such as shortness of breath, chest pain, and coughing up blood. On the other hand, PE can also stand for physical exam, which is a medical examination performed by a healthcare professional to assess a patient's overall health and detect any abnormalities or signs of illness.
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26.
Define the acronym:
COPD: _________________________________________________________________________
Explanation COPD stands for chronic obstructive pulmonary disease. This is a chronic lung disease that causes difficulty in breathing. It is typically caused by long-term exposure to irritants such as cigarette smoke, air pollution, or chemical fumes. COPD is characterized by symptoms such as coughing, wheezing, shortness of breath, and chest tightness. It is a progressive disease that worsens over time and can significantly impact a person's quality of life. Treatment for COPD focuses on managing symptoms, improving lung function, and preventing further damage to the lungs.
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27.
Define the acronym:
GERD: _________________________________________________________________________
Explanation GERD stands for gastro-esophageal reflux disease. This is a chronic condition where stomach acid flows back into the esophagus, causing symptoms such as heartburn, chest pain, and difficulty swallowing. The acronym helps to identify and refer to this specific medical condition, making it easier for healthcare professionals to communicate and diagnose patients.
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28.
Define the acronym:
AAA: __________________________________________________________________________
Explanation AAA stands for abdominal aortic aneurysm. An abdominal aortic aneurysm refers to the enlargement or ballooning of the aorta, the main blood vessel that supplies blood to the abdomen, pelvis, and legs. This condition can be dangerous as the weakened area of the aorta may rupture, leading to severe internal bleeding and potentially life-threatening complications. Prompt diagnosis and treatment are crucial to manage and prevent complications associated with abdominal aortic aneurysm.
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29.
What are the 5 vital signs?
30.
What does subjective mean? Objective?
31.
The HPI and ROS are what type of information?
A.
Subjective
B.
Objective
Correct Answer
A. Subjective
Explanation The HPI (History of Present Illness) and ROS (Review of Systems) are subjective types of information. This means that they are based on the patient's personal experiences, perceptions, and feelings. The HPI involves the patient's account of their current symptoms, while the ROS includes the patient's report of any additional symptoms or concerns. These subjective pieces of information are important in understanding the patient's medical history and current condition, and they help healthcare providers make accurate diagnoses and treatment plans.
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32.
The Physical Exam is what type of information?
A.
Subjective
B.
Objective
Correct Answer
B. Objective
Explanation The physical exam is considered objective information because it involves the observation and measurement of physical signs and symptoms. It focuses on factual and measurable data such as blood pressure, heart rate, temperature, and physical appearance. This information is obtained through direct observation, palpation, auscultation, and other physical examination techniques. Unlike subjective information, which relies on the patient's feelings, experiences, and perceptions, the physical exam provides objective data that can be independently verified and interpreted by healthcare professionals.
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33.
While evaluating a patient complaining of dyspnea, your physician tells you that the breath sounds are normal. Where would you document this?
A.
HPI
B.
PMHx
C.
ROS
D.
PE
Correct Answer
D. PE
Explanation In this scenario, the correct place to document that the breath sounds are normal would be in the Physical Examination (PE) section. The PE section is where the healthcare provider records their findings from the physical examination of the patient, including any abnormal or normal findings related to the patient's symptoms. In this case, since the physician is evaluating the patient's breath sounds and determines them to be normal, it would be documented in the PE section.
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34.
What is the difference between the HPI and ROS?
35.
What is MDM? In your explaination use the terms: patient’s story, physical exam, orders, differential diagnosis, final diagnosis.
36.
What is an MI? What causes an MI? What are the risk factors? What would be the CC of someone with an MI? Name some associated symptoms of an MI? Name 2 ways an MI can be diagnosed?
37.
What is CHF? What could be a CC of a person with CHF? What are some associated symptoms for CHF? What 2 studies would diagnose CHF?
38.
What is A fib? What might someone feel with A-Fib? How is an A-Fib diagnosed?
39.
What could be the CC of someone with a PE? What are risk factors for a PE? What study would diagnose a PE?
40.
Which of the symptoms below can occur with a "true" allergic reaction?
A.
Vomiting
B.
Nausea
C.
Rash
D.
Headache
Correct Answer
C. Rash
Explanation A rash can occur as a symptom of a "true" allergic reaction. Allergic reactions are caused by the immune system's response to an allergen, which can trigger various symptoms such as itching, redness, and swelling of the skin, leading to the development of a rash. This reaction is known as allergic dermatitis and can range from mild to severe, depending on the individual's sensitivity to the allergen. Therefore, experiencing a rash is a common manifestation of an allergic reaction.
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41.
What is cellulitis? What are 3 symptoms of cellulitis?
42.
What is the difference between altered mental status (AMS) and a focal neurologic deficit?
43.
Provide examples of a focal neurologic deficit?
44.
What study would diagnose a PE?
A.
CXR
B.
Ultrasound of the Chest
C.
CT Chest
D.
CTA Chest
Correct Answer
D. CTA Chest
Explanation A PE (pulmonary embolism) is a blockage in one of the pulmonary arteries in the lungs, usually caused by a blood clot. To diagnose a PE, a CT (computed tomography) scan of the chest is typically performed. This imaging technique provides detailed images of the blood vessels in the lungs, allowing doctors to identify any blockages or abnormalities. A CT scan with contrast, known as CTA (CT angiography), is specifically used to visualize the blood vessels and is commonly used to diagnose a PE. Therefore, the correct answer is CTA Chest.
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45.
What study would diagnose a rib fracture?
A.
Ultrasound of the Chest
B.
EKG
C.
CXR / XR of ribs
D.
CT Abd/Pelvis without contrast
Correct Answer
C. CXR / XR of ribs
Explanation A rib fracture can be diagnosed through a CXR (chest X-ray) or XR (X-ray) of the ribs. This imaging study allows for the visualization of the bones in the chest area, including the ribs. By examining the X-ray images, a healthcare professional can identify any fractures or abnormalities in the ribs, confirming the diagnosis of a rib fracture. Ultrasound of the chest, EKG, and CT Abd/Pelvis without contrast are not typically used for diagnosing rib fractures.
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46.
What study would diagnose an ovarian torsion?
A.
CT Abd/Pelvis with PO contrast
B.
AAS XR (Acute Abdominal Series X-ray)
C.
Ultrasound of RUQ
D.
Pelvic Ultrasound (OB/Transvaginal)
Correct Answer
D. Pelvic Ultrasound (OB/Transvaginal)
Explanation A pelvic ultrasound, specifically an OB/transvaginal ultrasound, would be the appropriate study to diagnose an ovarian torsion. This type of ultrasound allows for a detailed examination of the pelvic organs, including the ovaries, and can help identify any twisting or torsion of the ovarian blood vessels. CT Abd/Pelvis with PO contrast and AAS XR (Acute Abdominal Series X-ray) are not typically used for diagnosing ovarian torsion. While an ultrasound of the RUQ (right upper quadrant) may be useful for evaluating other abdominal conditions, it would not specifically diagnose ovarian torsion.
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47.
What study would diagnose pancreatitis?
A.
Lipase
B.
WBC
C.
Amylase
D.
Abd XR
Correct Answer
A. Lipase
Explanation Pancreatitis is a condition characterized by inflammation of the pancreas. Lipase is an enzyme produced by the pancreas that helps in the digestion of fats. Elevated levels of lipase in the blood can indicate pancreatic inflammation, making it a diagnostic tool for pancreatitis. WBC (white blood cell) count can also be elevated in pancreatitis due to the body's immune response to the inflammation. Amylase is another enzyme produced by the pancreas, but it is not as specific for diagnosing pancreatitis as lipase. Abd XR (abdominal X-ray) is not a direct diagnostic test for pancreatitis and is usually used to evaluate other conditions.
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48.
What study would diagnose CAD?
A.
EKG
B.
CT Chest
C.
Cardiac Catheterization
D.
CXR
Correct Answer
C. Cardiac Catheterization
Explanation Cardiac catheterization is a diagnostic procedure used to diagnose coronary artery disease (CAD). It involves inserting a catheter into a blood vessel and guiding it to the heart to measure blood flow and pressure, as well as to identify any blockages or abnormalities in the coronary arteries. This procedure provides more detailed information about the extent and severity of CAD compared to other diagnostic tests such as EKG, CT chest, and CXR, making it the most appropriate study for diagnosing CAD.
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49.
What study will diagnose A.fib?
A.
WBC
B.
BNP
C.
Digoxin Level
D.
EKG
Correct Answer
D. EKG
Explanation An electrocardiogram (EKG) is a diagnostic test that measures the electrical activity of the heart. It can detect abnormal heart rhythms, such as atrial fibrillation (A.fib). A.fib is a condition where the heart's upper chambers beat irregularly and often too fast. By analyzing the patterns on the EKG, healthcare professionals can diagnose A.fib and determine the appropriate treatment plan. WBC (white blood cell count), BNP (brain natriuretic peptide), and digoxin level are not specific tests for diagnosing A.fib.
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50.
An indicator for CHF(congestive heart failure) is elevated levels of BNP (B-type natriuretic peptide).
A.
True
B.
False
Correct Answer
A. True
Explanation Elevated levels of BNP (B-type natriuretic peptide) serve as an indicator for congestive heart failure (CHF). BNP is a hormone released by the heart in response to increased pressure and stretching of the heart muscle, which occurs in CHF. Therefore, if BNP levels are elevated, it suggests the presence of CHF.
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Nicolette Natale |DO (Medicine)|
Physician and Medical Writer
Nicolette Natale is a dedicated healthcare professional with a diverse background in medicine and education. She holds a Doctor of Osteopathic Medicine degree from Nova Southeastern University, as well as Bachelor's degrees in English Literature and Psychology from the University of Miami. With over 6 years of experience, Nicolette is a physician, research coordinator, and medical writer who is committed to advancing medical research and providing quality patient care.
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