Scribe America OP Final Exam practice review questions with correct answers

New Patient No previous records, longer visit, detailed chart established patient Previous records available from last 3 years, shorter visit, concise chart 00:24 01:33 Diagnostic visit New problem, chief complaint: new symptom, goal is to determine the cause of the problem and appropriate treatment health management check up, CC: routine physical or management of chronic problems, goal is preventative care and/or assessing progress of ongoing medical problems Clinic Flow 1. Check-in 2. Physician Evaluation 3. Orders & Results 4. Assessment & Plan 5. Check-out Quality Measures chief complaint vital signs height, weight, BMI Smoking Status What goes in the History and Physical (H&P) HPI, ROS, PE DDx differential diagnosis Patient says high blood pressure Hypertension (HTN) Patient says high cholesterol Hyperlipidemia (HLD) Patient says thyroid problem Usually Hypothyroidism, sometimes Hyperthyroidism Patient says diabetes Diabetes Mellitus (DM) Patient says "I only take pills for my diabetes" Non-Insulin Dependent Diabetes Mellitus (NIDDM) Patient says "I take shots for my diabetes" Insulin Dependent Diabetes Mellitus (IDDM) Patient says heart disease Coronary Artery Disease (CAD) Patient says heart attack Myocardial Infarction (MI) and CAD Patient says heart failure Congestive Heart Failure (CHF) Patient says Irregular heartbeat arrhythmia Patient says murmur heart murmur Patient says episodes of abnormally fast/racing heartbeat supraventricular tachycardia (SVT) Patient says asthma asthma Patient says Emphysema/Chronic Bronchitis Chronic Obstructive Pulmonary Disease (COPD) Patient says blood clot in lung Pulmonary Embolism (PE) Patient says pneumonia Pneumonia (PNA) Patient says reflux Gastroesophageal Reflux Disease (GERD) Patient says ulcer Gastric Ulcer or Peptic Ulcer Disease (PUD) Patient says pancreatitis pancreatitis Patient says hepatitis Hepatitis A, B, or C Patient says diverticulitis Diverticulitis Patient says Crohn's/UC Crohn's Disease or Ulcerative Colitis Patient says irritable bowel Irritable Bowel Syndrome (IBS) Patient says bladder infection Urinary Tract Infection (UTI) Patient says kidney infection Pyelonephritis (Pyelo) Patient says kidney stones renal calculi Patient says I'm on dialysis Chronic Renal Failure (CRF) or End Stage Renal Disease (ESRD) on dialysis Patient says enlarged prostate Benign Prostate Hypertrophy (BPH) Gravida Total number of time the patient has been pregnant Para number of pregnancies reaching viable gestational age (23 weeks) that the patient has had Abortus total number of miscarriages or elective abortions patient says brain bleed (stroke) Hemorrhagic CVA Patient says stroke Cerebrovascular Accident (CVA) Patient says mini-stroke Transient Ischemic Attack (TIA) Patient says seizures Seizure disorder/Epilepsy Patient says bipolar bipolar disorder Patient says schizophrenia schizophrenia Patient says I drink a lot ETOH abuse or alcoholism Patient says I do drugs substance abuse Patient says Blood clot in my leg Lower Extremity Deep Vein Thrombosis (DVT)