Scribe America OP Final Exam with 100% Correct Answers 2023

pain vs tenderness - Correct answer-patient's feeling vs physician's assessment acute vs chronic - Correct answer-new onset vs long standing Meaningful Use (MU) - Correct answer-a set of government mandated criteria that must be obtained for every patient Medical decision making - Correct answer-the physician's thought process Mid-level providers: - Correct answer-Nurse Practitioner (LNP) or Physician's Assistant (PA) that works under the supervision of a physician to diagnose and treat patients Nurse or Medical Assistant - Correct answer-records medical histories and symptoms, monitors the patient, completes meaning use requirements, administers medications, assists with procedures Receptionist - Correct answer-answers phone calls, schedules appointments, answers patient questions, provides patient with summary of visit and written instructions from provider at check-out, and organizes the patient's paperwork Scribe - Correct answer-documents the patient's visit on behalf of the physician Scribes CANNOT... - Correct answer--partake in any activity that may affect patient health or outcome -touch patients -handle bodily fluids or specimens -sign or authenticate any chart or record -give verbal orders or submit electronic orders Scribes CAN... - Correct answer--document the history, physical exam, results, procedures, assessment and plan -access and document laboratory results and radiology findings -locate and obtain PMHx, previous charts, past results, and recent studies -Record physician interpretations of x-rays and EKGs New patients - Correct answer--no previous records -longer visit -detailed chart -if patient hasn't been seen in 3 years at the clinic, they are considered new Established patients - Correct answer--previous records available -shorter visit -concise chart -must've been seen in the clinic in the last three years Diagnostic visit - Correct answer--new problem -CC: new symptom -goal is to determine the cause of the problem and appropriate treatment -differential diagnosis is necessary Health Maintenance visit - Correct answer--check-up -CC: management of chronic problem -goal is to assess progress of ongoing/chronic medical problems allergy - Correct answer-a medication that causes a rash, itching, swelling, or difficulty breathing -if these symptoms not seen, it is an "adverse reaction", not an allergy Hypertension (HTN) - Correct answer-high blood pressure Hyperlipidemia (HLD) - Correct answer-high cholesterol Normal heart rate - Correct answer-60-100 bpm Pulmonary Embolism (PE) - Correct answer-blood clot in lung Gravida/Para/Abortion - Correct answer-G - the total number of times the patient has been pregnant P - the # of live births the pt has had A - the # of miscarriages or elective abortions Cerebrovascular Accident (CVA) - Correct answer-stroke Transient Ischemic Attack (TIA) - Correct answer-mini-stroke Tonsillectomy - Correct answer-tonsils removed Adenoidectomy - Correct answer-adenoids removed Coronary Artery Bypass Graft - Correct answer-heart bypass (PMHx CAD) Angioplasty - Correct answer-balloon Automatic Implanted Cardiac-Defribrillator (AICD) - Correct answer-defibrillator Mastectomy - Correct answer-breast removal Partial Lobectomy - Correct answer-part of lung removed Appendectomy - Correct answer-appendix removed Cholecystectomy - Correct answer-gallbladder removed Herniorrhaphy - Correct answer-hernia repair Colostomy - Correct answer-bag to collect stool Splenectomy - Correct answer-spleen removed Hysterectomy - Correct answer-Uterus removed (partial or total) Oophorectomy - Correct answer-ovary removed Salpingo-oophorectomy - Correct answer-ovary and fallopian tubes removed Prostatectomy - Correct answer-prostate removed Nephrectomy - Correct answer-kidney removed Arteriovenous Fistula - Correct answer-directly connecting an artery to a vein Arteriovenous Graft - Correct answer-synthetic tube under the skin to connect artery and vein Arthroplasty - Correct answer-Joint repair - to relieve pain, or restructure a joint Relevant FHx - Correct answer--HTN, DM, CA - MI/CAD with age of onset less than 55 y/o -PE, asthma -Crohns, IBS -CVA, aneurysm, seizures -sickle cell anemia, DVT Social History of note - Correct answer--tobacco use -alcohol use -illicit drug use -occupation -living circumstances Pediatric social history of note - Correct answer--caretaker (mother, father, grandparent) -attends daycare -attends school -has brothers/sisters -second hand smoke exposure -immunizations up to date Three most common routes of administrations of illicit drugs - Correct answer-oral, inhalation, injection Etiology - Correct answer-the cause of a disease systole (systolic) - Correct answer-the phase of the heartbeat during which the muscle contracts, pumping blood to the body Diastolic - Correct answer-phase of the heartbeat during which muscle is relaxed and the heart fills with blood Diuretic - Correct answer-a substance that promotes the production of urine Paresthesia - Correct answer-sensation of tingling or numbness Polydipsia - Correct answer-excessive thirst Ischemia - Correct answer-loss of blood supply to tissue -of note: NOT infarct, infarct is when ischemia leads to infarct Why are comorbidities more complex in terms of patient care? - Correct answer--the treatment of one disease may affect or contradict the treatment of the second -adverse drug interactions -compounding symptoms may lead to poor compliance with treatment plans -if both illnesses affect a specific organ system, the patient is at increased risk of organ failure For complex patients, it is important to document: - Correct answer--symptoms in chronological order -the status and progress of each illness -level of compliance with treatment plan Chronic illness - Correct answer-lasting longer than 3 months HTN etiology - Correct answer-an increase in blood pressure causes excess force against the arterial walls HTN risk factors - Correct answer-FHx of HTN, obesity, DM, high sodium diet, smoking, ETOH use HTN CC - Correct answer--often asymptomatic -headache, chest pain, palpitations, blurred vision, epistaxis HTN PE - Correct answer-lower extremity edema, carotid bruit, JVD, abnormal heart sounds HTN is diagnosed by - Correct answer-BP check and monitoring with sphygmanometer Hypotensive - Correct answer-Sys: less than 90 Dys: less than 60 Normal BP - Correct answer-Sys: 90 to 120 Dys: 60 to 80 Prehypertensive - Correct answer-Sys: 121 to 140 Dys: 81 to 90 Hypertensive - Correct answer-Sys: greater than 140 Dys: greater than 90 If untreated, HTN can cause: - Correct answer--MI/CAD -CHF -CVA -Renal failure -Impaired vision HTN management - Correct answer--BP log -decreased ETOH intake -low-sodium diet -smoking cessation -exercise HTN pharmacological management - Correct answer--diuretics: Hydrochlorothiazide (HCTZ) -Beta blockers: Lopressor (metoprolol), Toprol (metoprolol), Tenormin (atenolol) -Ca Channel Blockers: Norvasc (amlopidine), Cardizem (diltiazem) -ACE inhibitors: Lotensin (benazepril), Zestril (lisinopril) -ARBs: Cozaar (losartin), Benicar (olmesartan) Type 1 DM - Correct answer-Juvenile or childhood -insulin dependent, ALWAYS type 2 DM - Correct answer-because of lifestyle -insulin resistance - consistently high blood glucose levels cause cells to become resistant to insulin Type 2 DM risk factors - Correct answer-obesity, high carb diet, lack of exercise, HTN, HLD, FHx Type 2 DM CC - Correct answer--unusual weight loss or gain -polyuria, polydipsia, blurred vision, fatigue, N/v Type 2 DM PE - Correct answer-distal paresthesias, pedal edema, weight change since last visit Type 2 DM Dx by - Correct answer-fasting blood glucose / hemoglobin A1c (average over last 3 months) Diseases caused by DM - Correct answer--Peripheral neuropathy -Peripheral vascular disease -diabetic retinopathy -renal failure -CAD DM non-pharmalogical management - Correct answer--Blood glucose log -weight loss -low-carb diet -exercise DM Pharmalogical management - Correct answer-Insulin (injected): -Humalog(before or after meals) -Lantus(once a day) -sliding scale (patient determines insulin dosage based on current glucose levels) Oral medication: -Metformin -Glyburide HLD etiology - Correct answer-an elevated level of lipid in the blood causes plaque build-up along arterial walls HLD risk factors - Correct answer-obesity, high lipid diet, physical inactivity, FHx, DM, ETOH use HLD CC - Correct answer--asymptomatic -typically diagnosed through routine bloodwork HLD Dx by - Correct answer-fasting bloodwork measuring cholesterol and triglyceride levels - resulting in elevated LDL HDL - Correct answer-high density lipoprotein -good cholesterol, we want HDL to be high LDL - Correct answer-low density lipoprotein -bad cholesterol, we want this to be low -aides in the formation of plaque on arterial walls Diseases caused by HLD - Correct answer--arterial atherosclerosis (thickening and hardening of vessel walls) -CAD/MI -CVA/TIA -Pancreatitis HLD non-pharmacological management - Correct answer--decrease ETOH intake -lose weight -close follow-up -exercise -change diet: avoid fatty foods, eat high fiber and high omega 3` HLD pharmacological management - Correct answer-"statins" inhibit the production of cholesterol: -Lipitor (Atorvostatin) -Crestor (rosuvastatin) -Zocor (simuastatin) Cardiac triple threat - Correct answer-when a patient has HLD, HTN, and CAD CAD etiology - Correct answer-narrowing of the coronary arteries limits blood supply to the heart muscle causing ischemia CAD risk factors - Correct answer-HTN, HLD, DM, smoking, FHx 55 y/o CAD CC - Correct answer--chest pain or pressure -worse with exertion, improved with rest or nitroglycerin CAD associated medications - Correct answer-ASA, NTG (nitroglycerine) - blood thinning medications CAD Dx by - Correct answer-cardiac catheterization by cardiologist CAD non-pharmacological management - Correct answer--control risk factors -weight loss -manage stress and depression -smoking cessation -exercise CAD surgical management - Correct answer-increasing in invasiveness: -Cardiac catheter: diagnosis CAD -Angioplasty: balloon insertion -Stent: tubing inserted -CABG: invasive open heart surgery to bypass area of blockage