Scribe America Outpatient Final Exam 2023 with complete solution

subjective vs objective feeling vs fact pain vs tenderness patients feeling vs physicians assessment benign normal, nothing of concern acute vs chronic new onset vs long standing baseline an individuals normal state of being ausculation listening to sound with a stethoscope palpation act of pressing on an area (by the physician) inpatient admitted to the hospital overnight outpatient seen and sent home the same day chief complaint main reason for the patients visit meaningful use set of government mandated criteria that must be obtained for every patient medical decision making physicians though process Scribes can... document history, physician exam, results, procedures. access and document laboratory and radiology findings. locate and obtain PMHx, previous charts, past results. Scribes cannot... partake in any activity that may affect patient health, touch patients, handle bodily fluids, sign any charts, give verbal orders or submit electronic orders. are physician assistants and nurse practitioners considered medical providers? YES T/F: The scribe can listen to a patient's heart and lungs as long as it is for learning purposes and under the supervision of the physician. False Lucy has been seen by Dr. Heart for the past 2 years. She is here today for a routine appointment with Dr. Heart. Is Lucy a new or established patient? Established a patient made an appointment because she developed a rash a few days ago. what type of visit would this be? diagnostic diagnostic visits consist of new problems, new symptoms health management visits consist of check-ups, management visits a patient has an appointment for management of her diabetes. what type of visit would this be? health management who is the first person to speak with the patient after he/she is place in a room? Nurse/MA What are the meaningful use requirements the nurse/MA will obtain? Chief complaint; Vital signs (HR, BP, T, RR), Height, weight, BMI; Smoking status What does H&P abbreviate and who performs this evaluation? history and physical, performed by the provider Is a differential diagnosis necessary for a health maintenance visit? nope. what information will be included in the patient's plan? give 3 examples. F/U for specialist, instructions for lifestyle, F/U for next routine appointment name the 8 elements of the HPI Location, Quality, Severity, Context, Timing, Duration, Associated signs and symptoms, Modifying factors polydipsia excessive thirst paresthesia sensation of tingling or numbness anticoagulant a drug that prevents blood clotting chronic illness longer than 3 months if a patient has had respiratory symptoms for the past 5 weeks, are the symptoms considered chronic? No Having multiple comorbidities increases the __________ of patient care complexity List two ways comorbidity increases complexity? -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 plan (mo' drugs, mo' problems) -If both illnesses affect a specific organ system, the patient is at increased risk of organ failure Type 2 diabetes the inadequacy of insulin in controlling the blood glucose level (insulin resistance) diabetes risk factors obesity, high carb diet, lack of exercise, HTN, HLD, FHx chief complaint of diabetes weight loss or gain. polyuria, polydipsia, blurred vision, fatigue physical exam diabetes distal paresthesias, pedal edema, weight change diagnosis of diabetes fasting blood glucose, hemoglobin A1c Diseases caused by diabetes peripheral neuropathy, PVD, Diabetic retinopathy, renal failure, cardiac disease non-pharmacological management for DM weight loss, low-carb diet, exercise, blood glucose log you can take oral medication for what kind of diabetes? type 2 (you can do insulin and oral meds) what kind of medications can you take for DM? Injected: Humalog, Lantus Oral: Metformin, Glyburide with sliding scale insulin treatment, the patient adjusts the dosage of insulin based on____________. current glucose Name two body systems that would be at increased risk of failure if the patient had both HTN and DM. renal and cardiovascular SOAP subjective, objective, assessment, plan History of Present Illness (HPI) story of the patient's chief complaint What are the 3 primary methods of structuring an outpatient HPI? Single complaint formula, multiple complain formula, chronological complain formula Which HPI structure is best to use for a complex patient with multiple comorbidities and a recent work-up? chronological What are four important details to include in the HPI of a patient who has been evaluated by another healthcare provider for similar symptoms? Who ordered the test (name and specialty), specific name of test, results, diagnosis given to patient. review of systems Head-to-toe checklist of patient's symptoms intermittent comes and goes waxing and waning always present but changing in intensity modifying factor something that makes a symptoms better or worse exacerbate to make worse Subjective includes what? chief complaint, HPI, ROS Where is the past history? PMHx, SHx, FHx are their own section under the S and above the O Objective includes what? vital signs, PE, Orders, Results Assessment includes what? the patient's diagnosis, description of progress since last visit Plan includes what? F/U and treatment for each diagnosis T/F: The structure of the SOAP note closely follows the clinic flow True T/F: You will usually document the assessment before documenting the HPI? False The doctor says to the patient, "I'd like you to follow up with your GI doctor in the next two weeks." In what section of the SOAP note does this belong? Plan Importance of the chief complaint its what brought the patient in, ALSO, billing, w/o it, you cant be reimbursed what words can you add to your chief complaint to make it reimbursable management or treatment. (ex. 3 month diabetes management visit, Discuss treatment options for elevated TSH, evaluation of medication management for HTN) The HPI is the... story and context of the patient's chief complaint T/F: Abbreviations are permitted in the HPI as long as they are approved medical abbreviations True T/F: It is okay for scribes to misspell words because doctors do it all the time False How would you document the onset of symptoms that began on Wednesday? x days ago If the patient says, "It hurts when I touch it," what would you write in the HPI? Symptoms worsened by palpation of the area. thyroid problem hypothyroidism or hyperthyroidism it only take pills for my diabetes non-insulin dependent diabetes mellitus (NIDDM) heart disease Usually Coronary Artery Disease (CAD) heart attack Myocardial Infarction (MI) and CAD heart failure Congestive Heart Failure (CHF) irregular heartbeat Atrial Fibrillation (A-Fib) Episodes of abnormally fast/racing heartbeat Supraventricular Tachycardia (SVT) emphysema/chronic bronchitis Chronic Obstructive Pulmonary Disease (COPD) blood clot in the lung Pulmonary Embolism (PE) reflux Gastroesophageal Reflux Disease (GERD) ulcer Gastric Ulcer or Peptic Ulcer Disease (PUD) kidney infection Pyelonephritis (Pyelo) "I'm on dialysis" means... Chronic Renal Failure (CRF) on dialysis How would you document the past history for a patient who is currently pregnant, has been pregnant 3 times in the past, and has 2 kids at home? G: 4, P: 2, A: 1 stroke Cerebrovascular Accident (CVA) minor-stroke Transient Ischemic Attack (TIA) brain bleed Hemorrhagic CVA "Blood clot in my leg" Lower Extremity Deep Vein Thrombosis (DVT) "bulge in my aorta" Abdominal Aortic Aneurysm (AAA) "bad blood flow to my legs" Peripheral Vascular Disease (PVD) bulging disc Herniated Disk [Note: Patient may also have Degenerative Disc Disease (DDD)] arthritis Usually Osteoarthritis (OA) sometimes Rheumatoid Arthritis (RA) joint pain (chronic) Degenerative Joint Disease (DJD) weak/fragile bones osteoporosis A & T adenoidectomy & tonsillectomy heart bypass Coronary Artery Bypass Graft (CABG) -- PMHx CAD stents Coronary Stents -- PMHx CAD heart cath cardiac catheterization balloon Angioplasty -- PMHx CAD valve surgery Valve repair or replacement (Bovine vs. Mechanical)