ScribeAmerica OP Final Exam Top ranked study
Materials
New Patient - ANSWER-No previous records, longer visit, detailed chart
established patient - ANSWER-Previous records available from last 3 years, shorter
visit, concise chart
Diagnostic visit - ANSWER-New problem, chief complaint: new symptom, goal is to
determine the cause of the problem and appropriate treatment
health management - ANSWER-check up, CC: routine physical or management of
chronic problems, goal is preventative care and/or assessing progress of ongoing
medical problems
Clinic Flow - ANSWER-1. Check-in
2. Physician Evaluation
3. Orders & Results
4. Assessment & Plan
5. Check-out
Quality Measures - ANSWER-chief complaint
vital signs
height, weight, BMI
Smoking Status
What goes in the History and Physical (H&P) - ANSWER-HPI, ROS, PE
DDx - ANSWER-differential diagnosis
Patient says high blood pressure - ANSWER-Hypertension (HTN)
Patient says high cholesterol - ANSWER-Hyperlipidemia (HLD)
Patient says thyroid problem - ANSWER-Usually Hypothyroidism, sometimes
Hyperthyroidism
Patient says diabetes - ANSWER-Diabetes Mellitus (DM)
Patient says "I only take pills for my diabetes" - ANSWER-Non-Insulin Dependent
Diabetes Mellitus (NIDDM)
, Patient says "I take shots for my diabetes" - ANSWER-Insulin Dependent Diabetes
Mellitus (IDDM)
Patient says heart disease - ANSWER-Coronary Artery Disease (CAD)
Patient says heart attack - ANSWER-Myocardial Infarction (MI) and CAD
Patient says heart failure - ANSWER-Congestive Heart Failure (CHF)
Patient says Irregular heartbeat - ANSWER-arrhythmia
Patient says murmur - ANSWER-heart murmur
Patient says episodes of abnormally fast/racing heartbeat - ANSWER-supraventricular
tachycardia (SVT)
Patient says asthma - ANSWER-asthma
Patient says Emphysema/Chronic Bronchitis - ANSWER-Chronic Obstructive
Pulmonary Disease (COPD)
Patient says blood clot in lung - ANSWER-Pulmonary Embolism (PE)
Patient says pneumonia - ANSWER-Pneumonia (PNA)
Patient says reflux - ANSWER-Gastroesophageal Reflux Disease (GERD)
Patient says ulcer - ANSWER-Gastric Ulcer or Peptic Ulcer Disease (PUD)
Patient says pancreatitis - ANSWER-pancreatitis
Patient says hepatitis - ANSWER-Hepatitis A, B, or C
Patient says diverticulitis - ANSWER-Diverticulitis
Patient says Crohn's/UC - ANSWER-Crohn's Disease or Ulcerative Colitis
Patient says irritable bowel - ANSWER-Irritable Bowel Syndrome (IBS)
Patient says bladder infection - ANSWER-Urinary Tract Infection (UTI)
Patient says kidney infection - ANSWER-Pyelonephritis (Pyelo)
Patient says kidney stones - ANSWER-renal calculi
Patient says I'm on dialysis - ANSWER-Chronic Renal Failure (CRF) or End Stage
Renal Disease (ESRD) on dialysis
Materials
New Patient - ANSWER-No previous records, longer visit, detailed chart
established patient - ANSWER-Previous records available from last 3 years, shorter
visit, concise chart
Diagnostic visit - ANSWER-New problem, chief complaint: new symptom, goal is to
determine the cause of the problem and appropriate treatment
health management - ANSWER-check up, CC: routine physical or management of
chronic problems, goal is preventative care and/or assessing progress of ongoing
medical problems
Clinic Flow - ANSWER-1. Check-in
2. Physician Evaluation
3. Orders & Results
4. Assessment & Plan
5. Check-out
Quality Measures - ANSWER-chief complaint
vital signs
height, weight, BMI
Smoking Status
What goes in the History and Physical (H&P) - ANSWER-HPI, ROS, PE
DDx - ANSWER-differential diagnosis
Patient says high blood pressure - ANSWER-Hypertension (HTN)
Patient says high cholesterol - ANSWER-Hyperlipidemia (HLD)
Patient says thyroid problem - ANSWER-Usually Hypothyroidism, sometimes
Hyperthyroidism
Patient says diabetes - ANSWER-Diabetes Mellitus (DM)
Patient says "I only take pills for my diabetes" - ANSWER-Non-Insulin Dependent
Diabetes Mellitus (NIDDM)
, Patient says "I take shots for my diabetes" - ANSWER-Insulin Dependent Diabetes
Mellitus (IDDM)
Patient says heart disease - ANSWER-Coronary Artery Disease (CAD)
Patient says heart attack - ANSWER-Myocardial Infarction (MI) and CAD
Patient says heart failure - ANSWER-Congestive Heart Failure (CHF)
Patient says Irregular heartbeat - ANSWER-arrhythmia
Patient says murmur - ANSWER-heart murmur
Patient says episodes of abnormally fast/racing heartbeat - ANSWER-supraventricular
tachycardia (SVT)
Patient says asthma - ANSWER-asthma
Patient says Emphysema/Chronic Bronchitis - ANSWER-Chronic Obstructive
Pulmonary Disease (COPD)
Patient says blood clot in lung - ANSWER-Pulmonary Embolism (PE)
Patient says pneumonia - ANSWER-Pneumonia (PNA)
Patient says reflux - ANSWER-Gastroesophageal Reflux Disease (GERD)
Patient says ulcer - ANSWER-Gastric Ulcer or Peptic Ulcer Disease (PUD)
Patient says pancreatitis - ANSWER-pancreatitis
Patient says hepatitis - ANSWER-Hepatitis A, B, or C
Patient says diverticulitis - ANSWER-Diverticulitis
Patient says Crohn's/UC - ANSWER-Crohn's Disease or Ulcerative Colitis
Patient says irritable bowel - ANSWER-Irritable Bowel Syndrome (IBS)
Patient says bladder infection - ANSWER-Urinary Tract Infection (UTI)
Patient says kidney infection - ANSWER-Pyelonephritis (Pyelo)
Patient says kidney stones - ANSWER-renal calculi
Patient says I'm on dialysis - ANSWER-Chronic Renal Failure (CRF) or End Stage
Renal Disease (ESRD) on dialysis
