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