SCRIBEAMERICA OUTPATIENT FINAL EXAM LATEST
REAL EXAM 150 QUESTIONS AND CORRECT ANSWERS
(VERIFIED ANSWERS) |AGRADE
subjective vs objective - ANSWER: Feeling (patient; HPI, ROS) vs. fact (provider; PE)
pain vs tenderness - ANSWER: Patient's feeling (subjective) vs. physician's
observation (objective)
benign - ANSWER: Normal, nothing of concern
acute vs chronic - ANSWER: new onset vs. long standing
baseline - ANSWER: An individual's normal state of being
auscultation - ANSWER: Listening with a stethoscope
palpation - ANSWER: The act of pressing on an area (by the doctor)
Inpatient - ANSWER: Admitted to the hospital overnight
outpatient - ANSWER: Seen and sent home the same day
chief complaint - ANSWER: the main reason for the patient's visit
mid-level provider - ANSWER: advanced practice provider (APP), nurse practioner
(NP), or PA which works under supervision of physician
nurse of medical assistant - ANSWER: Records medical histories and symptoms,
monitors the patient, completes meaningful use requirements, administers
medications, assists with procedures
receptionist - 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 - ANSWER: Documents the patient's visit on behalf of the physician
what can scribes do vs not do - ANSWER: scribes can: doc history, SOAP; access and
document lab results and radiology findings; locate and obtain PmHx and previous
chars; record physician interpretations of x-rays and EKGs
scribes cannot: partake in any activity which may affect pt health; touch patients;
handle bodily fluids, sign any char; give verbal orders or submit electronic orders
,New vs. Established Patient - ANSWER: new: no previous records, longer visit,
detailed chart (new pt if it has been more than 3 yrs since pt has been seen in this
clinic)
established: previous records available, shorter visit, concise chart
two types of clinic visits - ANSWER: diagnostic (new problem, CC is new symptom,
goal is to determine cause of problem and appropriate treatment) and health
maintenance (check up, CC is routine physical or management of existing problem,
goal is preventive care)
clinic flow - ANSWER: Check-in, Physician Evaluation, Orders & Results, Assessment
& Plan, Check-Out
clinic flow - check-in - ANSWER: pt walks into clinic -> room placement -> quality
measures obtained by nurse / MA -> nurse/MA assessment
clinic flow - physician eval - ANSWER: review pts medical records -> H&P (history and
physical) -> differential Dx if diagnostic visit
clinic flow - orders and results - ANSWER: Orders: laboratory studies, imaging
studies, and procedures
Results: may result during visit (rare) or in a few days
Clinic Flow - Assessment & Plan - ANSWER: Assessment (The list of diagnoses) -> Plan
(Follow-up with specialist if necessary, Instructions for lifestyle and preventative
care, and Follow-up for next routine appointment)
clinic flow - check-out - ANSWER: Check-out (Home vs. sent to the ED, Patient
education provided, and Patient will often stop at the front desk on the way out to
schedule next appointment)
SOAP sections - ANSWER: S: HPI, ROS, Past history, patient complaint (CC); O: PE,
orders and results, vital signs; A: current diagnoses; P: treatment and follow-up
HPI, ROS, PMSHx, SHx, FHx, PE acronyms - ANSWER: HPI: history of present illness
(story of patient's CC)
ROS: review of systems (head-to-toe checklist of pt's symptoms)
PMSHx: past medical surgical history
SHx: social history
FHx: family history
What part of SOAP do you use for health management visits as a reference -
ANSWER: A & P
, pt says 1) high cholesterol 2) thyroid problem 3) diabetes 4) "I only take pills for my
diabetes" 5) "I take shots (insulin) for my diabetes" .. scribe writes - ANSWER: 1)
hyperlipidemia (HLD) 2) usually hypothyroidism, sometimes hyperthyroidism 3)
diabetes mellitus (DM) 4) non-insulin dependent diabetes mellitus (NIDDM), 5)
insulin dependent diabetes mellitus (IDDM)
pt says 1) heart disease 2) heart attack 3) heart failure 4) irregular heartbeat 5)
murmur 6) episodes of abnormally fast / racing heartbeat .. scribe writes - ANSWER:
1) usually coronary artery disease (CAD) 2) myocardial infarction (MI) and CAD 3)
congestive heart failure (CHF) 4) arrhythmia 5) heart murmur 6) supraventricular
tachycardia (SVT)
pt says 1) asthma 2) emphysema / chronic bronchitis 3) blood clot in lung 4)
pneumonia .. scribe writes - ANSWER: scribe writes.. 1) asthma 2) chronic
obstructive pulmonary disease (COPD), 3) pulmonary embolism (PE), 4) pneumonia
(PNA)
pt says 1) reflux 2) ulcer 3) pancreatitis 4) hepatitis 5) diverticulitis 6) crohn's/UC 7)
irritable bowel.. scribe writes - ANSWER: 1) gastroesophageal reflux disease (GERD)
2) gastric ulcer or peptic ulcer disease (PUD) 3) pancreatitis 4) Hepatitis A, B, or C 5)
diverticulitis 6) Crohn's Disease or Ulcerative Colitis 7) Irritable Bowel Syndrome (IBS)
pt says 1) bladder infection 2) kidney infection 3) kidney stones 4) dialysis 5)
enlarged prostate .. scribe writes - ANSWER: 1) urinary tract infection (UTI) 2)
pyelonephritis (pyelo) 3) renal calculi 4) chronic renal failure (CRF) on dialysis or end
stage renal disease (ESRD) 5) benign prostatic hypertrophy (BPH)
GPA - ANSWER: G: gravida (total number of times the pt has been pregnant) P: para
(number of pregnancies that resulted in viable births) A: abortus (total number of
miscarriages or elective abortions)
pt says 1) brain bleed 2) stroke 3) mini-stroke 4) seizures .. scribe writes - ANSWER:
1) hemorrhagic CVA 2) ischemic cerebrovascular accident (CVA) 3) transient ischemic
attack (TIA) 4) history of seizures
pt says 1) I drink a lot 2) I do drugs .. scribe writes - ANSWER: 1) ETOH abuse or
Alcoholism 2) substance abuse
pt says 1) blood clot in my leg 2) bulge in my aorta 3) bad blood flow to my legs 4)
numbness in my legs .. scribe writes - ANSWER: 1) lower extremity deep vein
thrombosis (DVT) 2) aortic aneurysm 3) peripheral vascular disease (PVD) 4)
peripheral neuropathy
pt says 1) low back pain 2) bulging / herniated disc 3) arthritis - ANSWER: 1) chronic
low back pain 2) degenerative disc disease (DDD) 3) usually osteoarthritis (OA)
sometimes rheumatoid arthritis (RA)
REAL EXAM 150 QUESTIONS AND CORRECT ANSWERS
(VERIFIED ANSWERS) |AGRADE
subjective vs objective - ANSWER: Feeling (patient; HPI, ROS) vs. fact (provider; PE)
pain vs tenderness - ANSWER: Patient's feeling (subjective) vs. physician's
observation (objective)
benign - ANSWER: Normal, nothing of concern
acute vs chronic - ANSWER: new onset vs. long standing
baseline - ANSWER: An individual's normal state of being
auscultation - ANSWER: Listening with a stethoscope
palpation - ANSWER: The act of pressing on an area (by the doctor)
Inpatient - ANSWER: Admitted to the hospital overnight
outpatient - ANSWER: Seen and sent home the same day
chief complaint - ANSWER: the main reason for the patient's visit
mid-level provider - ANSWER: advanced practice provider (APP), nurse practioner
(NP), or PA which works under supervision of physician
nurse of medical assistant - ANSWER: Records medical histories and symptoms,
monitors the patient, completes meaningful use requirements, administers
medications, assists with procedures
receptionist - 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 - ANSWER: Documents the patient's visit on behalf of the physician
what can scribes do vs not do - ANSWER: scribes can: doc history, SOAP; access and
document lab results and radiology findings; locate and obtain PmHx and previous
chars; record physician interpretations of x-rays and EKGs
scribes cannot: partake in any activity which may affect pt health; touch patients;
handle bodily fluids, sign any char; give verbal orders or submit electronic orders
,New vs. Established Patient - ANSWER: new: no previous records, longer visit,
detailed chart (new pt if it has been more than 3 yrs since pt has been seen in this
clinic)
established: previous records available, shorter visit, concise chart
two types of clinic visits - ANSWER: diagnostic (new problem, CC is new symptom,
goal is to determine cause of problem and appropriate treatment) and health
maintenance (check up, CC is routine physical or management of existing problem,
goal is preventive care)
clinic flow - ANSWER: Check-in, Physician Evaluation, Orders & Results, Assessment
& Plan, Check-Out
clinic flow - check-in - ANSWER: pt walks into clinic -> room placement -> quality
measures obtained by nurse / MA -> nurse/MA assessment
clinic flow - physician eval - ANSWER: review pts medical records -> H&P (history and
physical) -> differential Dx if diagnostic visit
clinic flow - orders and results - ANSWER: Orders: laboratory studies, imaging
studies, and procedures
Results: may result during visit (rare) or in a few days
Clinic Flow - Assessment & Plan - ANSWER: Assessment (The list of diagnoses) -> Plan
(Follow-up with specialist if necessary, Instructions for lifestyle and preventative
care, and Follow-up for next routine appointment)
clinic flow - check-out - ANSWER: Check-out (Home vs. sent to the ED, Patient
education provided, and Patient will often stop at the front desk on the way out to
schedule next appointment)
SOAP sections - ANSWER: S: HPI, ROS, Past history, patient complaint (CC); O: PE,
orders and results, vital signs; A: current diagnoses; P: treatment and follow-up
HPI, ROS, PMSHx, SHx, FHx, PE acronyms - ANSWER: HPI: history of present illness
(story of patient's CC)
ROS: review of systems (head-to-toe checklist of pt's symptoms)
PMSHx: past medical surgical history
SHx: social history
FHx: family history
What part of SOAP do you use for health management visits as a reference -
ANSWER: A & P
, pt says 1) high cholesterol 2) thyroid problem 3) diabetes 4) "I only take pills for my
diabetes" 5) "I take shots (insulin) for my diabetes" .. scribe writes - ANSWER: 1)
hyperlipidemia (HLD) 2) usually hypothyroidism, sometimes hyperthyroidism 3)
diabetes mellitus (DM) 4) non-insulin dependent diabetes mellitus (NIDDM), 5)
insulin dependent diabetes mellitus (IDDM)
pt says 1) heart disease 2) heart attack 3) heart failure 4) irregular heartbeat 5)
murmur 6) episodes of abnormally fast / racing heartbeat .. scribe writes - ANSWER:
1) usually coronary artery disease (CAD) 2) myocardial infarction (MI) and CAD 3)
congestive heart failure (CHF) 4) arrhythmia 5) heart murmur 6) supraventricular
tachycardia (SVT)
pt says 1) asthma 2) emphysema / chronic bronchitis 3) blood clot in lung 4)
pneumonia .. scribe writes - ANSWER: scribe writes.. 1) asthma 2) chronic
obstructive pulmonary disease (COPD), 3) pulmonary embolism (PE), 4) pneumonia
(PNA)
pt says 1) reflux 2) ulcer 3) pancreatitis 4) hepatitis 5) diverticulitis 6) crohn's/UC 7)
irritable bowel.. scribe writes - ANSWER: 1) gastroesophageal reflux disease (GERD)
2) gastric ulcer or peptic ulcer disease (PUD) 3) pancreatitis 4) Hepatitis A, B, or C 5)
diverticulitis 6) Crohn's Disease or Ulcerative Colitis 7) Irritable Bowel Syndrome (IBS)
pt says 1) bladder infection 2) kidney infection 3) kidney stones 4) dialysis 5)
enlarged prostate .. scribe writes - ANSWER: 1) urinary tract infection (UTI) 2)
pyelonephritis (pyelo) 3) renal calculi 4) chronic renal failure (CRF) on dialysis or end
stage renal disease (ESRD) 5) benign prostatic hypertrophy (BPH)
GPA - ANSWER: G: gravida (total number of times the pt has been pregnant) P: para
(number of pregnancies that resulted in viable births) A: abortus (total number of
miscarriages or elective abortions)
pt says 1) brain bleed 2) stroke 3) mini-stroke 4) seizures .. scribe writes - ANSWER:
1) hemorrhagic CVA 2) ischemic cerebrovascular accident (CVA) 3) transient ischemic
attack (TIA) 4) history of seizures
pt says 1) I drink a lot 2) I do drugs .. scribe writes - ANSWER: 1) ETOH abuse or
Alcoholism 2) substance abuse
pt says 1) blood clot in my leg 2) bulge in my aorta 3) bad blood flow to my legs 4)
numbness in my legs .. scribe writes - ANSWER: 1) lower extremity deep vein
thrombosis (DVT) 2) aortic aneurysm 3) peripheral vascular disease (PVD) 4)
peripheral neuropathy
pt says 1) low back pain 2) bulging / herniated disc 3) arthritis - ANSWER: 1) chronic
low back pain 2) degenerative disc disease (DDD) 3) usually osteoarthritis (OA)
sometimes rheumatoid arthritis (RA)
