ScribeAmerica OP Final Exam Questions With Rationales.
New Patient - No previous records, longer visit, detailed chart
established patient - Previous records available from last 3 years, shorter visit, concise chart
Diagnostic visit - New problem, chief complaint: new symptom, goal is to determine the cause of the
problem and appropriate treatment
health management - check up, CC: routine physical or management of chronic problems, goal is
preventative care and/or assessing progress of ongoing medical problems
Clinic Flow - 1. Check-in
2. Physician Evaluation
3. Orders & Results
4. Assessment & Plan
5. Check-out
Quality Measures - chief complaint
vital signs
height, weight, BMI
Smoking Status
What goes in the History and Physical (H&P) - HPI, ROS, PE
DDx - differential diagnosis
Patient says high blood pressure - Hypertension (HTN)
https://www.stuvia.com/
,Patient says high cholesterol - Hyperlipidemia (HLD)
Patient says thyroid problem - Usually Hypothyroidism, sometimes Hyperthyroidism
Patient says diabetes - Diabetes Mellitus (DM)
Patient says "I only take pills for my diabetes" - Non-Insulin Dependent Diabetes Mellitus (NIDDM)
Patient says "I take shots for my diabetes" - Insulin Dependent Diabetes Mellitus (IDDM)
Patient says heart disease - Coronary Artery Disease (CAD)
Patient says heart attack - Myocardial Infarction (MI) and CAD
Patient says heart failure - Congestive Heart Failure (CHF)
Patient says Irregular heartbeat - arrhythmia
Patient says murmur - heart murmur
Patient says episodes of abnormally fast/racing heartbeat - supraventricular tachycardia (SVT)
Patient says asthma - asthma
Patient says Emphysema/Chronic Bronchitis - Chronic Obstructive Pulmonary Disease (COPD)
Patient says blood clot in lung - Pulmonary Embolism (PE)
Patient says pneumonia - Pneumonia (PNA)
Patient says reflux - Gastroesophageal Reflux Disease (GERD)
https://www.stuvia.com/
, Patient says ulcer - Gastric Ulcer or Peptic Ulcer Disease (PUD)
Patient says pancreatitis - pancreatitis
Patient says hepatitis - Hepatitis A, B, or C
Patient says diverticulitis - Diverticulitis
Patient says Crohn's/UC - Crohn's Disease or Ulcerative Colitis
Patient says irritable bowel - Irritable Bowel Syndrome (IBS)
Patient says bladder infection - Urinary Tract Infection (UTI)
Patient says kidney infection - Pyelonephritis (Pyelo)
Patient says kidney stones - renal calculi
Patient says I'm on dialysis - Chronic Renal Failure (CRF) or End Stage Renal Disease (ESRD) on dialysis
Patient says enlarged prostate - Benign Prostate Hypertrophy (BPH)
Gravida - Total number of time the patient has been pregnant
Para - number of pregnancies reaching viable gestational age (23 weeks) that the patient has had
Abortus - total number of miscarriages or elective abortions
patient says brain bleed (stroke) - Hemorrhagic CVA
https://www.stuvia.com/
New Patient - No previous records, longer visit, detailed chart
established patient - Previous records available from last 3 years, shorter visit, concise chart
Diagnostic visit - New problem, chief complaint: new symptom, goal is to determine the cause of the
problem and appropriate treatment
health management - check up, CC: routine physical or management of chronic problems, goal is
preventative care and/or assessing progress of ongoing medical problems
Clinic Flow - 1. Check-in
2. Physician Evaluation
3. Orders & Results
4. Assessment & Plan
5. Check-out
Quality Measures - chief complaint
vital signs
height, weight, BMI
Smoking Status
What goes in the History and Physical (H&P) - HPI, ROS, PE
DDx - differential diagnosis
Patient says high blood pressure - Hypertension (HTN)
https://www.stuvia.com/
,Patient says high cholesterol - Hyperlipidemia (HLD)
Patient says thyroid problem - Usually Hypothyroidism, sometimes Hyperthyroidism
Patient says diabetes - Diabetes Mellitus (DM)
Patient says "I only take pills for my diabetes" - Non-Insulin Dependent Diabetes Mellitus (NIDDM)
Patient says "I take shots for my diabetes" - Insulin Dependent Diabetes Mellitus (IDDM)
Patient says heart disease - Coronary Artery Disease (CAD)
Patient says heart attack - Myocardial Infarction (MI) and CAD
Patient says heart failure - Congestive Heart Failure (CHF)
Patient says Irregular heartbeat - arrhythmia
Patient says murmur - heart murmur
Patient says episodes of abnormally fast/racing heartbeat - supraventricular tachycardia (SVT)
Patient says asthma - asthma
Patient says Emphysema/Chronic Bronchitis - Chronic Obstructive Pulmonary Disease (COPD)
Patient says blood clot in lung - Pulmonary Embolism (PE)
Patient says pneumonia - Pneumonia (PNA)
Patient says reflux - Gastroesophageal Reflux Disease (GERD)
https://www.stuvia.com/
, Patient says ulcer - Gastric Ulcer or Peptic Ulcer Disease (PUD)
Patient says pancreatitis - pancreatitis
Patient says hepatitis - Hepatitis A, B, or C
Patient says diverticulitis - Diverticulitis
Patient says Crohn's/UC - Crohn's Disease or Ulcerative Colitis
Patient says irritable bowel - Irritable Bowel Syndrome (IBS)
Patient says bladder infection - Urinary Tract Infection (UTI)
Patient says kidney infection - Pyelonephritis (Pyelo)
Patient says kidney stones - renal calculi
Patient says I'm on dialysis - Chronic Renal Failure (CRF) or End Stage Renal Disease (ESRD) on dialysis
Patient says enlarged prostate - Benign Prostate Hypertrophy (BPH)
Gravida - Total number of time the patient has been pregnant
Para - number of pregnancies reaching viable gestational age (23 weeks) that the patient has had
Abortus - total number of miscarriages or elective abortions
patient says brain bleed (stroke) - Hemorrhagic CVA
https://www.stuvia.com/
